Robot-assisted radical cystectomy with intracorporeal urinary diversion: impact on an established enhanced recovery protocol Anthony Koupparis, Christian Villeda-Sandoval, Nicola Weale†, Motaz El-Mahdy, David Gillatt and Edward Rowe Bristol Urological Institute and †Department of Anaesthetics, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
Objectives To assess the impact of the introduction of robot-assisted radical cystectomy (RARC) on an established enhanced recovery programme (ERP) and to examine the effect on mortality and morbidity rates, transfusion rates, and length of stay (LOS).
Patients and Methods Data on 102 consecutive patients undergoing RARC with full intracorporeal reconstruction were obtained from our prospectively updated institutional database. These data were compared to previously published retrospective results from three separate groups of patients undergoing open radical cystectomy (ORC) at our centre. Our primary focus was perioperative outcomes including transfusion rate, complication rates, 30- and 90-day mortality rates, and LOS.
Results
American Society of Anesthesiologists grade. A significant reduction in transfusion rate was seen in RARC vs ORC (P < 0.001). The median LOS for the RARC group was 8 vs 13 days for the ORC group (P < 0.001). There was trend to a lower total complication rate (48% vs 31%). The 30- and 90-day mortality rates were equivalent between the groups (2%).
Conclusions Introduction of RARC and intracorporeal reconstruction represents the single biggest impact on our ERP, with significant reduction in transfusion rates and LOS, and a trend towards a lower complication rate.
Keywords robot-assisted radical cystectomy, enhanced recovery, bladder cancer
The demographics of the comparative groups showed no significant difference in age, gender distribution, and
Introduction Since the initiation of enhanced recovery after surgery (ERAS) by Professor Henrik Kehlet [1] in the 1990s, enhanced recovery programmes (ERPs) or ‘fast-track’ programmes have become an important focus of perioperative management after major surgery including open radical cystectomy (ORC) [2–4]. We previously described the impact on outcomes after ORC after the introduction of an ERP at a time when perioperative care was governed by surgical dogma rather than evidence base [5]. The protocol focuses on preoperative counselling, nutrition, standard analgesic and anaesthetic regimens, and early mobilisation, and has continued to develop over several years [6]. ERAS protocols modify the physiological and psychological responses to major surgery; however, limiting the initial
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surgical insult for example with minimally invasive approaches is one of the key principles [7]. A significant change to our service was the introduction of robot-assisted RC (RARC) with intracorporeal reconstruction in 2010. This approach has the potential to reduce the surgical impact on patients undergoing RC, with less analgesia requirements, less blood loss, shorter length of stay (LOS), and quicker recovery [8]. It has subsequently evolved into the preferred approach for these patients in our institution. The present study aimed to assess the impact of RARC and intracorporeal reconstruction on an established ERP.
Patients and Methods An ERP was introduced in our institution on 1 October 2005. The effects on perioperative outcomes were examined by comparing 56 consecutive patients undergoing ORC before
© 2015 The Authors BJU International © 2015 BJU International | doi:10.1111/bju.13171 Published by John Wiley & Sons Ltd. www.bjui.org
RARC impact on an established enhanced recovery protocol
implementation (pre-ERP), and 56 consecutive ORC patients managed after its introduction (post-ERP) [5]. Significant alterations to the ERP were subsequently introduced in April 2009. The effects were examined again using a 56 consecutive patients managed on the original ERP immediately prior to the alterations, and 56 consecutive patients managed on the new ERP (post-ERP II) [6]. Our RARC service began in 2010 and we have performed >200 cases. For the present study, we have examined data from the 56 ORC patients from the preERP group, the post-ERP group, and the post-ERP II group. We have used these data to compare with perioperative outcomes of consecutive patients who underwent RARC with full intracorporeal reconstruction as part of our robotic urology service. Data on ORC were previously collected retrospectively from patient notes, cancer network, and hospital data. Data regarding patients undergoing RARC were collected from our prospectively updated institutional database. This information was cross-referenced for accuracy using North Bristol NHS Trust’s Information Systems department and Hospital Episodes Statistics data. Information was collected on patient demographics, mortality rates, complication rates graded to the modified Clavien–Dindo system [9], and LOS. Our statistical analyses focussed on the most contemporary group of patients undergoing ORC (post-ERP II group) and the RARC group. A descriptive analysis was performed and a comparison analysis between these groups was performed using a non-paired t-test for numerical variables, and chisquare and Fisher’s exact test were used for dichotomous and
categorical variables. A P < 0.05 was considered to indicate statistical significance. SPSSâ version 17.0 was used as statistical aid software, SPSS Inc., Chicago, IL, USA. Operative Approach All robotic procedures with intracorporeal reconstruction were performed by two surgeons (A.J.K. and E.W.R.), with extensive robotic experience. Our original aim was to provide intracorporeal reconstruction from the outset of our RARC service. The initial cases were performed as combined cases by two consultants, having already completed several hundred robotic cases. This team approach prevents surgeon fatigue and keeps console times down to a minimum. The mean (range) console time for the first 10 cases was 325 (300– 385) min. Our overall median (range) console time is 180 (120–400) min. For a training case we adopt a modular approach enabling console times to be kept to a maximum of 4 h (Fig. 1). If a prolonged procedure is required it is discussed at an early stage with the theatre team and we would routinely undock the robot, level the patient, and remove the pneumoperitoneum for a short period. If a concurrent nephroureterectomy is required, this is performed robotically before the RC as previously described [10]. The RC procedure involves a transperitoneal approach commencing with an extended lymph node dissection and careful ureteric dissection and division. This allows visualisation of the vesicle pedicles and easy transfer of the left ureter beneath the sigmoid colon. Vesicle pedicles are
Fig. 1 Bristol Urological Institute modular training scheme for RARC and intracorporeal ileal conduit, including console times (training orthotopic neobladder requires an additional 60 min). DVC, dorsal venous complex.
