title: Introducing an enhanced recovery programme to an established totally intracorporeal robot-assisted radical cystectomy service.
abstract: OBJECTIVE
  The aim of this study was to assess the effect of introducing an enhanced recovery programme (ERP) to an established robot-assisted radical cystectomy (RARC) service.
  
  
  METHODS
  Data were prospectively collected on 221 consecutive patients undergoing totally intracorporeal RARC between December 2003 and May 2014. The ERP was specifically designed to support an evolving RARC service, where increasing proportions of patients requiring radical cystectomy underwent RARC. Patient demographics and outcomes before and after implementation of the ERP were compared. The primary endpoint was length of stay (LOS). Secondary outcomes included age, American Society of Anesthesiologists (ASA) score, preoperative staging, operative time, complications and readmissions. Differences in outcomes between patients before and after implementation of ERP were tested with the Jonckheere-Terpstra trend test and quantile regression with backward selection.
  
  
  RESULTS
  Following implementation of the ERP, the demographics of the patients (n = 135) changed, with median age increasing from 66 to 70 years (p < 0.01), higher ASA grade (p < 0.001), higher preoperative stage cancer (pT ≥ 2, p < 0.05) and increased likelihood of undergoing an ileal conduit diversion (p < 0.001). Median LOS before ERP was 9 days [interquartile range (IQR) 8-13 days] and after ERP was 8 days (IQR 6-10 days) (p < 0.001). ASA grade and neoadjuvant chemotherapy also affected LOS (p < 0.05 and p < 0.01, respectively). There was no significant difference in 30 day complication rates, readmission rates or 90 day mortality, with 59% experiencing complications before ERP implementation and 57% after implementation. The majority of complications were low grade.
  
  
  CONCLUSIONS
  Patient demographics changed as the RARC service evolved from selected patients to a general service. Despite worsening demographics, LOS decreased following ERP implementation. This evidence-based ERP safely standardized perioperative care, resulting in decreased LOS and decreased variability in LOS.
authors: a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden.
authors: Justin W
authors: JW
authors: Collins
authors: a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden.
authors: Christofer
authors: C
authors: Adding
authors: a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden.
authors: Abolfazl
authors: A
authors: Hosseini
authors: b 2 Division of Clinical Cancer Epidemiology, Department of Oncology-Pathology, Karolinska Institutet , Stockholm, Sweden.
authors: Tommy
authors: T
authors: Nyberg
authors: a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden.
authors: Giovannalberto
authors: G
authors: Pini
authors: a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden.
authors: Linda
authors: L
authors: Dey
authors: a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden.
authors: Peter N
authors: PN
authors: Wiklund
mesh_terms: D000368:Aged; D002295:Carcinoma, Transitional Cell / Q000473:pathology / Q000601:surgery*; D015331:Cohort Studies; D015653:Cystectomy / Q000534:rehabilitation*; D004434:Early Ambulation; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011182:Postoperative Care / Q000379:methods*; D011446:Prospective Studies; D065287:Robotic Surgical Procedures / Q000534:rehabilitation*; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000473:pathology / Q000601:surgery*; D014547:Urinary Diversion / Q000534:rehabilitation*
keywords: Bladder cancer; enhanced recovery programme; robot-assisted radical cystectomy; totally intracorporeal RARC