Reporting Radical Cystectomy Outcomes Following Implementation of Enhanced Recovery After Surgery Protocols: A Systematic Review and Individual Patient Data Meta-analysis

Stephen B Williams; Marcus G K Cumberbatch; Ashish M Kamat; Ibrahim Jubber; Preston S Kerr; John S McGrath; Hooman Djaladat; Justin W Collins; Vignesh T Packiam; Gary D Steinberg; Eugene Lee; Wassim Kassouf; Peter C Black; Yannick Cerantola; James W F Catto; Siamak Daneshmand

doi:10.1016/j.eururo.2020.06.039

Reporting Radical Cystectomy Outcomes Following Implementation of Enhanced Recovery After Surgery Protocols: A Systematic Review and Individual Patient Data Meta-analysis

Eur Urol. 2020 Nov;78(5):719-730. doi: 10.1016/j.eururo.2020.06.039. Epub 2020 Jul 2.

Authors

Stephen B Williams¹, Marcus G K Cumberbatch², Ashish M Kamat³, Ibrahim Jubber², Preston S Kerr¹, John S McGrath⁴, Hooman Djaladat⁵, Justin W Collins⁶, Vignesh T Packiam⁷, Gary D Steinberg⁸, Eugene Lee⁹, Wassim Kassouf¹⁰, Peter C Black¹¹, Yannick Cerantola¹², James W F Catto¹³, Siamak Daneshmand¹⁴

Affiliations

¹ Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA.
² Academic Urology Unit, University of Sheffield, Sheffield, UK.
³ Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
⁴ Department of Urology, Royal Devon and Exeter NHS Trust, Exeter, UK.
⁵ USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
⁶ Department of Urology, University College London Hospital, London, UK.
⁷ Department of Urology, Mayo Clinic, Rochester, MN, USA.
⁸ Department of Urology, New York University, New York, NY, USA.
⁹ Department of Urology, University of Kansas, Kansas City, KS, USA.
¹⁰ Department of Urology, McGill University Health Center, Montreal, QC, Canada.
¹¹ Department of Urologic Science, University of British Columbia, Vancouver, BC, Canada.
¹² Service d'urologie, CHU vaudois, Lausanne, Switzerland.
¹³ Academic Urology Unit, University of Sheffield, Sheffield, UK. Electronic address: j.catto@sheffield.ac.uk.
¹⁴ USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA. Electronic address: daneshma@med.usc.edu.

PMID: 32624275
DOI: 10.1016/j.eururo.2020.06.039

Abstract

Context: Enhanced Recovery After Surgery (ERAS) is a perioperative approach to managing surgical patients. The impact of ERAS on radical cystectomy (RC) outcomes remains understudied.

Objective: To review the literature regarding ERAS protocols and RC outcomes. The primary outcome was hospital length of stay (LOS).

Evidence acquisition: A systematic review of the articles published from 1970 through 2018 was conducted. Individual patient data (IPD) were requested and a meta-analysis was performed.

Evidence synthesis: A total of 4197 articles were retrieved and 22 (reporting 4048 patients) were selected for the review. LOS followed by 30-d and that followed by 90-d complications were the most common endpoints. ERAS use was associated with reduced morbidity, quicker bowel recovery, and shorter LOS, without affecting mortality. IPD were obtained for 2077 patients from 11 studies. In multivariable models, LOS was associated with ERAS use (regression coefficient: -4.54 [95% confidence interval {CI}: -5.79 to -3.28] d with ERAS p < 0.001) and Charlson Comorbidity Index (+1.64 [1.38-1.90] d for each point increase, p < 0.001), and varied between hospitals (from -1.59 [-3.03 to -0.14] to +4.55 [1.89-7.21] d, p < 0.03). Individual ERAS components associated with shorter LOS included no nasogastric (NG) tube (-8.70 [-11.9 to -5.53] d, p < 0.001) and local anesthesia blocks compared with regional anesthesia (-3.29 [-6.31 to -0.27] d, p = 0.03).

Conclusions: ERAS protocols were associated with reduced LOS and postoperative complication rate. Avoidance of NG tubes and use of local anesthesia blocks were significantly associated with reduced LOS. These findings reflect different components of recovery, which ERAS can optimize and further support documentation of the use of ERAS components when reporting RC outcomes.

Patient summary: Use of enhanced recovery in patients undergoing surgery to remove the bladder is associated with fewer surgical complications and a shorter hospital stay. Avoidance of nasogastric tubes and use of local anesthesia after the operation were associated with a shorter length of stay.

Keywords: Cystectomy; Enhanced Recovery After Surgery; Enhanced recovery; Length of stay; Outcomes.

Publication types

Meta-Analysis
Research Support, Non-U.S. Gov't
Research Support, U.S. Gov't, Non-P.H.S.
Systematic Review

MeSH terms

Cystectomy* / methods
Enhanced Recovery After Surgery*
Humans
Length of Stay
Treatment Outcome
Urinary Bladder Neoplasms / surgery*

Grants and funding

NIHR300047/DH_/Department of Health/United Kingdom