Sigmoid mobilisation
Posterior approach Lymph node dissection 90 min Ureteric dissection Ureteric transfer 4h Pedicles 60 min
Bladder removal Division DVC /urethra
Bowel anastamosis Reconstruction
90 min Ureteroileal anastamosis
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controlled with Weckâ Hem-o-lokâ clips in a step-wise approach towards the apex of the prostate gland in men and the pelvic sidewall in women. If oncologically and functionally appropriate preservation of the neurovascular bundle is performed in men. In appropriate female patients an organ-sparing approach is adopted with preservation of the ovaries, vagina, and para-vaginal tissues [11]. The dorsal venous complex and pelvic veins in women are appropriately controlled and the urethra managed to prevent tumour spillage. The specimen is placed in a retrieval bag and removed via the open vagina or removed at the end of the procedure in men via the camera port. A stented Bricker uretero-ileal anastomosis is made for intracorporeal ileal conduits and a modified Studer pouch performed for orthotopic neobladders.
significantly lower transfusion rate vs the ORC groups (P < 0.001). The complication rates graded to the modified Clavien–Dindo system are detailed in Table 3. Although there appears to be a trend towards a lower complication rate, this is was not found to be statistically significant. The trend in LOS over the last decade is shown as box plots in Fig. 2. There was a reduction in LOS with the introduction of our ERP (pre-ERP vs post-ERP); however, this remained stable despite several alterations (post-ERP vs post-ERP II). Introduction of our RARC service has lead to a significant reduction in LOS of 5 days (P < 0.001).
Discussion Results The demographics, summary of complication rates, mortality rates, and indications for surgery are shown in Tables 1 and 2. The statistical analysis between the RARC group and each of the ORC groups show no significant difference for age, gender, American Society of Anesthesiologists (ASA) grade, the type of urinary diversion, or indication for RC. Mortality rates and re-admission rates were comparable between the groups. The data shows a significant change in practice over recent years, with more routine use of neoadjuvant chemotherapy. There was a significant difference in the number of patients receiving neoadjuvant chemotherapy in the RARC group when compared with the ORC groups (P < 0.001). The minimally invasive nature of RARC is shown by the
ORC and urinary reconstruction remains a central pillar in the management of invasive bladder cancer. However, it is a complex procedure associated with significant risks of morbidity and mortality [12]. The present study shows the evolution of an ERP for RC over nearly a decade, with particular focus on the impact of a RARC with full intracorporeal reconstruction. The Bristol Urological Institute is one of the highest volume robotic urology centres in the UK, and the present data represents the largest UK series of RARC with intracorporeal reconstruction. The above data shows a significant reduction in transfusion rate and a significant reduction in LOS, consistent with a faster recovery time. RARC has been performed for over decade [13]. This minimally invasive approach subjects a patient to a decreased
Table 1 Demographic and operative details. Variable
Number of patients Men, n Women, n Mean (range) age, years Preoperative radiotherapy, n Preoperative chemotherapy, n (%) ASA score, n 1 2 3 Ileal conduit, n Orthotopic neobladder, n Transfusion rate, n (%) Overall complication rate, n (%) 30-day readmission, n 30-day mortality, n 90-day mortality, n
ORC Pre-ERP
Post-ERP
Post-ERP II
RARC
56 42 14 65.9 3 3 (5.4)
56 44 12 65.9 2 2 (3.6)
56 46 10 66.4 (37–83) 2 2 (3.6)
102 71 31 68.22 (18–86) 4 43 (42.2)
8 39 9 45 11 24 (43) 27 (48) 6 1 –
9 40 7 47 9 19 (34) 25 (44) 3 1 –
11 40 5 52 4 23 (41) 27 (48) 3 1 –
7 68 27 91 11 20 (19) 32 (31) 3 1 1
Light blue shading indicates statistically significant difference between RARC group when compared with each of the ORC groups, P < 0.001.
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RARC impact on an established enhanced recovery protocol
Table 2 Indications for RC in the most contemporary ORC group (postERP II) and the RARC group.
Fig. 2 Box plots of LOS (days) across all patients groups.
70 ORC post-ERP II, n
RARC, n
21 33 31 1 1 – – 2 – – – –
26 65 57 14 8 9 2 4 2 2 1 1
Non-muscle invasive Muscle invasive T2 T3 T4 N1 N2 Squamous cell carcinoma Small cell carcinoma Adenocarcinoma Rhabdoid tumour Benign
60 50 Length of stay (days)
Indication
40 30 20 10 0
pre-ERP
post-ERP
post-ERP II
RARC
Series
physiological stress, with less blood loss, reduced analgesic requirements, and a faster recovery [8]. However, it has been adopted in many centres, including our own without clear evidence of superiority. Our objective with the present data
was to examine the impact of RARC in our centre, which inevitably leads onto a discussion of the potential benefits of RARC vs ORC. This is a theme common to many
Table 3 Complication rates. Complication, n (%)
Overall Clavian–Dindo 1 2 3a Details
ORC Pre-ERP
Post-ERP
Post-ERP II
RARC
27 (48)
25 (44)
27 (48)
32 (31)
8 (14) 17 (30) 2 (4) Intra-abdominal collection requiring percutaneous drainage (2)
3 (5) 10 (18) 4 (7) Intra-abdominal collection requiring percutaneous drainage (1). Vesicovaginal fistulae managed with stents and prolonged drainage (3) 2 (4) Return to theatre for urine leak (1), post-op. bleeding (2), bowel obstruction (1)
2 (4) 16 (29) 4 (7) Pelvic collection drained percutaneously (3). Post-op. upper GI bleed treated with endoscopic injection (1)
9 (9) 14 (14) 3 (3) Sepsis and unilateral hydronephrosis requiring temporary nephrostomy (2). Pelvic collection drained percutaneously (1)
4 (7) Return to theatre for total abdominal wound dehiscence (2). Total abdominal wound dehiscence and extensive small bowel ischaemia (1). Vesico-vaginal fistula (1) –
3 (3) Return to theatre for apparent bleeding – no bleeding just irrigation fluid (1). Bleeding from dorsal venous complex (1). Re-fashion ischaemic conduit spout (1). Also developed pneumonia, sepsis and acute kidney injury 1 (1) Prolonged post-op. ventilation for 48 h
1 (1.8) Overwhelming sepsis from pseudomembranous colitis
2 (2) Laparotomy for small bowel anastomotic leak. Prolonged ITU stay requiring invasive ventilation and haemofiltration. Discharged from ITU with subsequent cardiac arrest post-op. day 63 Laparotomy for extensive small bowel ischaemia and prolonged ITU stay for respiratory and nutritional support. Developed pneumonia on ward and died post-op. day 42
3b Details
3 (5) Return to theatre for urine leak (2). Repair of initial vaginal closure (1)
4
1 Asystolic arrest immediately post-op, requiring prolonged ITU admission (1) 1 (1.8) Myocardial infarction day post-op. day 7
Details
5 Details
–
1 (1.8)
Post-op., postoperative; ITU, Intensive Therapy Unit.
