Elsevier

European Urology

Volume 70, Issue 4, October 2016, Pages 649-660
European Urology

Review – Bladder Cancer
Enhanced Recovery After Robot-assisted Radical Cystectomy: EAU Robotic Urology Section Scientific Working Group Consensus View

https://doi.org/10.1016/j.eururo.2016.05.020Get rights and content

Abstract

Context

Radical cystectomy (RC) is associated with frequent morbidity and prolonged length of stay (LOS) irrespective of surgical approach. Increasing evidence from colorectal surgery indicates that minimally invasive surgery and enhanced recovery programmes (ERPs) can reduce surgical morbidity and LOS. ERPs are now recognised as an important component of surgical management for RC. However, there is comparatively little evidence for ERPs after robot-assisted radical cystectomy (RARC). Due to the multimodal nature of ERPs, they are not easily validated through randomised controlled trials.

Objective

To provide a European Association of Urology (EAU) Robotic Urology Section (ERUS) policy on ERPs to guide standardised perioperative management of RARC patients.

Evidence acquisition

The guidance was formulated in four phases: (1) systematic literature review of evidence for ERPs in robotic, laparoscopic, and open RC; (2) an online questionnaire survey formulated and sent to ERUS Scientific Working Group members; (3) achievement of consensus from an expert panel using the Delphi process; and (4) a standardised reporting template to audit compliance and outcome designed and approved by the committee.

Evidence synthesis

Consensus was reached in multiple areas of an ERP for RARC. The key principles include patient education, optimisation of nutrition, RARC approach, standardised anaesthetic, analgesic, and antiemetic regimens, and early mobilisation.

Conclusions

This consensus represents the views of an expert panel established to advise ERUS on ERPs for RARC. The ERUS Scientific Working Group recognises the role of ERPs and endorses them as standardised perioperative care for patients undergoing RARC. ERPs in robotic surgery will continue to evolve with technological and pharmaceutical advances and increasing understanding of the role of surgery-specific ERPs.

Patient summary

There is currently a lack of high-level evidence exploring the benefits of enhanced recovery programmes (ERPs) in patients undergoing robot-assisted radical cystectomy (RARC). We reported a consensus view on a standardised ERP specific to patients undergoing RARC. It was formulated by experts from high-volume RARC hospitals in Europe, combining current evidence for ERPs with experts’ knowledge of perioperative care for robotic surgery.

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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