Narcotic Avoidance After Robotic Radical Cystectomy Allows Routine of Only Two-Day Hospital Stay

To evaluate the outcomes of a narcotic-sparing clinical pathway after robotic-assisted radical cystectomy (RARC) with ileal conduit targeting discharge on postoperative day #2 and report postoperative narcotic consumption, pain scores, and the resulting length of stay (LOS).

We reviewed a single-surgeon series of consecutive RARCs between August 2015 and September 2020. Acetaminophen and ketorolac were given with thorough patient education reserving oral narcotics for breakthrough pain. Intravenous narcotics were intentionally excluded from postoperative orders. Alvimopan was given once it became available. Subcutaneous ropivacaine pain pumps were removed before discharge. Discharge criteria included diet, oral analgesia, ambulation, and bowel function. Narcotic use and pain scores were evaluated to deternine the success of the applied narcotic-avoidance strategy.

None of the 54 patients required intravenous narcotics postoperatively, and 19 patients (35%) never required even oral narcotics. Mean pain scores were higher in patients who required oral narcotics (4.3/11 vs 3.0/11, P = .001, respectively). Among 35 patients who received narcotics, mean tablets taken were 4.3/d (range, 1-13) with 68% using 8 or less tablets during their entire LOS. Mean LOS was 2.1 d (range 1-4). Five patients (9%) were discharged on POD#1, 37/54 (68.5%) on POD #2, 10/54 (18.5%) on POD#3 and 2/54 (4%) on POD #4. Eight patients (15%) were readmitted within 90 days.

Minimizing narcotics after RARC with conduit allowed for a 2-day LOS in the majority of patients and the shortest ever reported mean LOS after cystectomy, essentially halving hospitalization time. Patient education is critical to minimizing narcotic usage.