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publications relating to the outcomes of RARC, and is particularly topical currently as national bodies within the UK NHS are reviewing the provision of robotic surgical procedures, and in particular RARC. In terms of published data examining the benefit of RARC over ORC, the picture is inconsistent. There have been a variety of case series, matched-cohorts, and prospective
studies examining this area [8,14–17]. They all report a significant reduction in blood loss and transfusion rates of 40–8% to 0–5%. LOS varies from equivalence with ORC [17], to reductions of 8.3 days [8]. Similarly, complications rates have been reported as equivalent [17], significantly reduced with RARC [8,14], or even increased [15].
Fig. 3 Schematic diagram showing the anaesthetic approach for RARC and ORC.
Open Cystectomy
Preoperative carbohydrate drinks
Perioperative management Invasive montioring Arterial line Central line Thoracic epidural unless contraindicated
Intraoperative management Consider goal directed fluid therapy Consider intraoperative cell salvage in high risk cases Arterial blood gas assessment of metabolic state
Postoperative management High dependency care post op Avoid NG tube High depency care post op Regular paracectamol Epidural analgesia
Robotic Cystectomy
Preoperative carbohydrate drinks
Perioperative mangement Consider gabapentin or pregabalin preoperatively Invasive montioring Arterial line Consider central line in highrisk cases
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Intraoperative management Consider goal directed fluid therapy Arterial blood gas assessment of metabolic state IV Magnesium 2g
Postoperative management Consider HDU post op for high-risk cases Avoid NG tube Regular paracectamol Either oxycontin bd with oromorph for breakthrough OR PCA oxycodone 1mg bolus 5 min lockout
RARC impact on an established enhanced recovery protocol
Randomised data is relatively scarce; Parekh et al. [17] published the results from 40 patients who were randomised between the two approaches and found a similar LOS (6 days) and complication rate (25%), with a slightly reduced transfusion rate of 50% vs 40% in favour of RARC. A similar picture is seen from a recent publication from Memorial-Sloan-Kettering [18]; data from 118 patients randomised between ORC and RARC showed a comparable LOS (8 days) and similar perioperative outcomes (21% vs 22% Clavian grade 3–5, RARC vs ORC). Several recent systematic reviews have attempted to provide a clearer picture of the outcomes of the two approaches. Ishii et al. [19] examined published data on 748 patients between 2000 and 2013. They found lower high-grade complications
and mortality rates associated with RARC, with an expected lower transfusion rate. A similar picture was presented by Tang et al. [20] with fewer complications, shorter LOS, and lower transfusion rates. A more tempered review was presented by Novara et al. [21] examining perioperative outcomes and complications of RARC vs ORC. Analyses of 105 published articles showed lower transfusion rates and LOS, with a more limited beneficial effect on complication rates. In our own centre the introduction of RARC has resulted in a significant improvement in transfusion rate (19% vs 41%) and a 5 day reduction in LOS, when compared with the most recent ORC group (post-ERP II). These observations show the importance of limiting the initial surgical insult as part of any ERP.
Fig. 4 Bristol Urological Institute RC patient diary.
