Intracorporeal robot-assisted radical cystectomy, together with an enhanced recovery programme, improves postoperative outcomes by aggregating marginal gains

Objective To assess the cumulative effect of an enhanced recovery after surgery (ERAS) pathway and a minimally invasive RARC with intracorporeal urinary diversion (iRARC) in comparison to open radical cystectomy (ORC) on hospital length of stay (LOS) and perioperative outcomes. Materials & methods Between Feb 2009 and Oct 2017, 304 radical cystectomy cases were performed at a single institution (54 ORC, 250 RARC). Data were prospectively collected. We identified 45 consecutive ORC cases performed without ERAS before the commencement of the RARC programme (Cohort A), 50 consecutive iRARC cases performed without ERAS (Cohort B) and 40 iRARC cases with ERAS (Cohort C). Primary outcome measure was hospital LOS while secondary outcome measures included perioperative 90-day complications and readmission rates. Complications were accessed using the Clavian-Dindo classification. Results Patients in all cohorts were evenly match in age, sex, body mass index (BMI), neoadjuvant treatment, tumour stage, lymph node yield, previous pelvic radiotherapy and surgery, perioperative anaemia as well as physiological state. iRARC with ERAS patients had a significantly higher ASA (III-IV) and were more likely to receive neobladder reconstruction. Median hospital LOS were shorter in iRARC with ERAS (7 days, IQR: 6-10) compared to iRARC without ERAS (11, 8-15) and ORC (17 (14-21). In a propensity score-matched cohort of iRARC patients, patients with ERAS has a significantly lower 90-day readmission rates. Additionally, implementing ERAS in an iRARC cohort resulted in a significantly lower 90-day all (p<0.001) and GI related complications (p=0.001). the use of ERAS and younger patients were independently associated with a hospital LOS ≤10 days on multinomial logistic regression. Conclusion A comprehensive ERAS programme can significantly reduce hospital LOS in patients undergoing iRARC without increasing 90-day readmission rates. An ERAS programme can augment the benefits of iRARC in improving perioperative outcomes. In studies comparing ORC and RARC, the presence or absence of an ERAS programme will be a confounding factor and only level I evidence can be interpreted reliably. This article is protected by copyright. All rights reserved.