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Article of the Week: Introduction of RARC within an established enhanced recovery programme

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Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Introduction of robot-assisted radical cystectomy within an established enhanced recovery programme

Catherine Miller*,†, Nicholas J. Campain†, Rachel Dbeis†, Mark Daugherty†, Nicholas Batchelor†, Elizabeth Waine† and John S. McGrath†

 

*Urology Department, Torbay Hospital, Torquay, and †Exeter Surgical Health Services Research Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK

 

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How to Cite

Miller, C., Campain, N. J., Dbeis, R., Daugherty, M., Batchelor, N., Waine, E. and McGrath, J. S. (2017), Introduction of robot-assisted radical cystectomy within an established enhanced recovery programme. BJU International, 120: 265–272. doi: 10.1111/bju.13702

Abstract

Objectives

To describe the implementation phase of a robot-assisted radical cystectomy (RARC) programme including side-effect profiles and impact on length of stay (LOS).

Patients and Methods

In all, 114 consecutive patients (82% male) underwent RARC and urinary diversion between April 2013 and December 2015 [ileal conduit (97 patients) and orthotopic neobladder (17)]. Surgery was performed by two surgeons within a designated regional cancer centre. No exclusion criteria were applied. All patients were managed on the Exeter Enhanced Recovery Pathway (ERP) in a unit where embedded enhanced recovery practice was already established. Data were collected prospectively on the national cystectomy registry – the British Association of Urological Surgeons (BAUS) Complex Operations Dataset.

aotw-aug-2017-2

Results

RARC was technically feasible in all but one case. The mean operating time was 3–5 h with an overall transfusion rate of 8.8%. There were higher-grade complications (Clavien–Dindo grade III–IV) in 18.4% of patients, with a 30-day mortality rate of 0.9%. The median (range) LOS after RARC was 7 (3–68) days, with a re-admission rate of 18.4%.

Conclusions

The present series shows that RARC can be safely implemented in a unit experienced in robot-assisted surgery (RAS). Case-selection in this setting is not deemed necessary. There are benefits in terms of lower transfusion rates and reduced LOS. The side-effect profile appears to differ from that of open RC, and despite the fact that complication rate is equivalent; ‘technical’ complications are over-represented in the RAS group. As such, they should improve with experience, recognition, and modification of surgical technique. ERPs can be safely applied to all patients undergoing RARC to maximise the benefits of minimally invasive surgery.

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Editorial: Speeding up recovery from radical cystectomy: how low can we go?

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Radical cystectomy (RC) is the ‘gold standard’ treatment for muscle-invasive bladder cancer (BCa) [1]. It offers the best chance of cure in patients with curable disease and excellent palliation in those with local symptoms from advanced disease. Longitudinal reports suggest many patients accept and adapt to the impact of RC, leading to minimal overall impact on their quality of life [2]. As such, RC also offers a viable alternative to BCG for patients with high-risk non-muscle-invasive BCa. Whilst I recognize the vital role that chemotherapy and radiotherapy play in treating this disease, and that radiotherapy may be a better choice for some patients than RC, it is the morbidity from RC that hinders its wider use and encourages alternatives [3]. For example, studies in the USA show that up to one-third of patients with muscle-invasive cancers do not receive radical treatment [4], and implementation of centralized cancer services in the UK has only now shown survival improvements, as morbidity from RC comes down [5]. The lowering of peri-operative morbidity and mortality from RC is changing the face of the operation and increasing its use.

