Impact of Enhanced Recovery after Surgery^® Protocol Compliance on Length of Stay, Bowel Recovery and Complications...

Despite existing standardized surgical techniques and the development of new perioperative care protocols, radical cystectomy (RC) morbidity remains a serious challenge for urologists. Postoperative ileus (POI) is one of the most common postoperative complications, often leading to a longer length of stay (LOS). The aim of our study was to assess the impact of compliance to the Enhanced Recovery After Surgery (ERAS^®) protocol on bowel recovery, 30-day complications and LOS after RC for bladder cancer (BC).

Data from consecutive patients undergoing RC for BC within an ERAS^® dedicated protocol were analyzed. Exclusion criteria were urinary diversion other than ileal conduit and palliative RC. Patients were divided into two groups according to their compliance (A: low-compliance and B: high-compliance). ERAS^® compliance was extracted from the ERAS^® Interactive Audit System (EIAS) database. Postoperative complications were prospectively recorded by a dedicated study nurse 30 days after RC. POI was defined as the placement of a nasogastric tube. Logistic regression analysis was used to identify predictors of 30-day complications and POI.

After considering the exclusion criteria, 108 patients were included for the final analysis. The median global compliance to the ERAS^® protocol was 61%. A total of 78 (72%) patients had a compliance <65% (group A), while the remaining 30 (28%) had a compliance >65% (group B). No significant differences were found among the two groups regarding the 30-day complication rate (86% in group A versus 73% in group B, p = 0.82) and LOS (14 days in group A versus 15 days in group B, p = 0.82). The time to stool was significantly shorter in group B (4 days versus 6 days, p = 0.02), and the time to tolerate solid food was slightly faster in group B but not significant (8 versus 7 days, p = 0.23). The POI rate was significantly lower in patients with a higher ERAS^® compliance (20% versus 46%, p = 0.01). A multivariate analysis showed that ERAS^® compliance was not significantly associated with 30-day total complications. However, a lower compliance to the ERAS^® protocol and age > 75 years were significant independent predictors of POI.

Our study provides further evidence to support the beneficial effect of the ERAS^® protocol in patients undergoing RC, particularly in terms of facilitating a faster recovery of bowel function and preventing POI. Future research should focus on investigating novel approaches and interventions to improve compliance with the ERAS^® protocol. This may involve patient education, multidisciplinary teamwork, and continuous quality improvement initiatives.