Enhanced Recovery After Surgery (ERAS) versus standard recovery after radical cystectomy – a matched-pair analysis

Enhanced Recovery After Surgery (ERAS) versus standard recovery after radical cystectomy – a matched-pair analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Enhanced Recovery After Surgery (ERAS) versus standard recovery after radical cystectomy – a matched-pair analysis Nikita Dhruva Fischer, Maximilian Peter Brandt, Stefan Epple, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3853491/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Radical cystectomy (RC) is marked by a tremendous potential for short and long-term complications. By introduction of Enhanced Recovery After Surgery (ERAS) protocols serious endeavors have been made in order to reduce postoperative morbidity in favor of a fast-track recovery. In this study, we investigated the impact of our in-house ERAS protocol on postoperative complications and hospital stay. Methods We identified 106 patients who received standard care of treatment post-surgery (non-ERAS group). After implementation of our ERAS protocol, we prospectively recorded data from 53 patients (ERAS group) up to 90 days post-surgery. Non-ERAS patients were matched with ERAS patients with respect to preoperative clinical characteristics. Statistical analysis was conducted by matched-pair analysis and Wilcoxon-Mann-Whitney-Test. Results Altogether 51 patients were matched. Considering patients with a hospital stay of ≤ 30 and ≤ 20 days we noticed a significant difference in favor of ERAS protocol (p = 0.043, p = 0.004) with regards to hospital stay. Removal of single-J stents occurred on day 11 (8–17) in the non-ERAS group and on day 8 ( 8 – 15 ) in the ERAS group post-surgery (p < 0.001). No difference could be identified in overall and 90-day complication rate (p = 0.443). Conclusion Adherence to ERAS protocol achieved a significantly shorter hospital stay in patients with a hospital stay of ≤ 30 and ≤ 20 days with no increase in complication rates. Furthermore, early removal of single-J stents did not result in higher rates of postoperative complications and hospital readmission. Cystoprostatectomy ERAS Hospital Stay Complications matched-pair analysis Background Radical cystectomy (RC), the gold standard treatment for muscle-invasive bladder cancer, is burdened by its high complication rate, resulting in a high socio-economic burden ( 1 ). Hautmann et al. reported an overall complication rate as high as 58% with a 90-day mortality rate of 2.3% in a case study of 1013 patients who underwent RC. Classified by Clavien Dindo up to 36% of all patients suffered grade 1–2 and 22% grade 3–5 complications ( 2 ) . Complications depend on individual patient characteristics such as biological age, gender, cardiovascular comorbidity, body mass index (BMI), American Society of Anesthesiologists (ASA) score, pathologies in the pelvic area, type of urinary diversion and last but not least the surgeon’s proficiency and expertise ( 3 ). The patient’s chronological age could not be proven as a relevant predictor of postoperative outcome ( 4 ). In our previous publications our group has repeatedly addressed the necessity of tools and scores to predict outcome of RC in order to individually tailor the intensity of monitoring patients after this major surgery ( 5 , 6 ). ERAS (Enhanced Recovery After Surgery) protocols were originally introduced by general surgery to promote fast-track recovery in colorectal surgery. The intention of ERAS protocols is to establish a multimodal treatment profile uniting forces of all disciplines involved in patient care (surgery, anesthesiology, nursing care, physiotherapy, psychotherapy, stoma therapy) from the moment of initial patient contact until patient discharge ( 7 ). Cystectomy patients might be optimal candidates for an ERAS pathway as the potential for reduction of surgical strain and complications is high. ERAS protocols for patients undergoing RC have been shown to reduce the length of hospitalization, time to recovery of bowel function, and complications with no increase in mortality ( 8 ). Avoidance of routine nasogastral (NG) tube placement and the use of local anesthesia blocks were significantly linked to reduced duration of hospital stay ( 9 , 10 ). The first elaborate ERAS guideline for RC was published in the year of 2009 and depicts 22 individual measures. In the year of 2020 we published our institution’s own adaptation of the ERAS protocol which is the basis of the current study ( 11 ) . Over the last decade, many studies have been conducted to examine the impact of ERAS protocols on postoperative outcome. To our knowledge, this is the only ERAS study of a matched-pair analysis in patients undergoing open RC. Methods Study population After institutional review board approval (No. 2020–15029), we collected clinical and histopathological data of patients who had undergone open RC with ileal conduit urinary diversion for bladder cancer at the University Medical Center Mainz between 2016 and 2019. Patients with a variant pathology (i.e., squamous cell carcinoma) were excluded. Furthermore, patients were excluded when RC was combined with another surgery, such as nephrectomy or rectum extirpation. Overall, 106 patients were allocated to standard care after RC (non-ERAS group). Our in-house ERAS protocol was implemented from June 2019 onwards. In this period, 53 patients were prospectively assigned to the ERAS group. All RC were performed by open surgery, ureter implantation into the ileal conduit was performed by Wallace technique (end-to-end) for the left and Nesbit technique (end-to-side) for the right ureter. Matched-pair analysis Each analyzed case of non-ERAS (n = 106) was matched with one ERAS case (n = 53) applying matching criteria in the following prioritization order: gender, BMI, ASA Score, operating time and age at surgery. Primary endpoint of the study was duration of hospital stay, secondary endpoint was the occurrence and frequency of postoperative complications. Patient information was gathered from the patients’ chart and digitally recorded. Complications were categorized into gastrointestinal (GI), cardiovascular, urogenital, thromboembolic and wound-related and classified according to Clavien-Dindo. Ninety-day follow-up was recorded by means of scheduled outpatient visits or when the patient presented himself due to a postoperative complication and emergency readmission was necessary. Statistical analysis Analyses were performed using Statistical Package for the Social Sciences version 27.0 IBM Software, New York, USA. Skewed continuous variables and ordinal data were compared between ERAS and non-ERAS group using Mann–Whitney U test and nominal data by using Fisher exact test. The analysis of demographic and clinical characteristics of the patients was performed using descriptive techniques, including mean, median, standard deviation, minimum and maximum value. All p values 40) were excluded since there was no corresponding non-ERAS partner. ASA Score was accurately matched in 50 out of 51 pairs (98%). Merely one pair lacked matching according to ASA score: ERAS patient (ASA Score 2) with arterial hypertension and Whipple’s procedure in the past was matched with a non-ERAS patient (ASA Score 3) with rheumatoid arthritis. Operating time (maximum discrepancy of 60 minutes) was accurately matched in 49 out of 51 pairs (96%). The operating time of two pairs