Implementation of enhanced recovery after surgery protocols to robotic assisted radical cystectomy with intracorporeal urinary diversion using orthotopic U-shape ileal neobladder

Objective To discuss outcome and safety after implementation of enhanced recovery after surgery(ERAS) protocols to patients who underwent robotic assisted radical cystectomy(RARC) with intracorporeal orthotopic "U" shaped ileal neobladder creation using STAPLER technique. Methods Between October 2014 and April 2019, 71 patients(59 males and 12 females)with MIBC(Muscle Invasive Bladder Cancer) who underwent RARC with intracorporeal urinary diversion using orthotopic "U" shaped ileal neobladder in Zhejiang Provincial People's Hospital(People's Hospital of Hangzhou Medical College)were studied retrospectively. They had an average age of (65.2±5.6)y and BMI of (22.18±3.75)kg/m2. The median age-adjusted charlson comorbidity index(aCCI) was 4, median ASA score was 2. All patients underwent these inspections pre-RARC: chest Xray, vascular ultrasound(jugular vein included), abdominal ultrasound, CT urography, cystoscopy with biopsy or TURBT(trans-urethral resection of a bladder tumour). All patients were pathological diagnosed with MIBC, with no evidence of systemic metastasis and no history of radiotherapy, systemic chemotherapy and open abdominal surgery before RARC. All 71 patients received RARC with intracorporeal orthotopic "U" shaped ileal neobladder creation using STAPLER technique. Between October 2014 and September 2016, 37 cases(29 males and 8 females) were managed without ERAS protocols perioperatively. They had an average age of (65.3±5.7)y and BMI of (23.66±3.47)kg/m2. The median aCCI was 4, median ASA score was 2. Between October 2016 and April 2019, another group of 34 cases (30 males and 4 females) were managed with ERAS protocols including nutritional assessment, thrombosis prevention, pain assessment and management, perioperative diet management etc. They had an average age of (64.5±4.3)y and BMI of (21.87±4.85)kg/m2. The median aCCI was 4, median ASA score was 2. There were no statistical significance between the two groups with regard to general information. Surgical and follow-up data were collected for all patients. Results Surgeries were successful in all 71 cases with postoperative follow up for 3-51 months. In ERAS group, there were 22 cases in pT2 and 12 cases pT3 according to classification of malignant tumours: with 2 cases of incidental prostate cancer (IPCa). In non-ERAS group, pT2 in 25 cases and pT3 in 12 cases: with 1 case of IPCa. Statistical significance were observed between groups with regard to the first anal exhaust time [(20.5±18.7)h vs.(29.9±17.4)h, P=0.032], the first defecation time [(72.6±27.1)h vs.(88.7±35.8)h, P=0.004], length of hospital stay after surgey [(14.1±3.3)d vs.(16.2±4.8)d, P=0.037], numeric rating scales (NRS) Pain Score 8.0, 24.0, 48.0 h after surgery [(3.2±0.5)vs.(3.6±0.8), P=0.015; (1.9±0.3)vs.(2.2±0.6), P=0.011; (1.3±0.4)vs.(1.6±0.7), P=0.032], respectively. There were no significance between groups with regard to operating time [(290±65)min vs.(282±46)min, P=0.549], intraoperative blood loss [(190.5±235.6)ml vs.(221.1±250.3)ml, P=0.438], transfusion rate [5.9%(2/34)vs. 8.1%(3/37), P=0.922], readmission within 30 days after surgery [2.9%(1/34)vs. 5.4%(2/37), P=0.940], early severe complications(within 30 days) [2.9%(1/34)vs. 2.7%(1/37), P=0.940], late severe complications (after 30 days) [5.9%(2/34)vs. 8.1%(3/37), P=0.922]. Conclusions The implementation of ERAS protocols to patients who underwent RARC with intracorporeal orthotopic "U" shaped ileal neobladder using STAPLER technique is safe and effective. It can reduce postoperative pain and hospital stay, shorten bowel recovery time, improve early functional recovery without increasing major complications. This adoption should be encouraged. Key words: Urinary bladder neoplasms; Enhanced recovery after surgery(ERAS); Urinary bladder cancer; Pure robotic-assisted; Radical cystectomy; Perioperative; Orthotopic U-shape ileal neobladder