Background
Radical Cystectomy (RC) with intestinal urinary diversion represents a challenging surgical procedure and it is affected by relevant perioperative mortality and morbidity. In order to improve perioperative outcomes and to lower the length of hospital stay, traditional management has been implemented over years by several Enhanced recovery after surgery (ERAS) and Fast Track (FT) protocols. The aim of this study is to compare perioperative outcomes of patients who underwent our Fast Track protocol and patients who followed a standard schedule at the same single, tertiary Centre.
Materials and Methods
We prospectively collected data from patients with Bladder Cancer (BC) and who underwent RC with intestinal urinary diversion at our institution between January 2016 and January 2019. After a preliminary evalutation and according to protocol compliance, patients were submitted to the Fast Track protocol or assigned to the control group. Primary outcomes were: post-operative vomiting, time from surgery to first flatus, time to defecation, post- operative pain, 30-days and 30 to 90-days complication rates, hospitalization and readmission within 90 days. Differences in categorical and continuous variables were analyzed using the chi squared test and the Mann-Whitney U-test, respectively.
Results
Overall 191 patients underwent RC with intestinal urinary diversion at our institution during the study period. 75 patients (39%) followed the FT protocol and 116 (61%) the standard preparation. No significant differences were found between the two groups in terms of age, gender, BMI, Charlson comorbidity index, clinical stage and grade, urinary diversion type, operative time, intraoperative blood transfusion, pathologic stage and grade, number of lymph nodes removed, nodal status and postoperative pain. Patients in the FT group had faster time to flatus (2 vs. 3 days p<0.001) and defecation (5 vs. 6 days p=0.006), shorter hospitalization (12 vs. 14 days p=0.008) and lower 90-days readmission rate (8% vs. 19% p=0.04). Overall and Clavien-stratified 30-days complication rates were similar between the two groups, while the overall 30 to 90-days complication rate was lower in the FT group (6.7% vs. 21.6%, p=0,006).
Conclusions
Bladder Cancer often requires a complex surgical approach, which is nowadays affected by consistent mortality and morbidity. Compared with a standard perioperative management, our Fast Track Protocol did not have a significant impact on pre and intra-operative outcomes, but it allowed to achieve important functional post-operative outcomes, such as a shorter time to canalization and a feasible opiod-sparing analgesia. It also contributed to reduce patients hospitalization and readmission. Finally, our Protocol did not increase post-operative acute complications, while it was associated with a lower rate of post-operative subacute complications.