showed a difference of 61 minutes. (ERAS: 481 minutes vs. non-ERAS 420 minutes) and 85 minutes (ERAS: 430 minutes vs. non-ERAS 515 minutes) respectively. Matching was approved due to the overall comparatively lengthy duration of the surgery. Patient characterization as defined by matching criteria is shown in Table 1 . Table 1 Patient characteristics defined by matching criteria. Fifty-one patients who underwent RC with ileal conduit urinary diversion were assigned to either ERAS or non-ERAS group respectively. ERAS (n = 51) non-ERAS (n = 51) Age – yr. mean range 72.4 39–86 71.9 49–83 Gender – no. (%) male female 39 (76.5) 12 (23.5) 39 (76.5) 12 (23.5) BMI – kg/m 2 mean 27.7 27.5 ASA-Score – no. (%) 2 3 4 14 (27.5) 35 (68.6) 2 (3.9) 13 (25.5) 36 (70.6) 2 (3.9) Operating time – min. mean 340 353 The primary endpoint of the study was duration of hospital stay which was 18.3 days in the ERAS group versus 17.8 in the non-ERAS group. The median duration of hospital stay was 14 days in the ERAS group and 15 days in the non-ERAS group (p = 0.194). However, short stays were especially and more often registered in the ERAS group which encouraged a subgroup analysis ruling out cases with an exceptionally short (in case of death) and extraordinary long hospitalization (> 30 days). The subgroup analysis dismissed 5 patients in the ERAS group and 2 patients in the non-ERAS group. The difference in duration of hospital stay was statistically significant (p = 0,043). Hence, duration of hospital stay was significantly shorter in the ERAS group when an overall hospitalization ≤ 30 days was considered. Statistical significance prevailed when an overall hospitalization ≤ 20 days was examined (p = 0.004) counting in 39 ERAS patients and 43 non-ERAS patients. The corresponding results are summarized in Table 2 . Table 2 Statistical analysis of mean and median duration of hospital stay based on all patients and on a subgroup of patients with a hospitalization of ≤ 20 and ≤ 30 days. Mean Median Range SD p-value All patients n = 51 non-ERAS 17.75 15 10–85 10.98 0.194 n = 51 ERAS 18.27 14 10–64 12.21 Hospital stay ≤ 30 days n = 49 non-ERAS 15.92 14 10–30 4.19 0.043 n = 46 ERAS 15.15 13 10–30 5.07 Hospital stay ≤ 20 days n = 43 non-ERAS 14.63 14 10–20 2.21 0.004 n = 39 ERAS 13.31 13 10–19 2.4 Secondary endpoint of the study was the frequency of postoperative complications which were comparable in both groups. Twenty-three ERAS patients (45%) and 22 non-ERAS patients (44%) developed complications. All complications including their prevalence are demonstrated in Table 3 . Altogether two patients died during hospitalization (both ERAS patients), one of whom was 86 years old and developed pancreatitis and acute kidney failure and died on postoperative day 18. The second patient, who died on postoperative day 59, suffered pneumogenic sepsis as a consequence of a prolonged stay in intensive-care after ileus, peritonitis and stoma surgery. Distribution according to Clavien Dindo classification is shown in Table 4 . Table 3 Summary of postoperative complications in ERAS and non-ERAS group. non-ERAS n (%) ERAS n (%) GI-motility disorder 5 (9.8) 6 (11.7) Ileus operative treatment 0 1 (2.0) Ileus conservative treatment 2 (3.9) 1 (2.0) Pre-ileus 2 (3.8) 4 (7.8) Gastroparesis 1 (2.0) 0 Thrombembolic events 6 (11.7) 6 (11.7) Pulmonary embolism 4 (7.8) 5 (9.8) Deep vein thrombosis 2 (3.9) 0 Muscle vein thrombosis, M. gastrocnemius 0 1 (2.0) Cardiac events 3 (5.9) 3 (5.9) STEMI 0 1 (2.0) NSTEMI 1 (2.0) 0 Paroxysmal atrial fibrillation 1 (2.0) 0 TAA (Cardioversion) 0 2 (3.9) Cardiac arrest 1 (2.0) 0 Urogenital tract 5 (9.8) 3 (5.9) Acute kidney failure - dialysis 0 1 (2.0) Acute kidney failure + dialysis 1 (2.0) 0 Nephrostomy tube 2 (3.9) 2 (3.9) Urteral stenosis 2 (3.9) 0 Wound healing disorders 5 (9.8) 8 (15.7) General wound healing disorder 4 (7.8) 2 (3.9) VAC treatment 1 (2.0) 5 (9.8) Secondary wound closure 0 1 (2.0) Infections 4 (7.8) 6 (11.7) UTI-infection 2 (3.9) 2 (3.9) Pneumonia - intubation 1 (2.0) 1 (2.0) Pneumonia + intubation 1 (2.0) 0 Respiratory failure after aspiration 0 1 (2.0) Sepsis 0 1 (2.0) Septic shock 0 1 (2.0) Vascular events 1 (2,0) 3 (5,9) Hematoma evacuation 0 1 (2,0) Acute arterial occlusion (external iliac artery), compartment syndrome 1 (2.0) 0 Cerebral ischemia 0 1 (2.0) Bleeding common iliac vein 0 1 (2.0) Other * * Lymphocele 2 (3.9) 1 (2.0) Ascites puncture 0 1 (2.0) Pankreatitis 0 1 (2.0) Pleural effusion + drainage 0 1 (2.0) Anastomotic leakage Ureter-Conduit 1 (2.0) 1 (2.0) Anastomotic leakage Ileo-ileostomy 0 2 (3.9) Temporary ileostomy 1 (2.0) 4 (7.8) Fistula 0 1 (2.0) Peritonitis 1 (2.0) 1 (2.0) Rectum perforation 1 (2.0) 0 Urinary tract complications after primary discharge leading to a clinical visit Acute kidney failure (no dialysis) 1 (2.0) 1 (2.0) Hydronephrosis 1 (2.0) 0 Nephrostomy Tube 1 (2.0) 1 (2.0) Febrile UTI infection 3 (5.9) 5 (10.2) Urosepsis 1 (2.0) 1 (2.0) Table 4 Classification of postoperative complications according to Clavien Dindo. non-ERAS ERAS n % n % Postoperative Complications (Clavien Dindo) 0 29 56.9 28 54.9 1 4 7.8 2 3.9 2 10 19.6 8 15.7 3a 2 3.9 2 3.9 3b 2 3.9 6 11.8 4a 2 3.9 3 5.9 4b 2 3.9 0 0.0 5 0 0.0 2 3.9 The frequency of GI complications was not higher in the ERAS group despite early-aggressive removal of the NG tube instantly post-surgery in 88% of patients compared to 31% in the non-ERAS group. The latest removal of the NG tube was on day 6 post-surgery in the non-ERAS group compared to day 4 in the ERAS group. The mean resting time was 0.22 versus 1.79 days in ERAS and non-ERAS groups respectively. The occurrence of the first defecation showed no difference, with a median latency of 4 days in both groups. Frequency of readmission after initial discharge was comparable in both groups. Eleven (22%) ERAS patients were re-admitted at least once compared to 8 non-ERAS patients (16%; p = 0.45). The mean time to readmission was 44.6 days in the ERAS group and 42.9 days in the non-ERAS group. We further investigated the impact of early removal of single-J stents. Stents were discarded on postoperative day 8 (median) in the ERAS group as compared to day 11 (median) in the non-ERAS group (p < 0.001) after previous fluoroscopy contrast imaging. The rate of urinary tract complications after initial discharge is also shown in Table 3 . The number of urinary tract infections was higher in the ERAS group, though not statistically significant. The rate of hydronephrosis however was as low as 0%. In summary, complication rate involving the upper urinary tract was not higher despite early removal of single-J stents. Discussion We performed a study of 51 accurately matched and paired patients who underwent open RC with ileal conduit urinary diversion in order to investigate the relevance of ERAS protocol. Interestingly, there was no significant difference in duration of hospital stay between ERAS and non-ERAS group when the entire cohort was considered (14 vs. 15 days, p = 0.194). However, hospitalization shorter than 30 and 20 days was significantly different in favor of the ERAS group (p = 0.043 and p = 0.004 respectively). Despite the fact that statistical significance was only present in a subgroup analysis, 90% of the ERAS cohort and 96% of the non-ERAS cohort were still included. The subgroup analysis including patients with a hospital stay < 20 days still contained 77% of patients in the ERAS group and 84% in the non-ERAS group. Similar