Day of Surgery
• • • • •
Sit up in bed □ Drink clear fluids Drink Fortijuce □ Chew gum □ Don't forget breathing exercises
Day 1 after Surgery
• • • • • • •
Sit out in chair □□ Walk around bed □□□ Drink free fluids □ Drink Fortisips or Fortijuce □□□ Chew gum □□□ Passed wind □ or Bowels open □ Don't forget breathing exercises
Day 2 after Surgery
• Sit out □□ • Walk around bed space and to bathroom □□□ • Start to eat a light diet □□□ • Drink Fortisips or Fortijuce □□□ • Chew gum □□□ • Passed wind □ or Bowels open □ • Don't forget breathing exercises
Day 3 after Surgery
• Dress in own clothes □ • Sit out □□ • Walk around room and to quiet room to collect Fortisip/Fortijuce □□□ • Light diet □□□ • Drink Fortisips or Fortijuce □□□ • Chew gum □□□ • Passed wind □ or Bowels open□ • Don't Forget Breathing exercises
Day 4 after Surgery
• Dress in own clothes □ • Walk around room and to the quiet room to collect Fortisip/Fortijuce □□□ • Light diet □□□ • Drink Fortisips and Fortijuces □□□ • Chew gum □□□ • Passed wind □ or Bowels open□ • Don't forget breathing exercises • You may be able to go home today
Day 5 after Surgery
• • • • • • • •
Dress in own clothes □ Walk freely around the ward □□□ Light diet □□□ Fortisips and Fortijuces □□□ Chew gum □□□ Passed wind □ or Bowels open□ Don't forget breathing exercises Today is your planned day of discharge
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For overall complication rates there appears at first glance to be a lower complication rate in the RARC group vs the postERP II ORC group, 31% vs 48%. A similarly higher complication rate is seen in the pre-ERP (48%) and post-ERP (44%) ORC groups. A similar positive trend in the RARC group is seen when examining specific Clavian–Dindo grades. However, these observations are not statistically significant. Although there are some dramatic differences in the outcomes of these patients, they are not as marked as we would have believed them to be when compared with previous ORC groups. There are a variety of factors that may explain this. The lack of statistical significance in terms of complication rates is partly due to the different numbers of patients in each group (102 vs 56). Furthermore, it is interesting to note that nearly half of all RARC patients now receive neoadjuvant chemotherapy (42% vs 3.6%), suggesting they may be less fit for surgery. However, one of the limitations of the present study is the inability to compare the groups with a robust indicator of fitness and risk of postoperative complications. The introduction of RARC has resulted in the single biggest reduction in LOS, but it is still only equivalent to several open series [22,23]. We would suggest that the explanation lies in the fact that our present ERP is aimed at the management of patients undergoing ORC, rather than one which embraces the benefits of minimally invasive surgery. Our ERP has therefore gone full-circle, with the need for a fundamental overhaul. We have already instituted several changes. For example, our anaesthetic approach now reflects the reduction in surgical stress, lower transfusion rate, and postoperative analgesic requirements (Fig. 3). Small incisions, minimal tissue damage, and bowel handling have lead a departure from epidural anaesthesia and the associated effects on fluid balance, bowel recovery, and mobilisation. Patients now choose between regular oral analgesia and patient-controlled analgesia for postoperative pain relief.
present study has limitations. The previous data on ORC groups are retrospective, and although each of the groups represent a number of consecutive patients they are not matched, which may obviously introduce bias. Inevitably the previous retrospective data will not be as accurate as the prospectively collected information on RARC patients. We would suggest the differences in complication rates would be more marked in favour of the RARC group; however, this is purely speculation. In conclusion, we found that the adoption of RARC, with full intracorporeal reconstruction, in our centre has led to the single biggest impact on our ERAS programme since the original inception. ERPs are multimodal interventions requiring a motivated multidisciplinary team. Although, the introduction of RARC has dramatically reduced the surgical stress of surgery, the present data shows that the full benefit of this approach cannot be achieved without full engagement of the entire team. We would therefore suggest that introduction of a RARC service into a centre is accompanied by a thorough review of the ERP.
Conflicts of Interest None disclosed.
References 1 2
3
4
5
We have re-aligned expectations of the postoperative course, with preoperative counselling and patient diaries now reflecting a potential discharge from day 3 onwards (Fig. 4). The additional consequence has been that multidisciplinary team members, such as stoma care, have accelerated their timetable, with stoma tuition occurring in the first 48 h postoperatively. We are also reviewing the need to routinely send all of our patients to intensive care postoperatively. A significant challenge is to ensure their prompt discharge back to the ward, as the intensive care environment is not designed for the rapid mobilisation and self-care that can be achieved with minimally invasive surgery.
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We have attempted to document the effect of RARC in our centre, by using previous data for comparison. As a result the
