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Modified enhanced recovery after surgery protocol versus nonenhanced recovery after surgery in radical cystectomy surgery (preliminary study)

Purpose: Enhanced recovery after surgery (ERAS) protocol has proven to lower both length of stay and recovery time, while being cost-effective at the same time. There are three ERAS protocols implemented for radical cystectomy (RC). All of those were published by different institutions, such as the European Association of Urology, the Société Internationale d'Urologie, and the American Urological Association. We modified and proposed ERAS components from preoperative care until postoperative care to evaluate the implementation of ERAS for RC. Standard ERAS protocol is not fully applicable in Hasan Sadikin General Hospital due to financial factors and the limited list of drugs available to choose from our universal health coverage prescription system; thus, we had to make some modifications. This study aims at evaluating the preliminary results of an implementation of modified ERAS protocol in RC at our hospital. Materials and Methods: A cohort retrospective study of 21 consecutive patients who underwent RC (9 ERAS vs. 12 non-ERAS). The primary outcomes were the reduced length of stay (LOS) and hospitalization cost. The secondary outcomes included less intraoperative blood loss, faster bowel movement, lower transfusion rates, and decreased readmission rates. Results: Patients with ERAS had lower blood loss (ERAS median [range]: 1100 [500–2000] ml vs. 1650 [100–3000] ml for non-ERAS, P = 0.219), lower transfusion rates (ERAS: 55.6% vs. 91.7% for non-ERAS, P = 0.119), and fewer readmissions (ERAS: 0% vs. 8.3% for non-ERAS, P = 1.000). Bowel movement was faster in ERAS group (ERAS mean [range]: 6.11 ± 2.977 [3.00–12.00] h vs. 12.50 ± 5.385 [6.00–24.00] h for non-ERAS, P = 0.005). Duration of hospitalization was shorter with ERAS (5 [3–7] days) than without ERAS (8 [5–20] days, P = 0.003). The total mean costs were significantly higher in the non-ERAS group compared to the ERAS group ($1529 ± 346 for ERAS vs. $2580 ± 1415 for non-ERAS, P=0.028). Conclusion: Modified ERAS protocols for RC at our institution reduced the LOS and hospitalization cost and lead to faster bowel movement and no readmission.