statements were made by Frees et al. in their randomized pilot study evaluating ERAS protocol versus standard protocol for patients treated with RC. In their study, patients following ERAS had a significantly shorter hospital stay, although this was a preliminary study with a smaller number of patients (12 ERAS; 15 non-ERAS) and involved neobladder reconstruction as well as ileal conduits. Preoperative patient characteristics were reported to be similar in both groups ( 12 ). A shorter hospital stay was also declared by Vlad et al. who examined a similar sized cohort as our study (45 ERAS and 45 non-ERAS patients). Allocation was made by randomization without a matching process. Preoperative risks were declared as comparable in the entire collective ( 13 ). In a multicenter study conducted by Lin et. al with 144 ERAS and 145 non-ERAS patients, no significant difference was found regarding duration of hospital stay. The study benefits from its large cohort and multicenter nature involving 25 hospitals, however patient collective, operating technique and adaptation of ERAS protocol were not as consistent ( 14 ). Other studies involved laparoscopic or robot-assisted RC. In our personal opinion, due to the evident benefits with regard to blood loss, wound healing and postoperative pain as compared to open surgery, laparoscopic as well as robot-assisted procedures need to be examined separately ( 12 ). Special attention was given to postoperative complications. Altogether 45% of ERAS and 43% of non-ERAS patients experienced some sort of complication within 90 days post-surgery. Mortality rate was 4% in the ERAS group versus 0% in the non-ERAS group. No significant difference could be found according to Clavien-Dindo classification. The subgroup analysis of both comparison groups did not show a substantial difference in complications either. The results are however in accordance with other ERAS studies ( 10 , 13 , 14 ). However, a reduction of surgical complications has also been shown in various other publications on adherence to ERAS protocols ( 8 , 15 ). According to the authors, specific complications can vary due to inclusion criteria (some studies preferred to include ASA 1 and 2 patients only), collective size, different focus of the analysis and lack of matched-pair formation. The absence of complications regarding the upper urinary tract despite early removal of single-J stents is highly encouraging. ERAS Society does not specifically deal with stent removal. Recommendations state that stents should rest for at least 5 days in situ and the topic is not taken further up. The subject also lacks attention in previous ERAS studies. Hence, our solid 90-day follow-up with respect to complications of the upper urinary tract fills an important knowledge gap in the literature about ERAS protocols and urinary stents and in consequence we suggest that early removal of stents seems to be a feasible option without bearing an increased risk of urinary tract infections, obstructive uropathy and/or urinary leakage. We acknowledge that the results of our study are limited by its partially retrospective data collection (non-ERAS-group). After implementation of ERAS, all patients were treated according to the ERAS protocol. Thus, the non-ERAS group was not treated during the same time period as the ERAS-group which is a noteworthy limitation. Furthermore, we have not considered differences in surgical expertise. However, we consider the design of our study especially with its matched-pair formation and definition of inclusion and exclusion criteria to be a major strength. To our knowledge, no other matched-pair analysis has been conducted to evaluate RC ERAS protocols. Further studies should include a higher number of patients and a multicenter approach. Conclusion RC is a complex surgery with high complication rates. ERAS protocols have been introduced in order to optimize pre-, intra- and postoperative treatment. We report that devotion to ERAS protocol resulted in a significantly shorter hospital stay in patients with a hospital stay of ≤ 30 and ≤ 20 days with a comparable complication rate. In particular, early removal of single-J stents did not provoke higher urinary tract complications or hospital readmission. Abbreviations ASA American Society of Anesthesiologists BMI Body mass index ERAS Enhanced Recovery After Surgery NG tube Nasogastral tube RC radical cystectomy Declarations Ethics approval and consent to participate The study was conducted after obtaining institutional review board approval (No. 2020-15029) from the ethics committee of the medical association of Rhineland-Pfalz (Ethikkommssion bei der Landesärztekammer Rheinland-Pfalz) . Informed consent was obtained from all participants. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Consent for publication Not applicable Availability of data and materials All data generated or analysed during this study are included in this published article and its supplementary information files. Raw data are available upon request to the corresponding author. Competing Interests The authors declare that they have no competing interests. Funding None Disclosures None Authors’ contributions Fischer ND – project development, data collection, data analysis, manuscript writing Brandt MP – project development, data collection, data analysis, manuscript writing Epple S – data collection, data analysis, manuscript writing Horn F – data collection, data analysis, manuscript writing Haack M –data collection, manuscript editing Duwe G – data collection, manuscript editing Sparwasser P – data collection, manuscript editing Dotzauer R – data collection, manuscript editing Thomas A – data collection, manuscript editing Tsaur I – data collection, manuscript editing Haferkamp A – data collection, manuscript editing Jäger W – project development, data collection, data analysis, manuscript writing Acknowledgements Not applicable References Lee R, Chughtai B, Herman M, Shariat SF, Scherr DS. Cost-analysis comparison of robot-assisted laparoscopic radical cystectomy (RC) vs open RC. BJU Int. 2011;108(6 Pt 2):976–83. Hautmann RE, de Petriconi R, Gottfried HW, Kleinschmidt K, Mattes R, Paiss T. The ileal neobladder: complications and functional results in 363 patients after 11 years of followup. J Urol. 1999;161(2):422-7; discussion 7–8. Bolenz C. Urothelkarzinom der Harnblase: Chirurgische Therapie. Die Urologie: in 3 Bänden. Springer; 2023. pp. 803–18. Clark PE, Stein JP, Groshen SG, Cai J, Miranda G, Lieskovsky G, et al. Radical cystectomy in the elderly: comparison of clinical outcomes between younger and older patients. Cancer. 2005;104(1):36–43. Borgmann H, Kamal MM, Metzger A, Dotzauer R, Fischer N, Sparwasser P, et al. High–Normal Preoperative Potassium Level Is Associated with Reduced 30–Day Morbidity and Shorter Hospital Stay after Radical Cystectomy. J Clin Med. 2022;11(5):1174. Kamal M, Borgmann H, Metzger A, Schregel C, Nabar N, Haack M, et al. The PT 2 D-Score: a novel tool to predict complications and economic outcome after radical cystectomy. World J Urol. 2020;38:3155–60. Cerantola Y, Valerio M, Persson B, Jichlinski P, Ljungqvist O, Hubner M, et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS((R))) society recommendations. Clin Nutr. 2013;32(6):879–87. Williams SB, Cumberbatch MGK, Kamat AM, Jubber I, Kerr PS, McGrath JS, et al. Reporting Radical Cystectomy Outcomes Following Implementation of Enhanced Recovery After Surgery Protocols: A Systematic Review and Individual Patient Data Meta-analysis. Eur Urol. 2020;78(5):719–30. Mir MC, Zargar H, Bolton DM, Murphy DG, Lawrentschuk N. Enhanced recovery after surgery protocols for radical cystectomy surgery: review of current evidence and local protocols. ANZ J Surg. 2015;85(7–8):514–20. Pang KH, Groves R, Venugopal S, Noon AP, Catto JW. Prospective implementation of enhanced recovery after surgery protocols to radical cystectomy. Eur Urol. 2018;73(3):363–71. Fischer N, Epple S, Wittenmeier E, Betz U, Haferkamp A, Jäger W. Implementation of Enhanced Recovery after Surgery (ERAS®) protocol in radical cystectomy at the University Medical Center Mainz. Der Urologe. 