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Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78: 606–17 Eskicioglu C, Forbes SS, Aarts MA, Okrainec A, McLeod RS. Enhanced recovery after surgery (ERAS) programs for patients having colorectal surgery: a meta-analysis of randomized trials. J Gastrointest Surg 2009; 13: 2321–9 Pruthi RS, Chun J, Richman M. Reducing time to oral diet and hospital discharge in patients undergoing radical cystectomy using a perioperative care plan. Urology 2003; 62: 661–6 Pruthi RS, Nielsen M, Smith A, Nix J, Schultz H, Wallen EM. Fast track program in patients undergoing radical cystectomy: results in 362 consecutive patients. J Am Coll Surg 2010; 210: 93–9 Arumainayagam N, McGrath J, Jefferson KP, Gillatt DA. Introduction of an enhanced recovery protocol for radical cystectomy. BJU Int 2008; 101: 698–701 Koupparis A, Dunn J, Gillatt D, Rowe E. Improvement of an enhanced recovery protocol for radical cystecomy. Br J Med Surg Urol 2010; 3: 237–40 Cerantola Y, Valerio M, Persson B et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: enhanced Recovery After Surgery (ERAS((R))) society recommendations. Clin Nutr 2013; 32: 879–87 Khan MS, Challacombe B, Elhage O et al. A dual-centre, cohort comparison of open, laparoscopic and robotic-assisted radical cystectomy. Int J Clin Pract 2012; 66: 656–62 Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240: 205–13 Pisipati S, Bach C, Daneshwar D, Rowe EW, Koupparis AJ. Concurrent upper and lower urinary tract robotic surgery: a case series. Can Urol Assoc J 2014; 8: E853–8 Warren KS, Oxley J, Koupparis A. Pure malignant rhabdoid tumour of the bladder. Can Urol Assoc J 2014; 8: E260–2
RARC impact on an established enhanced recovery protocol
12 Lowrance WT, Rumohr JA, Chang SS, Clark PE, Smith JA Jr, Cookson MS. Contemporary open radical cystectomy: analysis of perioperative outcomes. J Urol 2008; 179: 1313–8 13 Menon M, Hemal AK, Tewari A et al. Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion. BJU Int 2003; 92: 232–6 14 Gondo T, Yoshioka K, Nakagami Y et al. Robotic versus open radical cystectomy: prospective comparison of perioperative and pathologic outcomes in Japan. Jpn J Clin Oncol 2012; 42: 625–31 15 Styn NR, Montgomery JS, Wood DP et al. Matched comparison of robotic-assisted and open radical cystectomy. Urology 2012; 79: 1303–8 16 Knox ML, El-Galley R, Busby JE. Robotic versus open radical cystectomy: identification of patients who benefit from the robotic approach. J Endourol 2013; 27: 40–4 17 Parekh DJ, Messer J, Fitzgerald J, Ercole B, Svatek R. Perioperative outcomes and oncologic efficacy from a pilot prospective randomized clinical trial of open versus robotic assisted radical cystectomy. J Urol 2013; 189: 474–9 18 Bochner BH, Dalbagni G, Sjoberg DD et al. Comparing open radical cystectomy and robot-assisted laparoscopic radical cystectomy: a randomized clinical trial. Eur Urol 2015; 67: 1042–50 19 Ishii H, Rai BP, Stolzenburg JU et al. Robotic or open radical cystectomy, which is safer? A systematic review and meta-analysis of comparative studies. J Endourol 2014; 28: 1215–23
20 Tang K, Xia D, Li H et al. Robotic vs. open radical cystectomy in bladder cancer: a systematic review and meta-analysis. Eur J Surg Oncol 2014; 40: 1399–411 21 Novara G, Catto JW, Wilson T et al. Systematic review and cumulative analysis of perioperative outcomes and complications after robot-assisted radical cystectomy. Eur Urol 2015; 67: 376–401 22 Dutton TJ, Daugherty MO, Mason RG, McGrath JS. Implementation of the Exeter enhanced recovery programme for patients undergoing radical cystectomy. BJU Int 2014; 113: 719–25 23 Shabsigh A, Korets R, Vora KC et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol 2009; 55: 164–74
Correspondence: Anthony Koupparis, Bristol Urological Institute, North Bristol NHS Trust, Southmead Hospital, Bristol BS10 5NB, UK. e-mail: [email protected] Abbreviations: ASA, American Society of Anesthesiologists; ERAS, enhanced recovery after surgery; ERP, enhanced recovery programme; LOS, length of stay; (O)(RA)RC, (open) (robot-assisted) radical cystectomy.
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Objectives To assess the impact of the introduction of robot-assisted radical cystectomy (RARC) on an established enhanced recovery programme (ERP) and to examine the effect on mortality and morbidity rates, transfusion rates, and length of stay (LOS).
Patients and Methods Data on 102 consecutive patients undergoing RARC with full intracorporeal reconstruction were obtained from our prospectively updated institutional database. These data were compared to previously published retrospective results from three separate groups of patients undergoing open radical cystectomy (ORC) at our centre. Our primary focus was perioperative outcomes including transfusion rate, complication rates, 30- and 90-day mortality rates, and LOS.
Results
American Society of Anesthesiologists grade. A significant reduction in transfusion rate was seen in RARC vs ORC (P < 0.001). The median LOS for the RARC group was 8 vs 13 days for the ORC group (P < 0.001). There was trend to a lower total complication rate (48% vs 31%). The 30- and 90-day mortality rates were equivalent between the groups (2%).
Conclusions Introduction of RARC and intracorporeal reconstruction represents the single biggest impact on our ERP, with significant reduction in transfusion rates and LOS, and a trend towards a lower complication rate.
Keywords robot-assisted radical cystectomy, enhanced recovery, bladder cancer
The demographics of the comparative groups showed no significant difference in age, gender distribution, and
Introduction Since the initiation of enhanced recovery after surgery (ERAS) by Professor Henrik Kehlet [1] in the 1990s, enhanced recovery programmes (ERPs) or ‘fast-track’ programmes have become an important focus of perioperative management after major surgery including open radical cystectomy (ORC) [2–4]. We previously described the impact on outcomes after ORC after the introduction of an ERP at a time when perioperative care was governed by surgical dogma rather than evidence base [5]. The protocol focuses on preoperative counselling, nutrition, standard analgesic and anaesthetic regimens, and early mobilisation, and has continued to develop over several years [6]. ERAS protocols modify the physiological and psychological responses to major surgery; however, limiting the initial
BJU Int 2015; 116: 924–931 wileyonlinelibrary.com
surgical insult for example with minimally invasive approaches is one of the key principles [7]. A significant change to our service was the introduction of robot-assisted RC (RARC) with intracorporeal reconstruction in 2010. This approach has the potential to reduce the surgical impact on patients undergoing RC, with less analgesia requirements, less blood loss, shorter length of stay (LOS), and quicker recovery [8]. It has subsequently evolved into the preferred approach for these patients in our institution. The present study aimed to assess the impact of RARC and intracorporeal reconstruction on an established ERP.