In this month’s issue of BJUI, Miller et al. [6] combine robot-assisted minimal access surgery with enhanced recovery to report outcomes in a consecutive series of ‘state-of-the-art’ RCs in their study from Exeter, UK. The authors show consistent improvements in outcome, such that length of stay halved over the duration of study recruitment. Importantly, recovery becomes more predictable (as shown by the converging mean and median length of stay figures), although it is unclear as to how many patients had prolonged stays. Whilst the authors should be congratulated for their efforts in delivering this service and for charting its implementation so meticulously, some key descriptive findings are missing. For example, what is the extent of the variation in their outcomes (range and quartiles) and do the data differ among surgeons? What happened to the 25% of patients who stayed longer than 10 days? Did all patients receive all components of their enhanced recovery programme, and if not, which were the most impactful? How did length of stay and complication rates differ by reconstructive choice and reconstructive location (intra- or extracorporeal)? Did patient selection stay the same over time, or did improved outcomes lower the ‘fit for cystectomy’ bar? Many of these answers will be missing, given that the primary source of information was the BAUS major operations registry. This self-completed dataset is extremely valuable for comparisons between units and trends over times, but has limited data complexity and granularity. Finally, whilst the field is moving towards total intracorporeal surgery, the reported complication rates appear similar for extra- and intracorporeal reconstruction, questioning the need for the added complexity of intracorporeal surgery.

Economists, commissioners and patients will want to know the importance of the forces driving these improved outcomes. Do the better outcomes reflect centralization of services, the team’s learning curve, the meticulous use of enhanced recovery or minimally invasive surgery through robotics? The latter has vastly different cost implications from the others. My guess is that, whilst all of these aspects were important, it was volume of service (from centralization) and enhanced recovery that were the main contributors. I speak having had a similar experience in my unit, although we started robotic surgery at a later date than did the present authors, and in the knowledge that this group previously published the dramatic impact of enhanced recovery on their length of stays after open RC [7].

Regardless of these concerns, the outcomes are to be welcomed by urologists and patients, and the team should be congratulated. As length of hospital stay becomes shorter, our next scientific focus should be on out-of-hospital recovery. We rarely see data on time taken to return to normal activity and on how patients adjust after surgery. Whilst return to work is important for younger patients, many patients with bladder cancer are retired so for these patients it is return to quality of life that matters most. This question becomes even more important in an era of centralized care, where many patients recover away from their surgical teams and, conversely, surgical teams are less aware of problems and outcomes. Perhaps it will be out of the hospital that the effort and cost of minimally invasive surgery are justified.

James W.F. Catto
Academic Urology Unit, University of Sheffield, Sheffield, UK

 

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References

 

1 Witjes JA, Comperat E, Cowan NC et al. EAU guidelines on muscle- invasive and metastatic bladder cancer: summary of the 2013 guidelines. Eur Urol 2014; 65: 778–92

 

2 Hardt J, Filipas D, Hohenfellner R, Egle UT. Quality of life in patients with bladder carcinoma after cystectomy: first results of a prospective study. Qual Life Res 2000; 9: 1–12

 

3 Shabsigh A, Korets R, Vora KC et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol 2009; 55: 164–74

 

4 Gore JL, Litwin MS, Lai J et al. Use of radical cystectomy for patients with invasive bladder cancer. J Natl Cancer Inst 2010; 102: 802–11

 

5 Hounsome LS, Verne J, McGrath JS, Gillatt DA. Trends in operative caseload and mortality rates after radical cystectomy for bladder cancer in England for 1998–2010. Eur Urol 2015; 67: 1056–62

 

6 Miller C, Campain NJ, Dbeis R et al. Introduction of robot-assisted radical cystectomy within an established enhanced recovery programme. BJU Int 2017; 120: 265–72

 

7 Smith J, Pruthi RS, McGrath J. Enhanced recovery programmes for patients undergoing radical cystectomy. Nat Rev Urol 2014; 11: 437–4

 

Article of the week: Enhanced Recovery Programme for radical cystectomy

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Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by prominent members of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one

Implementation of the Exeter Enhanced Recovery Programme for patients undergoing radical cystectomy

Thomas J. Dutton, Mark O. Daugherty, Robert G. Mason and John S. McGrath

Exeter Surgical Health Services Research Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK

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OBJECTIVES

• To describe our experience with the implementation and refinement of an enhanced recovery programme (ERP) for radical cystectomy (RC) and urinary diversion.

• To assess the impact on length of stay (LOS), complication and readmission rates.

PATIENTS AND METHODS

• In all, 165 consecutive patients undergoing open RC (ORC) and urinary diversion between January 2008 and April 2013 were entered into an ERP.

• A retrospective case note review was undertaken.

• Outcomes recorded included LOS, time to mobilisation, complication rates within the first 30 days (Clavien-Dindo classification) and readmissions.