2021;60:169–77. Frees SK, Aning J, Black P, Struss W, Bell R, Chavez-Munoz C, et al. A prospective randomized pilot study evaluating an ERAS protocol versus a standard protocol for patients treated with radical cystectomy and urinary diversion for bladder cancer. World J Urol. 2018;36:215–20. Vlad O, Catalin B, Mihai H, Adrian P, Manuela O, Gener I et al. Enhanced recovery after surgery (ERAS) protocols in patients undergoing radical cystectomy with ileal urinary diversions: a randomized controlled trial. Medicine. 2020;99(27). Lin T, Li K, Liu H, Xue X, Xu N, Wei Y, et al. Enhanced recovery after surgery for radical cystectomy with ileal urinary diversion: a multi-institutional, randomized, controlled trial from the Chinese bladder cancer consortium. World J Urol. 2018;36(1):41–50. Karl A, Buchner A, Becker A, Staehler M, Seitz M, Khoder W, et al. A new concept for early recovery after surgery for patients undergoing radical cystectomy for bladder cancer: results of a prospective randomized study. J Urol. 2014;191(2):335–40. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1ERASBMCUrology.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Gutenberg University Mainz","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Peter","middleName":"","lastName":"Sparwasser","suffix":""},{"id":271501864,"identity":"c0744bbe-d01c-4eb6-9d6b-4d7f0e52ab26","order_by":7,"name":"Robert Dotzauer","email":"","orcid":"","institution":"University Medical Center, Johannes Gutenberg University Mainz","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Robert","middleName":"","lastName":"Dotzauer","suffix":""},{"id":271501865,"identity":"cd9ed5d3-d144-4340-93ec-03dd89d8dfe0","order_by":8,"name":"Anita Thomas","email":"","orcid":"","institution":"University Medical Center, Johannes Gutenberg University Mainz","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Anita","middleName":"","lastName":"Thomas","suffix":""},{"id":271501866,"identity":"e8288857-070c-4ee3-bb7d-d1545fa2ffd7","order_by":9,"name":"Igor Tsaur","email":"","orcid":"","institution":"University Medical 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12:59:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3853491/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3853491/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55795504,"identity":"4a23df13-8f3d-4e86-ab28-24b8bebce123","added_by":"auto","created_at":"2024-05-03 10:41:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":584195,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3853491/v1/ae35539e-d8e6-4732-b8b1-e6fcace00795.pdf"},{"id":50817410,"identity":"0359c742-e01b-4374-92d8-0bc3e4fcb0c3","added_by":"auto","created_at":"2024-02-07 20:08:46","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":133381,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1ERASBMCUrology.docx","url":"https://assets-eu.researchsquare.com/files/rs-3853491/v1/8eeabba873b817170211cf40.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Enhanced Recovery After Surgery (ERAS) versus standard recovery after radical cystectomy – a matched-pair analysis","fulltext":[{"header":"Background","content":"\u003cp\u003eRadical cystectomy (RC), the gold standard treatment for muscle-invasive bladder cancer, is burdened by its high complication rate, resulting in a high socio-economic burden (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Hautmann et al. reported an overall complication rate as high as 58% with a 90-day mortality rate of 2.3% in a case study of 1013 patients who underwent RC. Classified by Clavien Dindo up to 36% of all patients suffered grade 1\u0026ndash;2 and 22% grade 3\u0026ndash;5 complications (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) .\u003c/p\u003e \u003cp\u003eComplications depend on individual patient characteristics such as biological age, gender, cardiovascular comorbidity, body mass index (BMI), American Society of Anesthesiologists (ASA) score, pathologies in the pelvic area, type of urinary diversion and last but not least the surgeon\u0026rsquo;s proficiency and expertise (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The patient\u0026rsquo;s chronological age could not be proven as a relevant predictor of postoperative outcome (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In our previous publications our group has repeatedly addressed the necessity of tools and scores to predict outcome of RC in order to individually tailor the intensity of monitoring patients after this major surgery (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eERAS (Enhanced Recovery After Surgery) protocols were originally introduced by general surgery to promote fast-track recovery in colorectal surgery. The intention of ERAS protocols is to establish a multimodal treatment profile uniting forces of all disciplines involved in patient care (surgery, anesthesiology, nursing care, physiotherapy, psychotherapy, stoma therapy) from the moment of initial patient contact until patient discharge (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCystectomy patients might be optimal candidates for an ERAS pathway as the potential for reduction of surgical strain and complications is high. ERAS protocols for patients undergoing RC have been shown to reduce the length of hospitalization, time to recovery of bowel function, and complications with no increase in mortality (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Avoidance of routine nasogastral (NG) tube placement and the use of local anesthesia blocks were significantly linked to reduced duration of hospital stay (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The first elaborate ERAS guideline for RC was published in the year of 2009 and depicts 22 individual measures. In the year of 2020 we published our institution\u0026rsquo;s own adaptation of the ERAS protocol which is the basis of the current study (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) .\u003c/p\u003e \u003cp\u003eOver the last decade, many studies have been conducted to examine the impact of ERAS protocols on postoperative outcome. To our knowledge, this is the only ERAS study of a matched-pair analysis in patients undergoing open RC.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eAfter institutional review board approval (No. 2020\u0026ndash;15029), we collected clinical and histopathological data of patients who had undergone open RC with ileal conduit urinary diversion for bladder cancer at the University Medical Center Mainz between 2016 and 2019. Patients with a variant pathology (i.e., squamous cell carcinoma) were excluded. Furthermore, patients were excluded when RC was combined with another surgery, such as nephrectomy or rectum extirpation. Overall, 106 patients were allocated to standard care after RC (non-ERAS group). Our in-house ERAS protocol was implemented from June 2019 onwards. In this period, 53 patients were prospectively assigned to the ERAS group. All RC were performed by open surgery, ureter implantation into the ileal conduit was performed by Wallace technique (end-to-end) for the left and Nesbit technique (end-to-side) for the right ureter.