Patients and Methods An ERP was introduced in our institution on 1 October 2005. The effects on perioperative outcomes were examined by comparing 56 consecutive patients undergoing ORC before
© 2015 The Authors BJU International © 2015 BJU International | doi:10.1111/bju.13171 Published by John Wiley & Sons Ltd. www.bjui.org
RARC impact on an established enhanced recovery protocol
implementation (pre-ERP), and 56 consecutive ORC patients managed after its introduction (post-ERP) [5]. Significant alterations to the ERP were subsequently introduced in April 2009. The effects were examined again using a 56 consecutive patients managed on the original ERP immediately prior to the alterations, and 56 consecutive patients managed on the new ERP (post-ERP II) [6]. Our RARC service began in 2010 and we have performed >200 cases. For the present study, we have examined data from the 56 ORC patients from the preERP group, the post-ERP group, and the post-ERP II group. We have used these data to compare with perioperative outcomes of consecutive patients who underwent RARC with full intracorporeal reconstruction as part of our robotic urology service. Data on ORC were previously collected retrospectively from patient notes, cancer network, and hospital data. Data regarding patients undergoing RARC were collected from our prospectively updated institutional database. This information was cross-referenced for accuracy using North Bristol NHS Trust’s Information Systems department and Hospital Episodes Statistics data. Information was collected on patient demographics, mortality rates, complication rates graded to the modified Clavien–Dindo system [9], and LOS. Our statistical analyses focussed on the most contemporary group of patients undergoing ORC (post-ERP II group) and the RARC group. A descriptive analysis was performed and a comparison analysis between these groups was performed using a non-paired t-test for numerical variables, and chisquare and Fisher’s exact test were used for dichotomous and
categorical variables. A P < 0.05 was considered to indicate statistical significance. SPSSâ version 17.0 was used as statistical aid software, SPSS Inc., Chicago, IL, USA. Operative Approach All robotic procedures with intracorporeal reconstruction were performed by two surgeons (A.J.K. and E.W.R.), with extensive robotic experience. Our original aim was to provide intracorporeal reconstruction from the outset of our RARC service. The initial cases were performed as combined cases by two consultants, having already completed several hundred robotic cases. This team approach prevents surgeon fatigue and keeps console times down to a minimum. The mean (range) console time for the first 10 cases was 325 (300– 385) min. Our overall median (range) console time is 180 (120–400) min. For a training case we adopt a modular approach enabling console times to be kept to a maximum of 4 h (Fig. 1). If a prolonged procedure is required it is discussed at an early stage with the theatre team and we would routinely undock the robot, level the patient, and remove the pneumoperitoneum for a short period. If a concurrent nephroureterectomy is required, this is performed robotically before the RC as previously described [10]. The RC procedure involves a transperitoneal approach commencing with an extended lymph node dissection and careful ureteric dissection and division. This allows visualisation of the vesicle pedicles and easy transfer of the left ureter beneath the sigmoid colon. Vesicle pedicles are
Fig. 1 Bristol Urological Institute modular training scheme for RARC and intracorporeal ileal conduit, including console times (training orthotopic neobladder requires an additional 60 min). DVC, dorsal venous complex.
Sigmoid mobilisation
Posterior approach Lymph node dissection 90 min Ureteric dissection Ureteric transfer 4h Pedicles 60 min
Bladder removal Division DVC /urethra
Bowel anastamosis Reconstruction
90 min Ureteroileal anastamosis
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controlled with Weckâ Hem-o-lokâ clips in a step-wise approach towards the apex of the prostate gland in men and the pelvic sidewall in women. If oncologically and functionally appropriate preservation of the neurovascular bundle is performed in men. In appropriate female patients an organ-sparing approach is adopted with preservation of the ovaries, vagina, and para-vaginal tissues [11]. The dorsal venous complex and pelvic veins in women are appropriately controlled and the urethra managed to prevent tumour spillage. The specimen is placed in a retrieval bag and removed via the open vagina or removed at the end of the procedure in men via the camera port. A stented Bricker uretero-ileal anastomosis is made for intracorporeal ileal conduits and a modified Studer pouch performed for orthotopic neobladders.
significantly lower transfusion rate vs the ORC groups (P < 0.001). The complication rates graded to the modified Clavien–Dindo system are detailed in Table 3. Although there appears to be a trend towards a lower complication rate, this is was not found to be statistically significant. The trend in LOS over the last decade is shown as box plots in Fig. 2. There was a reduction in LOS with the introduction of our ERP (pre-ERP vs post-ERP); however, this remained stable despite several alterations (post-ERP vs post-ERP II). Introduction of our RARC service has lead to a significant reduction in LOS of 5 days (P < 0.001).
Discussion Results The demographics, summary of complication rates, mortality rates, and indications for surgery are shown in Tables 1 and 2. The statistical analysis between the RARC group and each of the ORC groups show no significant difference for age, gender, American Society of Anesthesiologists (ASA) grade, the type of urinary diversion, or indication for RC. Mortality rates and re-admission rates were comparable between the groups. The data shows a significant change in practice over recent years, with more routine use of neoadjuvant chemotherapy. There was a significant difference in the number of patients receiving neoadjuvant chemotherapy in the RARC group when compared with the ORC groups (P < 0.001). The minimally invasive nature of RARC is shown by the
ORC and urinary reconstruction remains a central pillar in the management of invasive bladder cancer. However, it is a complex procedure associated with significant risks of morbidity and mortality [12]. The present study shows the evolution of an ERP for RC over nearly a decade, with particular focus on the impact of a RARC with full intracorporeal reconstruction. The Bristol Urological Institute is one of the highest volume robotic urology centres in the UK, and the present data represents the largest UK series of RARC with intracorporeal reconstruction. The above data shows a significant reduction in transfusion rate and a significant reduction in LOS, consistent with a faster recovery time. RARC has been performed for over decade [13]. This minimally invasive approach subjects a patient to a decreased
Table 1 Demographic and operative details. Variable
Number of patients Men, n Women, n Mean (range) age, years Preoperative radiotherapy, n Preoperative chemotherapy, n (%) ASA score, n 1 2 3 Ileal conduit, n Orthotopic neobladder, n Transfusion rate, n (%) Overall complication rate, n (%) 30-day readmission, n 30-day mortality, n 90-day mortality, n
ORC Pre-ERP
Post-ERP
Post-ERP II
RARC
56 42 14 65.9 3 3 (5.4)
56 44 12 65.9 2 2 (3.6)
56 46 10 66.4 (37–83) 2 2 (3.6)
102 71 31 68.22 (18–86) 4 43 (42.2)
8 39 9 45 11 24 (43) 27 (48) 6 1 –
9 40 7 47 9 19 (34) 25 (44) 3 1 –
11 40 5 52 4 23 (41) 27 (48) 3 1 –
7 68 27 91 11 20 (19) 32 (31) 3 1 1
Light blue shading indicates statistically significant difference between RARC group when compared with each of the ORC groups, P < 0.001.
