Review – Bladder CancerEnhanced Recovery After Robot-assisted Radical Cystectomy: EAU Robotic Urology Section Scientific Working Group Consensus View
Introduction
An enhanced recovery programme (ERP) describes a standardised multimodal perioperative care pathway that aims to minimise the physiologic and psychological stress effects of surgery. ERPs are also known as enhanced recovery after surgery (ERAS) or fast-track surgery programmes. The concept of ERAS was first introduced in the 1990s in colorectal surgery as a means to improve postoperative recovery and shorten length of stay (LOS) [1].
Despite improvements in care, radical cystectomy (RC) continues to be associated with frequent morbidity, high complication rates, and prolonged LOS [2], [3]. The goal of a modern ERP is to have a positive impact on patient care from diagnosis, through surgery, to return of normal function. However, there is a lack of high-level evidence for ERPs following RC, and hence many principles applied to ERP in urologic practice have been imported from colorectal surgery [4].
There is increasing evidence from open colorectal surgery research that implemented ERPs can successfully reduce complication rates, LOS, and the time taken to get back to normal activities following major pelvic surgery [5]. It is also recognised that minimally invasive surgery (MIS) reduces the surgical stress response compared with open surgery [6]. Robot-assisted radical cystectomy (RARC) aligns itself with the original stated principles of enhanced recovery that MIS is advantageous to aid quicker patient recovery [7].
Several meta-analyses have highlighted that RARC compared with open RC decreases blood loss and transfusion rates, has a shorter time to normal diet, and reduces LOS [2], [8], [9]. RARC has also been found to be advantageous in patient groups susceptible to complications, such as the elderly [10]. An approach that combines robotic surgery with an ERP optimised for RARC patients has the potential to further improve patient outcomes. However, due to the multimodal nature of ERPs and inability to blind, they are difficult to study in randomised controlled trials (RCTs) [11]. Given current levels of evidence for the benefits of ERPs, there are also ethical issues with performing RCTs [11]. Therefore, to address the gaps in knowledge on how best to combine current evidence for ERPs with the evidence for patient management specific to robotic surgery, the European Association of Urology (EAU) Robotic Urology Section (ERUS) Scientific Working Group formed a panel of experts to formulate the guidelines for an ERP specifically designed for patients undergoing RARC.
The purpose of this paper was to examine current evidence for ERPs for RC, seeking to assess critically the depth and breadth of implementation of the current ERAS society guidelines for RC [4]. We also sought an expert panel consensus view on whether an optimised ERP for robotic surgery might differ from current ERAS guidelines for open RC. Additional future goals of this task force are to collect prospective audit data on ERP implementation. There is a potential need for both the adaptation of current ERPs that are tailored to the specifics of robotic surgery and standardised reporting templates. Such a reporting template would enable comparison of outcomes between centres, assess implementation, and provide a structure for quality assessment of future interventions. Our consensus statement therefore aims to guide health care providers on the important elements of a standardised ERP that is specific to RARC and provide a suitable reporting template.
Section snippets
Materials and methods
In April 2015, the ERUS Scientific Working Group established a working panel tasked with formulating a consensus view on an ERP optimised for patients undergoing RARC. Chaired by Peter Wiklund, the expert panel included ERUS members with a specialist interest in robotic cystectomy surgery and/or enhanced recovery protocols.
The project was carried out in four phases: (1) a systematic literature review of current evidence for ERPs in robotic, laparoscopic and open RC was completed; (2) a survey
Formulation of guidance
Consensus was reached in multiple areas of an ERP for RARC. Table 3 summarises the main findings.
Preoperative counselling and patient education
Preoperative verbal and written information for patients and their caregivers is important for both knowledge and to ensure compliance. Information should include details on the operation, hospital stay, a description of the ERP, discharge criteria, stoma care information for conduit patients, and catheter care information for neobladder patients. Comprehensive patient information has been shown to
Conclusions
This consensus view was formulated by an expert panel specifically assembled by the ERUS Scientific Working Group. There was consensus that an optimised ERP for RARC differs from an ERP designed for either colorectal patients or open RC patients. Recognised differences to an ERP designed for RARC, compared with open surgery, include a minimally invasive approach, less blood loss, avoidance of epidural, earlier mobilisation, and reduced postoperative analgesia requirements. A standardised
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