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eMatched-pair analysis\u003c/h2\u003e \u003cp\u003eEach analyzed case of non-ERAS (n\u0026thinsp;=\u0026thinsp;106) was matched with one ERAS case (n\u0026thinsp;=\u0026thinsp;53) applying matching criteria in the following prioritization order: gender, BMI, ASA Score, operating time and age at surgery. Primary endpoint of the study was duration of hospital stay, secondary endpoint was the occurrence and frequency of postoperative complications. Patient information was gathered from the patients\u0026rsquo; chart and digitally recorded. Complications were categorized into gastrointestinal (GI), cardiovascular, urogenital, thromboembolic and wound-related and classified according to Clavien-Dindo. Ninety-day follow-up was recorded by means of scheduled outpatient visits or when the patient presented himself due to a postoperative complication and emergency readmission was necessary.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAnalyses were performed using Statistical Package for the Social Sciences version 27.0 IBM Software, New York, USA. Skewed continuous variables and ordinal data were compared between ERAS and non-ERAS group using Mann\u0026ndash;Whitney U test and nominal data by using Fisher exact test. The analysis of demographic and clinical characteristics of the patients was performed using descriptive techniques, including mean, median, standard deviation, minimum and maximum value. All p values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were defined as statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAltogether, 53 ERAS patients were prospectively monitored of which two (BMI groups 30\u0026ndash;35 and \u0026gt;\u0026thinsp;40) were excluded since there was no corresponding non-ERAS partner. ASA Score was accurately matched in 50 out of 51 pairs (98%). Merely one pair lacked matching according to ASA score: ERAS patient (ASA Score 2) with arterial hypertension and Whipple\u0026rsquo;s procedure in the past was matched with a non-ERAS patient (ASA Score 3) with rheumatoid arthritis. Operating time (maximum discrepancy of 60 minutes) was accurately matched in 49 out of 51 pairs (96%). The operating time of two pairs showed a difference of 61 minutes. (ERAS: 481 minutes vs. non-ERAS 420 minutes) and 85 minutes (ERAS: 430 minutes vs. non-ERAS 515 minutes) respectively. Matching was approved due to the overall comparatively lengthy duration of the surgery. Patient characterization as defined by matching criteria is shown in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics defined by matching criteria. Fifty-one patients who underwent RC with ileal conduit urinary diversion were assigned to either ERAS or non-ERAS group respectively.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERAS\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;51)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003enon-ERAS\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;51)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge \u0026ndash; yr.\u003c/p\u003e \u003cp\u003emean\u003c/p\u003e \u003cp\u003erange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72.4\u003c/p\u003e \u003cp\u003e39\u0026ndash;86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71.9\u003c/p\u003e \u003cp\u003e49\u0026ndash;83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender \u0026ndash; no. (%)\u003c/p\u003e \u003cp\u003emale\u003c/p\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (76.5)\u003c/p\u003e \u003cp\u003e12 (23.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (76.5)\u003c/p\u003e \u003cp\u003e12 (23.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI \u0026ndash; kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003cp\u003emean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA-Score \u0026ndash; no. (%)\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (27.5)\u003c/p\u003e \u003cp\u003e35 (68.6)\u003c/p\u003e \u003cp\u003e2 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (25.5)\u003c/p\u003e \u003cp\u003e36 (70.6)\u003c/p\u003e \u003cp\u003e2 (3.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperating time \u0026ndash; min.\u003c/p\u003e \u003cp\u003emean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e340\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e353\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe primary endpoint of the study was duration of hospital stay which was 18.3 days in the ERAS group versus 17.8 in the non-ERAS group. The median duration of hospital stay was 14 days in the ERAS group and 15 days in the non-ERAS group (p\u0026thinsp;=\u0026thinsp;0.194). However, short stays were especially and more often registered in the ERAS group which encouraged a subgroup analysis ruling out cases with an exceptionally short (in case of death) and extraordinary long hospitalization (\u0026gt;\u0026thinsp;30 days). The subgroup analysis dismissed 5 patients in the ERAS group and 2 patients in the non-ERAS group. The difference in duration of hospital stay was statistically significant (p\u0026thinsp;=\u0026thinsp;0,043). Hence, duration of hospital stay was significantly shorter in the ERAS group when an overall hospitalization\u0026thinsp;\u0026le;\u0026thinsp;30 days was considered. Statistical significance prevailed when an overall hospitalization\u0026thinsp;\u0026le;\u0026thinsp;20 days was examined (p\u0026thinsp;=\u0026thinsp;0.004) counting in 39 ERAS patients and 43 non-ERAS patients. The corresponding results are summarized in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStatistical analysis of mean and median duration of hospital stay based on all patients and on a subgroup of patients with a hospitalization of \u0026le;\u0026thinsp;20 and \u0026le;\u0026thinsp;30 days.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enon-ERAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u0026ndash;85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.194\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u0026ndash;64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital stay\u003c/p\u003e \u003cp\u003e\u0026le;\u0026thinsp;30 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enon-ERAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.043\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital stay\u003c/p\u003e \u003cp\u003e\u0026le;\u0026thinsp;20 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enon-ERAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSecondary endpoint of the study was the frequency of postoperative complications which were comparable in both groups. Twenty-three ERAS patients (45%) and 22 non-ERAS patients (44%) developed complications. All complications including their prevalence are demonstrated in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Altogether two patients died during hospitalization (both ERAS patients), one of whom was 86 years old and developed pancreatitis and acute kidney failure and died on postoperative day 18. The second patient, who died on postoperative day 59, suffered pneumogenic sepsis as a consequence of a prolonged stay in intensive-care after ileus, peritonitis and stoma surgery. Distribution according to Clavien Dindo classification is shown in Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of postoperative complications in ERAS and non-ERAS group.