Introduction. The «gold standard» in the complex surgical treatment of muscle-invasive bladder cancer (BC) is radical cystectomy (RCE), however, early postoperative complications after it reach 70%. In this regard, the use of the protocol for accelerated recovery of patients after surgery (ERAS) in case of RCE is highly relevant from a practical and scientific point of view.The goal of the study was to compare outcomes obtained with the ERAS (enhanced recovery after surgery) protocol in patients undergoing radical cystectomy.
Materials and methods: This comparative study included 132 patients (108 males (81.8%) and 24 females (18.1%)), who underwent RCE performed by the same surgeon at the Pirogov RNRMU Urology Clinic (Pirogov Municipal Clinical Hospital No. 1) from august 2011 to July 2019. Since 2015, all patients treated with radical cystectomy were managed according to the ERAS (enhanced recovery after surgery) protocol. The mean age of patients was 65.5 (32-85) years, with a men to women ratio of 5:1. To allow comparative analysis, all patients were divided into 2 groups: Group 1 was treated according to the ERAS protocol and comprised 73 patients (55.3%), while Group 2 was managed without the ERAS protocol and consisted of 59 patients (44.6%).
Results: 70 complications (53%) were observed within a 90-day postoperative period: according to the Clavien–Dindo classification, grade I-II complications were seen in 40 patients (30.%), while grade III-IV complications were observed in 30 subjects (22.7%).The mortality rate within the early postoperative period (90 days) was 9.8% (13 deaths). In this study, the use of the ERAS protocol in patients undergoing RCE resulted in a 21.9% reduction in the incidence of Clavien–Dindo grade I-II complications compared with the no ERAS group (40.6%) (р <0,05). Clavien–Dindo grade III-IV complications were more common with the ERAS protocol: 24.6% of all cases vs. 20.3% in the no ERAS group. There is no statistically significant difference in the mortality rate in both groups of patients. The 90-day readmission rate was higher in the ERAS group (21.9%). It should be underlined that the applying of the ERAS protocol decreased the hospital stay by 3.2 days on the average and shortened the time to bowel activation by 2.1 days on the average in the first group using the protocol of accelerated recovery.
Discussion: The desire to reduce the risks of postoperative complications after RCE, the search and analysis of effective methods of treating complications, the need to reduce the length of hospital stay led to the development of the ERAS protocol and its use in RCE. The literature has demonstrated the cost-effectiveness of applying the protocol for the accelerated rehabilitation of patients after RCE, reducing the number of complications in the postoperative period, and fewer re-hospitalizations, which is also confirmed by the results of our study.
Conclusion: The use of the ERAS protocol in RCE allows to reduce the incidence of early postoperative surgical complications, however, despite the use of the ERAS protocol, the RCE re-mains an operation of a high complexity category and is associated with a high frequency of com-plications.
Conflict of interest. The authors declare no conflict of interest.