Impact of Enhanced Recovery after Surgery Protocol Compliance on Length of Stay, Bowel Recovery and Complications after Radical Cystectomy.

BACKGROUND

Despite existing standardized surgical techniques and the development of new perioperative care protocols, radical cystectomy (RC) morbidity remains a serious challenge for urologists. Postoperative ileus (POI) is one of the most common postoperative complications, often leading to a longer length of stay (LOS). The aim of our study was to assess the impact of compliance to the Enhanced Recovery After Surgery (ERAS) protocol on bowel recovery, 30-day complications and LOS after RC for bladder cancer (BC).

METHODS

Data from consecutive patients undergoing RC for BC within an ERAS dedicated protocol were analyzed. Exclusion criteria were urinary diversion other than ileal conduit and palliative RC. Patients were divided into two groups according to their compliance (A: low-compliance and B: high-compliance). ERAS compliance was extracted from the ERAS Interactive Audit System (EIAS) database. Postoperative complications were prospectively recorded by a dedicated study nurse 30 days after RC. POI was defined as the placement of a nasogastric tube. Logistic regression analysis was used to identify predictors of 30-day complications and POI.

RESULTS

After considering the exclusion criteria, 108 patients were included for the final analysis. The median global compliance to the ERAS protocol was 61%. A total of 78 (72%) patients had a compliance <65% (group A), while the remaining 30 (28%) had a compliance >65% (group B). No significant differences were found among the two groups regarding the 30-day complication rate (86% in group A versus 73% in group B, = 0.82) and LOS (14 days in group A versus 15 days in group B, = 0.82). The time to stool was significantly shorter in group B (4 days versus 6 days, = 0.02), and the time to tolerate solid food was slightly faster in group B but not significant (8 versus 7 days, = 0.23). The POI rate was significantly lower in patients with a higher ERAS compliance (20% versus 46%, = 0.01). A multivariate analysis showed that ERAS compliance was not significantly associated with 30-day total complications. However, a lower compliance to the ERAS protocol and age > 75 years were significant independent predictors of POI.

CONCLUSIONS

Our study provides further evidence to support the beneficial effect of the ERAS protocol in patients undergoing RC, particularly in terms of facilitating a faster recovery of bowel function and preventing POI. Future research should focus on investigating novel approaches and interventions to improve compliance with the ERAS protocol. This may involve patient education, multidisciplinary teamwork, and continuous quality improvement initiatives.