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003enon-ERAS\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eERAS\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGI-motility disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e5 (9.8)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e6 (11.7)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIleus operative treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIleus conservative treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-ileus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (7.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGastroparesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThrombembolic events\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e6 (11.7)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e6 (11.7)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary embolism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (9.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeep vein thrombosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuscle vein thrombosis, M. gastrocnemius\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiac events\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3 (5.9)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e3 (5.9)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSTEMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNSTEMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParoxysmal atrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTAA (Cardioversion)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiac arrest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrogenital tract\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e5 (9.8)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e3 (5.9)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute kidney failure - dialysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute kidney failure\u0026thinsp;+\u0026thinsp;dialysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNephrostomy tube\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrteral stenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound healing disorders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e5 (9.8)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e8 (15.7)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral wound healing disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAC treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (9.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary wound closure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfections\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e4 (7.8)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e6 (11.7)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUTI-infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumonia - intubation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumonia\u0026thinsp;+\u0026thinsp;intubation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory failure after aspiration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeptic shock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVascular events\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1 (2,0)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e3 (5,9)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHematoma evacuation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2,0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute arterial occlusion (external iliac artery), compartment syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebral ischemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding common iliac vein\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymphocele\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAscites puncture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePankreatitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePleural effusion\u0026thinsp;+\u0026thinsp;drainage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomotic leakage Ureter-Conduit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomotic leakage Ileo-ileostomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTemporary ileostomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (7.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeritonitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRectum perforation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary tract complications after primary discharge leading to a clinical visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute kidney failure (no dialysis)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHydronephrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNephrostomy Tube\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFebrile UTI infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (10.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrosepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClassification of postoperative complications according to Clavien Dindo.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003enon-ERAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eERAS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e\u003cb\u003ePostoperative Complications\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(Clavien Dindo)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e54.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe frequency of GI complications was not higher in the ERAS group despite early-aggressive removal of the NG tube instantly post-surgery in 88% of patients compared to 31% in the non-ERAS group. The latest removal of the NG tube was on day 6 post-surgery in the non-ERAS group compared to day 4 in the ERAS group. The mean resting time was 0.22 versus 1.79 days in ERAS and non-ERAS groups respectively. The occurrence of the first defecation showed no difference, with a median latency of 4 days in both groups. Frequency of readmission after initial discharge was comparable in both groups. Eleven (22%) ERAS patients were re-admitted at least once compared to 8 non-ERAS patients (16%; p\u0026thinsp;=\u0026thinsp;0.45). The mean time to readmission was 44.6 days in the ERAS group and 42.9 days in the non-ERAS group.\u003c/p\u003e \u003cp\u003eWe further investigated the impact of early removal of single-J stents. Stents were discarded on postoperative day 8 (median) in the ERAS group as compared to day 11 (median) in the non-ERAS group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) after previous fluoroscopy contrast imaging. The rate of urinary tract complications after initial discharge is also shown in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The number of urinary tract infections was higher in the ERAS group, though not statistically significant. The rate of hydronephrosis however was as low as 0%. In summary, complication rate involving the upper urinary tract was not higher despite early removal of single-J stents.