Surgical approach as a determinant factor of clinical outcome following radical cystectomy: Does Enhanced Recovery After Surgery (ERAS) level the playing field?

Abstract

Purpose: To determine whether surgical approach is a determinant of clinical outcomes following radical cystectomy (RC) and urinary diversion when using an Enhanced Recovery After Surgery (ERAS) protocol.

Materials and methods: We studied all patients undergoing both open radical cystectomy (ORC) and robotic-assisted radical cystectomy (RARC) and urinary diversion with ERAS for bladder urothelial carcinoma from May 2012 to December 2016. Surgical and clinical outcomes within 90 days after surgery were compared between ORC and RARC, including readmission and major complication rates (Clavien-Dindo grade ≥III). Multivariable logistic regression modeling was used to determine factors that predict readmission and major complications.

Results: A total of 345 and 143 patients underwent ORC and RARC, respectively. The ORC group had a greater proportion of continent urinary diversion (71.9 vs. 40.6%, P< 0.001), shorter operative time (5.4 vs. 7.3 hours, P< 0.001), higher estimated blood loss (500 vs. 200 ml, P< 0.001), and higher intraoperative and postoperative transfusion rates (20.9 vs. 9.1%, P= 0.002 and 20 vs. 11.9%, P= 0.04, respectively). Median length of stay was 4 days for ORC (interquartile range 4-6 days) and 6 days for RARC (interquartile range 4-7 days; P< 0.001). There was no significant difference between ORC and RARC groups in major complication rates (20 vs. 23.8%, P= 0.51) or readmission rates (32.2 vs. 36.4%, P= 0.4) within 90 days after surgery. Multivariable logistic regression analysis showed that surgical approach was not an independent factor predictive of readmission (P= 0.33) or major complications (P= 0.76).

Conclusions: Surgical approach is not a determinant of readmission or major complications following RC in the context of an ERAS protocol.

Keywords: Cystectomy; Patient readmission; Postoperative complications; Urinary bladder neoplasms.