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RARC impact on an established enhanced recovery protocol
Table 2 Indications for RC in the most contemporary ORC group (postERP II) and the RARC group.
Fig. 2 Box plots of LOS (days) across all patients groups.
70 ORC post-ERP II, n
RARC, n
21 33 31 1 1 – – 2 – – – –
26 65 57 14 8 9 2 4 2 2 1 1
Non-muscle invasive Muscle invasive T2 T3 T4 N1 N2 Squamous cell carcinoma Small cell carcinoma Adenocarcinoma Rhabdoid tumour Benign
60 50 Length of stay (days)
Indication
40 30 20 10 0
pre-ERP
post-ERP
post-ERP II
RARC
Series
physiological stress, with less blood loss, reduced analgesic requirements, and a faster recovery [8]. However, it has been adopted in many centres, including our own without clear evidence of superiority. Our objective with the present data
was to examine the impact of RARC in our centre, which inevitably leads onto a discussion of the potential benefits of RARC vs ORC. This is a theme common to many
Table 3 Complication rates. Complication, n (%)
Overall Clavian–Dindo 1 2 3a Details
ORC Pre-ERP
Post-ERP
Post-ERP II
RARC
27 (48)
25 (44)
27 (48)
32 (31)
8 (14) 17 (30) 2 (4) Intra-abdominal collection requiring percutaneous drainage (2)
3 (5) 10 (18) 4 (7) Intra-abdominal collection requiring percutaneous drainage (1). Vesicovaginal fistulae managed with stents and prolonged drainage (3) 2 (4) Return to theatre for urine leak (1), post-op. bleeding (2), bowel obstruction (1)
2 (4) 16 (29) 4 (7) Pelvic collection drained percutaneously (3). Post-op. upper GI bleed treated with endoscopic injection (1)
9 (9) 14 (14) 3 (3) Sepsis and unilateral hydronephrosis requiring temporary nephrostomy (2). Pelvic collection drained percutaneously (1)
4 (7) Return to theatre for total abdominal wound dehiscence (2). Total abdominal wound dehiscence and extensive small bowel ischaemia (1). Vesico-vaginal fistula (1) –
3 (3) Return to theatre for apparent bleeding – no bleeding just irrigation fluid (1). Bleeding from dorsal venous complex (1). Re-fashion ischaemic conduit spout (1). Also developed pneumonia, sepsis and acute kidney injury 1 (1) Prolonged post-op. ventilation for 48 h
1 (1.8) Overwhelming sepsis from pseudomembranous colitis
2 (2) Laparotomy for small bowel anastomotic leak. Prolonged ITU stay requiring invasive ventilation and haemofiltration. Discharged from ITU with subsequent cardiac arrest post-op. day 63 Laparotomy for extensive small bowel ischaemia and prolonged ITU stay for respiratory and nutritional support. Developed pneumonia on ward and died post-op. day 42
3b Details
3 (5) Return to theatre for urine leak (2). Repair of initial vaginal closure (1)
4
1 Asystolic arrest immediately post-op, requiring prolonged ITU admission (1) 1 (1.8) Myocardial infarction day post-op. day 7
Details
5 Details
–
1 (1.8)
Post-op., postoperative; ITU, Intensive Therapy Unit.
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publications relating to the outcomes of RARC, and is particularly topical currently as national bodies within the UK NHS are reviewing the provision of robotic surgical procedures, and in particular RARC. In terms of published data examining the benefit of RARC over ORC, the picture is inconsistent. There have been a variety of case series, matched-cohorts, and prospective
studies examining this area [8,14–17]. They all report a significant reduction in blood loss and transfusion rates of 40–8% to 0–5%. LOS varies from equivalence with ORC [17], to reductions of 8.3 days [8]. Similarly, complications rates have been reported as equivalent [17], significantly reduced with RARC [8,14], or even increased [15].
Fig. 3 Schematic diagram showing the anaesthetic approach for RARC and ORC.
Open Cystectomy
Preoperative carbohydrate drinks
Perioperative management Invasive montioring Arterial line Central line Thoracic epidural unless contraindicated
Intraoperative management Consider goal directed fluid therapy Consider intraoperative cell salvage in high risk cases Arterial blood gas assessment of metabolic state
Postoperative management High dependency care post op Avoid NG tube High depency care post op Regular paracectamol Epidural analgesia
Robotic Cystectomy
Preoperative carbohydrate drinks
Perioperative mangement Consider gabapentin or pregabalin preoperatively Invasive montioring Arterial line Consider central line in highrisk cases
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Intraoperative management Consider goal directed fluid therapy Arterial blood gas assessment of metabolic state IV Magnesium 2g
Postoperative management Consider HDU post op for high-risk cases Avoid NG tube Regular paracectamol Either oxycontin bd with oromorph for breakthrough OR PCA oxycodone 1mg bolus 5 min lockout
RARC impact on an established enhanced recovery protocol
Randomised data is relatively scarce; Parekh et al. [17] published the results from 40 patients who were randomised between the two approaches and found a similar LOS (6 days) and complication rate (25%), with a slightly reduced transfusion rate of 50% vs 40% in favour of RARC. A similar picture is seen from a recent publication from Memorial-Sloan-Kettering [18]; data from 118 patients randomised between ORC and RARC showed a comparable LOS (8 days) and similar perioperative outcomes (21% vs 22% Clavian grade 3–5, RARC vs ORC). Several recent systematic reviews have attempted to provide a clearer picture of the outcomes of the two approaches. Ishii et al. [19] examined published data on 748 patients between 2000 and 2013. They found lower high-grade complications
and mortality rates associated with RARC, with an expected lower transfusion rate. A similar picture was presented by Tang et al. [20] with fewer complications, shorter LOS, and lower transfusion rates. A more tempered review was presented by Novara et al. [21] examining perioperative outcomes and complications of RARC vs ORC. Analyses of 105 published articles showed lower transfusion rates and LOS, with a more limited beneficial effect on complication rates. In our own centre the introduction of RARC has resulted in a significant improvement in transfusion rate (19% vs 41%) and a 5 day reduction in LOS, when compared with the most recent ORC group (post-ERP II). These observations show the importance of limiting the initial surgical insult as part of any ERP.
