Introduction

Radical cystectomy is the standard surgical treatment for muscle-invasive bladder cancer associated with substantial morbidity, prolonged hospital stay and mortality. We report a case series from an institution with a de novo cystectomy service. Our aim was to evaluate enhanced recovery after surgery protocol (ERP), focusing on length of stay (LOS), early complication and readmission rates, as key performance indicators that attest to quality of care after robotic assisted radical cystectomy (RARC).

Methods

Between April 2013 and October 2015, 150 (124 male and 26 female) patients underwent RARC with newly devised multimodal ERP in a new regional referral centre. On discharge patients were expected to return to their homes, support by family and friends is encouraged, however special nursing services were not provided.

Results

The median age was 70 years old, 74% of cases had a Body Mass Index (BMI) <30kg/m2, 53% a CardioPulmonary Exercise Test anaerobic threshold <11 and 86% American Anaesthesiology Score (ASA) score ≤2. The median LOS was 5 days (1st IQR 4 3rd IQR 7). 61% of the patients left hospital between day 3 and 5. Post-operative day 4 was the most frequent day of discharge from hospital. Age (p=0.003) and complications (p<0.001) were the only factors that showed a statistically significant association with the 4-day LOS cut-off. The incidences of post-treatment complications were 42% (63 of 150) for minor (Clavien-Dindo grade <3) and 8% (12 of 150) for major (≥ 3). There was only one death within 30 days of surgery. The incidence of readmission to hospital 30 days after operation was 14% (24 of 150). We found complications (p=0.005) and intra/ extra corporeal diversion (p=0.028) to be significantly associated with readmission.

Conclusions

Our multimodal stepwise approach to RARC and ERAS with the holistic care of the patient and involvement of the patient&[prime]s family and social surroundings leads to an unprecedented and reproducibly low LOS. Elderly patients should receive preoperative counselling about their increased risk of longer hospital stay, optimisation through prehabilitation programs and closer perioperative monitoring

Funding

None