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe performed a study of 51 accurately matched and paired patients who underwent open RC with ileal conduit urinary diversion in order to investigate the relevance of ERAS protocol. Interestingly, there was no significant difference in duration of hospital stay between ERAS and non-ERAS group when the entire cohort was considered (14 vs. 15 days, p\u0026thinsp;=\u0026thinsp;0.194). However, hospitalization shorter than 30 and 20 days was significantly different in favor of the ERAS group (p\u0026thinsp;=\u0026thinsp;0.043 and p\u0026thinsp;=\u0026thinsp;0.004 respectively). Despite the fact that statistical significance was only present in a subgroup analysis, 90% of the ERAS cohort and 96% of the non-ERAS cohort were still included. The subgroup analysis including patients with a hospital stay\u0026thinsp;\u0026lt;\u0026thinsp;20 days still contained 77% of patients in the ERAS group and 84% in the non-ERAS group.\u003c/p\u003e \u003cp\u003eSimilar statements were made by Frees et al. in their randomized pilot study evaluating ERAS protocol versus standard protocol for patients treated with RC. In their study, patients following ERAS had a significantly shorter hospital stay, although this was a preliminary study with a smaller number of patients (12 ERAS; 15 non-ERAS) and involved neobladder reconstruction as well as ileal conduits. Preoperative patient characteristics were reported to be similar in both groups (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA shorter hospital stay was also declared by Vlad et al. who examined a similar sized cohort as our study (45 ERAS and 45 non-ERAS patients). Allocation was made by randomization without a matching process. Preoperative risks were declared as comparable in the entire collective (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn a multicenter study conducted by Lin et. al with 144 ERAS and 145 non-ERAS patients, no significant difference was found regarding duration of hospital stay. The study benefits from its large cohort and multicenter nature involving 25 hospitals, however patient collective, operating technique and adaptation of ERAS protocol were not as consistent (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOther studies involved laparoscopic or robot-assisted RC. In our personal opinion, due to the evident benefits with regard to blood loss, wound healing and postoperative pain as compared to open surgery, laparoscopic as well as robot-assisted procedures need to be examined separately (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSpecial attention was given to postoperative complications. Altogether 45% of ERAS and 43% of non-ERAS patients experienced some sort of complication within 90 days post-surgery. Mortality rate was 4% in the ERAS group versus 0% in the non-ERAS group. No significant difference could be found according to Clavien-Dindo classification. The subgroup analysis of both comparison groups did not show a substantial difference in complications either. The results are however in accordance with other ERAS studies (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). However, a reduction of surgical complications has also been shown in various other publications on adherence to ERAS protocols (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). According to the authors, specific complications can vary due to inclusion criteria (some studies preferred to include ASA 1 and 2 patients only), collective size, different focus of the analysis and lack of matched-pair formation.\u003c/p\u003e \u003cp\u003eThe absence of complications regarding the upper urinary tract despite early removal of single-J stents is highly encouraging. ERAS Society does not specifically deal with stent removal. Recommendations state that stents should rest for at least 5 days in situ and the topic is not taken further up. The subject also lacks attention in previous ERAS studies. Hence, our solid 90-day follow-up with respect to complications of the upper urinary tract fills an important knowledge gap in the literature about ERAS protocols and urinary stents and in consequence we suggest that early removal of stents seems to be a feasible option without bearing an increased risk of urinary tract infections, obstructive uropathy and/or urinary leakage.\u003c/p\u003e \u003cp\u003eWe acknowledge that the results of our study are limited by its partially retrospective data collection (non-ERAS-group). After implementation of ERAS, all patients were treated according to the ERAS protocol. Thus, the non-ERAS group was not treated during the same time period as the ERAS-group which is a noteworthy limitation. Furthermore, we have not considered differences in surgical expertise.\u003c/p\u003e \u003cp\u003eHowever, we consider the design of our study especially with its matched-pair formation and definition of inclusion and exclusion criteria to be a major strength. To our knowledge, no other matched-pair analysis has been conducted to evaluate RC ERAS protocols. Further studies should include a higher number of patients and a multicenter approach.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eRC is a complex surgery with high complication rates. ERAS protocols have been introduced in order to optimize pre-, intra- and postoperative treatment. We report that devotion to ERAS protocol resulted in a significantly shorter hospital stay in patients with a hospital stay of \u0026le;\u0026thinsp;30 and \u0026le;\u0026thinsp;20 days with a comparable complication rate. In particular, early removal of single-J stents did not provoke higher urinary tract complications or hospital readmission.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eASA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;American Society of Anesthesiologists\u003c/p\u003e\n\u003cp\u003eBMI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Body mass index\u003c/p\u003e\n\u003cp\u003eERAS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Enhanced Recovery After Surgery\u003c/p\u003e\n\u003cp\u003eNG tube\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Nasogastral tube\u003c/p\u003e\n\u003cp\u003eRC \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; radical cystectomy\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted after obtaining institutional review board approval (No. 2020-15029) from the ethics committee of the medical association of Rhineland-Pfalz \u003cem\u003e(Ethikkommssion bei der Landes\u0026auml;rztekammer Rheinland-Pfalz)\u003c/em\u003e. \u0026nbsp;Informed consent was obtained from all participants. