Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) study

JE. Baack Kukreja, M Kiernan, B Schempp, A Siebert, A Hontar, B Nelson, J Dolan, K Noyes, A Dozier, A Ghazi, HH. Rashid, G Wu, EM. Messing. Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) study. British Journal of Urology International Volume 119, Issue 1. January 2017 Pages 38-49

What is already known:

Radical cystectomy is on paper one of the surgeries most suited to benefit from a comprehensive ERAS programme – elderly population, long lengths of hospital stay and high morbidity rates. Despite this uptake of ERAS programmes have been slow.

What this paper adds:

This US study analysed sequential patents before and after the introduction of an ERAS protocol in their institution using a propensity matched approach. They used a comprehensive ERAS programme including pre-operative counselling focusing on stoma care and discharge planning, carbohydrate loading and probiotics; intraoperative fluid management and “avoidance of salt and fluid overload” – using either pulse pressure variation or oesophageal Doppler, opiate avoiding analgesia – epidural for open procedure and local anaesthesia for laparoscopic surgery, they also included the use of oral alvimopan (a peripheral acting -opioid antagonist); with early mobilisation and early oral nutrition postoperatively. They demonstrated a significant reduction in hospital length of stay (5 vs 8 days, p<0.001), with no change in complications (although ileus rates were decreased) but also importantly showed no change readmission rates. Interestingly given the goal to avoid salt and fluid overload there was no difference in the amount of fluid given (both groups received on average 6 litres of fluid intraoperatively), but despite this the ileus rate still improved.

Chris Jones, Guildford.


ERAS for robotic assisted radical cystectomy surgery

Collins JW, Adding C, Hosseini A, Nyberg T, Pini G, Dey L, Wiklund PN. Introducing an enhanced recovery programme to an established totally intracorporeal robot-assisted radical cystectomy service. Scand J Urol. 2016;50(1):39-46.

What is already known:

Radical cystectomy is a high risk procedure, with high morbidity and high readmission rates. The ERAS society have previously published guidelines for this procedure (link).

What this paper adds:

The authors from the Karolinska Institute in Sweden describe the effects of starting a comprehensive ERAS programme in an already established centre for robotic assisted radical cystectomy. Despite the average age and ASA grade increasing they still showed a small but statistically significant reduction in length of stay (9 to 8 days), however there was no difference in 30 day complication or readmission rates.

Chris Jones, Guildford.


Radical Cystectomy and GI complications

Djaladat H, Daneshmand S. Gastrointestinal Complications in Patients Who Undergo Radical Cystectomy withEnhanced Recovery Protocol. Curr Urol Rep. 2016 Jul;17(7):50.

What is already known:

Gastro-intestinal complications are the most frequent after radical cystectomy – up to 30% of patients will experience major GI complications (including severe post-operative ileus requiring a nasogastric tube). This study is a review of how ERAS programs can affect GI complications after radical cystectomy. You can view the ERAS guidelines for cystectomy here.

What this paper adds:

The authors report an impressively low rate of severe post-operative ileus (6%), with a comprehensive ERAS program as well as the regular use of prokinetics and peripherally acting mu-opioid receptor antagonists. The authors also conduct a review of the pathophysiology and management of the common GI complications – post-operative ileus, nausea and vomiting.

Chris Jones, Guildford.


Perceptions versus reality, do we do what we think we do?

Baack Kukreja JE, Messing EM, Shah JB. Are we doing “better”? The discrepancy between perception and practice of enhanced recovery after cystectomy principles among urologic oncologists. Urol Oncol. 2016 Mar;34(3):120.e17-21.

What is already known?

ERAS society has published guidelines for patients undergoing radical cystectomy. (Link) But the uptake of ERAS programs in the US is unclear, so this study attempted to survey US cystectomy surgeons to establish current perioperative care. 

What this paper adds?

The authors had a 50% overall response rate from the survey, with 64% stating that they were following ERAS principles. However this study found that only 20% of respondents actually practiced all elements.

High adherence to the ERAS protocol may be associated with improved 5-year cancer-specific survival after colorectal cancer surgery (Gustafsson 2016). Whilst we do not know that this can be applied to cystectomy surgery, more work needs to be done to improve this low compliance rate.

Chris Jones, Guildford.