Fig. 4 Bristol Urological Institute RC patient diary.
Day of Surgery
• • • • •
Sit up in bed □ Drink clear fluids Drink Fortijuce □ Chew gum □ Don't forget breathing exercises
Day 1 after Surgery
• • • • • • •
Sit out in chair □□ Walk around bed □□□ Drink free fluids □ Drink Fortisips or Fortijuce □□□ Chew gum □□□ Passed wind □ or Bowels open □ Don't forget breathing exercises
Day 2 after Surgery
• Sit out □□ • Walk around bed space and to bathroom □□□ • Start to eat a light diet □□□ • Drink Fortisips or Fortijuce □□□ • Chew gum □□□ • Passed wind □ or Bowels open □ • Don't forget breathing exercises
Day 3 after Surgery
• Dress in own clothes □ • Sit out □□ • Walk around room and to quiet room to collect Fortisip/Fortijuce □□□ • Light diet □□□ • Drink Fortisips or Fortijuce □□□ • Chew gum □□□ • Passed wind □ or Bowels open□ • Don't Forget Breathing exercises
Day 4 after Surgery
• Dress in own clothes □ • Walk around room and to the quiet room to collect Fortisip/Fortijuce □□□ • Light diet □□□ • Drink Fortisips and Fortijuces □□□ • Chew gum □□□ • Passed wind □ or Bowels open□ • Don't forget breathing exercises • You may be able to go home today
Day 5 after Surgery
• • • • • • • •
Dress in own clothes □ Walk freely around the ward □□□ Light diet □□□ Fortisips and Fortijuces □□□ Chew gum □□□ Passed wind □ or Bowels open□ Don't forget breathing exercises Today is your planned day of discharge
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For overall complication rates there appears at first glance to be a lower complication rate in the RARC group vs the postERP II ORC group, 31% vs 48%. A similarly higher complication rate is seen in the pre-ERP (48%) and post-ERP (44%) ORC groups. A similar positive trend in the RARC group is seen when examining specific Clavian–Dindo grades. However, these observations are not statistically significant. Although there are some dramatic differences in the outcomes of these patients, they are not as marked as we would have believed them to be when compared with previous ORC groups. There are a variety of factors that may explain this. The lack of statistical significance in terms of complication rates is partly due to the different numbers of patients in each group (102 vs 56). Furthermore, it is interesting to note that nearly half of all RARC patients now receive neoadjuvant chemotherapy (42% vs 3.6%), suggesting they may be less fit for surgery. However, one of the limitations of the present study is the inability to compare the groups with a robust indicator of fitness and risk of postoperative complications. The introduction of RARC has resulted in the single biggest reduction in LOS, but it is still only equivalent to several open series [22,23]. We would suggest that the explanation lies in the fact that our present ERP is aimed at the management of patients undergoing ORC, rather than one which embraces the benefits of minimally invasive surgery. Our ERP has therefore gone full-circle, with the need for a fundamental overhaul. We have already instituted several changes. For example, our anaesthetic approach now reflects the reduction in surgical stress, lower transfusion rate, and postoperative analgesic requirements (Fig. 3). Small incisions, minimal tissue damage, and bowel handling have lead a departure from epidural anaesthesia and the associated effects on fluid balance, bowel recovery, and mobilisation. Patients now choose between regular oral analgesia and patient-controlled analgesia for postoperative pain relief.
present study has limitations. The previous data on ORC groups are retrospective, and although each of the groups represent a number of consecutive patients they are not matched, which may obviously introduce bias. Inevitably the previous retrospective data will not be as accurate as the prospectively collected information on RARC patients. We would suggest the differences in complication rates would be more marked in favour of the RARC group; however, this is purely speculation. In conclusion, we found that the adoption of RARC, with full intracorporeal reconstruction, in our centre has led to the single biggest impact on our ERAS programme since the original inception. ERPs are multimodal interventions requiring a motivated multidisciplinary team. Although, the introduction of RARC has dramatically reduced the surgical stress of surgery, the present data shows that the full benefit of this approach cannot be achieved without full engagement of the entire team. We would therefore suggest that introduction of a RARC service into a centre is accompanied by a thorough review of the ERP.
Conflicts of Interest None disclosed.
References 1 2
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We have re-aligned expectations of the postoperative course, with preoperative counselling and patient diaries now reflecting a potential discharge from day 3 onwards (Fig. 4). The additional consequence has been that multidisciplinary team members, such as stoma care, have accelerated their timetable, with stoma tuition occurring in the first 48 h postoperatively. We are also reviewing the need to routinely send all of our patients to intensive care postoperatively. A significant challenge is to ensure their prompt discharge back to the ward, as the intensive care environment is not designed for the rapid mobilisation and self-care that can be achieved with minimally invasive surgery.
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We have attempted to document the effect of RARC in our centre, by using previous data for comparison. As a result the
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Correspondence: Anthony Koupparis, Bristol Urological Institute, North Bristol NHS Trust, Southmead Hospital, Bristol BS10 5NB, UK. e-mail: [email protected] Abbreviations: ASA, American Society of Anesthesiologists; ERAS, enhanced recovery after surgery; ERP, enhanced recovery programme; LOS, length of stay; (O)(RA)RC, (open) (robot-assisted) radical cystectomy.
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