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article and its supplementary information files. Raw data are available upon request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFischer ND \u0026ndash;\u0026nbsp;project development, data collection, data analysis, manuscript writing\u003c/p\u003e\n\u003cp\u003eBrandt MP \u0026ndash; project development, data collection, data analysis, manuscript writing\u003c/p\u003e\n\u003cp\u003eEpple S \u0026ndash; data collection, data analysis, manuscript writing\u003c/p\u003e\n\u003cp\u003eHorn F \u0026ndash; data collection, data analysis, manuscript writing\u003c/p\u003e\n\u003cp\u003eHaack M \u0026ndash;data collection, manuscript editing\u003c/p\u003e\n\u003cp\u003eDuwe G \u0026ndash; data collection, manuscript editing\u003c/p\u003e\n\u003cp\u003eSparwasser P \u0026ndash; data collection, manuscript editing\u003c/p\u003e\n\u003cp\u003eDotzauer R \u0026ndash; data collection, manuscript editing\u003c/p\u003e\n\u003cp\u003eThomas A \u0026ndash; data collection, manuscript editing\u003c/p\u003e\n\u003cp\u003eTsaur I \u0026ndash; data collection, manuscript editing\u003c/p\u003e\n\u003cp\u003eHaferkamp A \u0026ndash; data collection, manuscript editing\u003c/p\u003e\n\u003cp\u003eJ\u0026auml;ger W \u0026ndash; project development, data collection, data analysis, manuscript writing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLee R, Chughtai B, Herman M, Shariat SF, Scherr DS. Cost-analysis comparison of robot-assisted laparoscopic radical cystectomy (RC) vs open RC. BJU Int. 2011;108(6 Pt 2):976\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHautmann RE, de Petriconi R, Gottfried HW, Kleinschmidt K, Mattes R, Paiss T. The ileal neobladder: complications and functional results in 363 patients after 11 years of followup. J Urol. 1999;161(2):422-7; discussion 7\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBolenz C. Urothelkarzinom der Harnblase: Chirurgische Therapie. Die Urologie: in 3 B\u0026auml;nden. Springer; 2023. pp. 803\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClark PE, Stein JP, Groshen SG, Cai J, Miranda G, Lieskovsky G, et al. Radical cystectomy in the elderly: comparison of clinical outcomes between younger and older patients. Cancer. 2005;104(1):36\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorgmann H, Kamal MM, Metzger A, Dotzauer R, Fischer N, Sparwasser P, et al. High\u0026ndash;Normal Preoperative Potassium Level Is Associated with Reduced 30\u0026ndash;Day Morbidity and Shorter Hospital Stay after Radical Cystectomy. J Clin Med. 2022;11(5):1174.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKamal M, Borgmann H, Metzger A, Schregel C, Nabar N, Haack M, et al. The PT 2 D-Score: a novel tool to predict complications and economic outcome after radical cystectomy. World J Urol. 2020;38:3155\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCerantola Y, Valerio M, Persson B, Jichlinski P, Ljungqvist O, Hubner M, et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS((R))) society recommendations. Clin Nutr. 2013;32(6):879\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilliams SB, Cumberbatch MGK, Kamat AM, Jubber I, Kerr PS, McGrath JS, et al. Reporting Radical Cystectomy Outcomes Following Implementation of Enhanced Recovery After Surgery Protocols: A Systematic Review and Individual Patient Data Meta-analysis. Eur Urol. 2020;78(5):719\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMir MC, Zargar H, Bolton DM, Murphy DG, Lawrentschuk N. Enhanced recovery after surgery protocols for radical cystectomy surgery: review of current evidence and local protocols. ANZ J Surg. 2015;85(7\u0026ndash;8):514\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePang KH, Groves R, Venugopal S, Noon AP, Catto JW. Prospective implementation of enhanced recovery after surgery protocols to radical cystectomy. Eur Urol. 2018;73(3):363\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFischer N, Epple S, Wittenmeier E, Betz U, Haferkamp A, J\u0026auml;ger W. Implementation of Enhanced Recovery after Surgery (ERAS\u0026reg;) protocol in radical cystectomy at the University Medical Center Mainz. Der Urologe. 2021;60:169\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrees SK, Aning J, Black P, Struss W, Bell R, Chavez-Munoz C, et al. A prospective randomized pilot study evaluating an ERAS protocol versus a standard protocol for patients treated with radical cystectomy and urinary diversion for bladder cancer. World J Urol. 2018;36:215\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVlad O, Catalin B, Mihai H, Adrian P, Manuela O, Gener I et al. Enhanced recovery after surgery (ERAS) protocols in patients undergoing radical cystectomy with ileal urinary diversions: a randomized controlled trial. Medicine. 2020;99(27).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin T, Li K, Liu H, Xue X, Xu N, Wei Y, et al. Enhanced recovery after surgery for radical cystectomy with ileal urinary diversion: a multi-institutional, randomized, controlled trial from the Chinese bladder cancer consortium. World J Urol. 2018;36(1):41\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarl A, Buchner A, Becker A, Staehler M, Seitz M, Khoder W, et al. A new concept for early recovery after surgery for patients undergoing radical cystectomy for bladder cancer: results of a prospective randomized study. J Urol. 2014;191(2):335\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cystoprostatectomy, ERAS, Hospital Stay, Complications, matched-pair analysis","lastPublishedDoi":"10.21203/rs.3.rs-3853491/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3853491/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRadical cystectomy (RC) is marked by a tremendous potential for short and long-term complications. By introduction of Enhanced Recovery After Surgery (ERAS) protocols serious endeavors have been made in order to reduce postoperative morbidity in favor of a fast-track recovery. In this study, we investigated the impact of our in-house ERAS protocol on postoperative complications and hospital stay.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe identified 106 patients who received standard care of treatment post-surgery (non-ERAS group). After implementation of our ERAS protocol, we prospectively recorded data from 53 patients (ERAS group) up to 90 days post-surgery. Non-ERAS patients were matched with ERAS patients with respect to preoperative clinical characteristics. Statistical analysis was conducted by matched-pair analysis and Wilcoxon-Mann-Whitney-Test.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAltogether 51 patients were matched. Considering patients with a hospital stay of \u0026le;\u0026thinsp;30 and \u0026le;\u0026thinsp;20 days we noticed a significant difference in favor of ERAS protocol (p\u0026thinsp;=\u0026thinsp;0.043, p\u0026thinsp;=\u0026thinsp;0.004) with regards to hospital stay. Removal of single-J stents occurred on day 11 (8\u0026ndash;17) in the non-ERAS group and on day 8 (\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13 CR14\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) in the ERAS group post-surgery (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No difference could be identified in overall and 90-day complication rate (p\u0026thinsp;=\u0026thinsp;0.443).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eAdherence to ERAS protocol achieved a significantly shorter hospital stay in patients with a hospital stay of \u0026le;\u0026thinsp;30 and \u0026le;\u0026thinsp;20 days with no increase in complication rates. Furthermore, early removal of single-J stents did not result in higher rates of postoperative complications and hospital readmission.\u003c/p\u003e","manuscriptTitle":"Enhanced Recovery After Surgery (ERAS) versus standard recovery after radical cystectomy – a matched-pair analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-07 20:08:41","doi":"10.21203/rs.3.rs-3853491/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"433ab5e4-0509-452a-9087-46527bbd17e2","owner":[],"postedDate":"February 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-03T10:40:44+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-07 20:08:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3853491","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3853491","identity":"rs-3853491","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}