Enhanced recovery after radical cystectomy for bladder cancer: a prospective observational case -control study

The perioperative management of patients undergoing major surgical interventions is a dynamic field, continually striving for advancements in quality, reduction of complications, and cost-effectiveness. The implementation of Enhanced Recovery After Surgery (ERAS) pathways has demonstrated remarkable success in various surgical disciplines, particularly in colorectal procedures. This study investigates whether the implementation of an ERAS protocol for radical cystectomy for bladder cancer at our institution results in a reduced complication rate compared to traditional standards.DRKS00035673 (retrospective) on 13th December 2024. This prospective observational case-control pilot study was conducted at the University Hospital Giessen, Germany. Following ethics committee approval, 30 patients were enrolled: 15 patients received perioperative management based on prevailing standard operating procedures, and the subsequent 15 patients were managed according to the newly developed ERAS protocol. The multidisciplinary team included urologists, anaesthesiologists, nursing staff, ICU staff, pharmacists, physiotherapists, dietitians, and administrative staff. Key components of the ERAS protocol included optimized pain management, early nutrition, thrombosis prophylaxis, intraoperative goal directed therapy and early mobilization. The primary outcome was the complication rate until the 30th postoperative day, while secondary outcomes included ICU and hospital mortality, length of stay, and quality of life assessed by the EQ-5D-5L questionnaire. Thirty patients were included in the final analysis. Patients in the control group underwent radical cystectomy between September 2018 and December 2019, and those in the ERAS group between July 2020 and March 2021. There were no significant differences in basic characteristics between the groups. The primary outcome showed numeric but no statistically significant difference in complication rates (86.7% in the control group vs. 60% in the ERAS group, p=0.21). However, the cumulative POMS score was significantly higher in the control group (7.87 vs. 2.87, p<0.01), and the Clavien-Dindo score was significantly lower in the ERAS group (p=0.02). Quality of life was significantly improved in the ERAS group on the 7th and 30th postoperative day. Our pilot study suggests feasibility of ERAS implementation in radical cystectomy. The primary endpoint (overall complication rate) did not differ significantly between groups; however, ERAS was associated with lower complication severity and improved early postoperative quality of life, which should be interpreted as exploratory given the small, non-randomised sequential design. Larger multicentre prospective implementation studies are warranted to confirm these findings and to evaluate the influence of protocol adherence and individual ERAS elements. DRKS00035673 (retrospective) on 13th December 2024