Objectives: Radical cystectomy is the standard surgical treatment for muscle-invasive bladder cancer associated with considerable surgical morbidity, prolonged hospital stay and mortality. Our aim was to report treatment outcomes after robotic assisted radical cystectomy (RARC) with enhanced recovery protocol (ERP), focusing on length of stay (LOS), complication and readmission rates, as objective measures of quality of care.
Methods: After the establishment of a tertiary referral centre in April 2013, 175 (142 male and 33 female) patients underwent RARC with newly devised multimodal ERP. On discharge patients are expected to return to their homes, support by family and friends are encouraged, however special nursing services are not provided. Prospectively collected demographic, operative and perioperative data were analysed.
Results: The median age at treatment was 71 years old, 73% had a BMI <30kg/m2, 27.4% a CPET anaerobic threshold <11 and 84.3% an ASA score ≤2. The median LOS was 5 days (1st-3rd IQR: 4-7 days). 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 a 4-day LOS. The incidence of post-treatment complications was 40% (70 of 175) for minor (Clavien-Dindo grade ≤II) and 8% (14 of 175) for major (grade ≥III) complications. There was one death (0.67%) within 30 days of surgery. Readmission 90 days after surgery occurred in 26 (15%) cases and significantly associated with treatment complications.
Conclusion: A multidisciplinary perioperative ERP after RARC resulted in a LOS of four days in the largest proportion of patients and low rates of major complications and readmission. Our holistic approach to minimally invasive radical cystectomy with engagement of a finely tuned team in key principles of ERP allows for reproducible outcomes in a high-volume center over and above that achieved by each factor alone.