RESULTS

• All patients were successfully entered into the ERP.

• As enhanced recovery principles became embedded in the unit, LOS reduced from a mean of 14 days over the initial year of the ERP to a mean of 9.2 days.

• The complication rate was 6.6% for Clavien ≥3, and 43.5% for Clavien ≤2. The 30-day mortality rate was 1.2%.

• The 30-day readmission rate was 13.9%.

• In the most contemporary subset of 52 patients: the median time after ORC to sit out of bed, mobilise and open bowels was day 1, 2 and 6, respectively.

CONCLUSIONS

• The ERP described for patients undergoing ORC appears to be safe.

• Benefits include early feeding, mobilisation and hospital discharge.

• The ERP will continue to develop with the incorporation of advancing evidence and technology, in particular the introduction of robot-assisted RC.

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Editorial: Enhanced recovery programmes: an important step towards going lean in healthcare

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Enhanced recovery programmes (also known as clinical care pathways) are excellent examples of ‘lean thinking’. The ‘lean’ approach is derived from the management philosophy known as the ‘Toyota Production System’ (TPS) that helped the Japanese company become the world’s largest automaker. This management approach has been widely adopted throughout the manufacturing world and has revolutionised the way many businesses operate. Indeed, the concept of clinical care pathways has its roots in the management theories of the TPS, Six Sigma, Business Process Redesign, the Theory of Constraints, and other such methodologies.

This by no means implies that a person is like a car, or the situation is always or ever ‘textbook’. Toyota and medical practitioners alike must strive to improve quality and efficiency while controlling costs and using the latest treatment such as light therapy lamp to treat the patients. And, in the case of healthcare, all of these goals must come under the provision of optimising patient care.

Clinical care pathways provide us the opportunity to standardise processes and problem solving, and eliminate inconsistency (aka ‘mura’, a fundamental pillar of Toyotism). The result is that in every aspect of the delivery of care, there exist clear expectations and demonstrated capabilities. Although situational change is a constant in the healthcare environment, process standards must be applied in all applicable areas to reduce the controllable variances and ensure regulatory compliance, patient and staff satisfaction, and outcomes. Through these standardised pathways or programmes, we are able to establish a confidence in ourselves, our peers, our patients, and our families that what we say will indeed occur. In other words, the right process will produce the right results.

Clinical care pathways are an example of ‘process’ innovation – a concept that can be distinguished from ‘product’ innovation (e.g. drug development, diagnostic tests, robotic and other surgical tools). Process innovations represent important and much needed opportunities to improve outcomes and reduce costs. Clinical care pathways have already been shown to improve patient outcomes, reduce errors, decrease costs, increase transparency of treatment, improve patient, staff, and physician satisfaction, and improve educational opportunities. Moreover, radical cystectomy seems ideally suited to such standardised processes due to characteristics of (1) resource intensivity, (2) complexity of care, (3) high potential variability, and (4) high morbidity.

In this month’s BJU International, Dutton et al. [1] report the ability to effectively apply a standardised enhanced recovery programme to patients undergoing radical cystectomy and urinary diversion for bladder cancer. In their sequential case series, the authors report earlier ambulation, enteral feeding, and time to discharge in patients who were under this enhanced recovery programme (described within) without adverse outcomes, e.g. increased re-admission rates. Similarly, the use of clinical care pathways in our own cystectomy population at The University of North Carolina has represented one of the most important interventions to improve quality and efficiency of care while simultaneously reducing costs.

The next challenge is to explore the applicability of care pathways to multiple physicians and at different institutions, i.e. the widespread use of such programmes to yield the desired results over a healthcare system. Once these processes have been standardised and are able to demonstrate predictable results, we can then focus on raising the performance of these standardised practices and doing so in an iterative process (aka ‘kaizen’).

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Raj S. Pruthi and Mathew C. Raynor
Department of Urology and the Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

Reference

  1. Dutton TJ, Daugherty MO, Mason RG, McGrath JS. Implementation of the Exeter Enhanced Recovery Programme for patients undergoing radical cystectomy. BJU Int 2014; 113: 719–725

 

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