ERAS vs. Traditional Protocol in Patients Who Had Radical Cystectomy with Ileal Conduit: A Retrospective Comparative Analysis of 182 Cases

Objective. To examine the effects of ERAS protocol application on hospital stay, postoperative antibiotic use, and gastrointestinal recovery time in radical cystectomy patients with ileal conduit. Materials and Methods. This retrospective study included 182 patients (112 traditional vs. 72 ERAS) who underwent radical cystectomy (RC) with ileal conduit between November 2017 and December 2020. Patients were compared in terms of time to start enteral feeding (SEF), length of hospital stay (LOS), time to first stool, duration of postoperative intravenous antibiotic use, postoperative ileus rate, and serum albumin levels. Results. The traditional and ERAS groups contained 112 and 72 patients, respectively. LOS (14.79 ± 6.44 vs. 10.44 ± 4.64 days, ), first stool time (4.43 ± 2.39 vs. 2.89 ± 1.81 days, ), and duration of postoperative intravenous antibiotic use (8.79 ± 5.17 vs. 4.61 ± 4.90, ) were to be found significantly shorter in the ERAS group. Conclusion. According to the results of this study, the ERAS protocol shortened the length of hospital stay, duration of antibiotic use, and time of first stool in patients who underwent RC with ileal conduit.

1. Introduction
Bladder cancers are the second most common of the genitourinary system. Approximately 20–40% of them are muscle invasive at the time of diagnosis [1]. Radical cystectomy (RC) and pelvic lymph node dissection are standard treatment modalities for muscle-invasive bladder tumors [2]. The primary goal of bladder cancer treatment is to minimize mortality and morbidity while obtaining the best oncological results [3]. Fortunately, morbidity and mortality from RC have decreased in recent years due to advances in surgical technique, anesthesia, and postoperative procedures [4].

Although various methods are used for urinary diversion, the ileal conduit is currently the most preferred method [5]. Early complications such as nausea, vomiting, fever, and ileus have been reported in patients after the ileal conduit procedure, however [6]. These complications affect the length of hospital stay and increase the cost of the operation.

In the past, the lack of a standard protocol in postoperative healthcare resulted in different approaches to patients, such as a postoperative bowel rest period and/or a preoperative bowel cleaning, and pain management decisions differed for each surgeon [7]. Today, enhanced recovery after surgery (ERAS) is in place, which is the concept of multimodal, perioperative interventions to improve postoperative outcomes. ERAS protocol consists of 21 topics that concern the preoperative, intraoperative, and postoperative periods. The protocol is based on anesthesia, analgesia, perioperative fluid management, nutrition, early mobilization, and shortening the healing process by reducing the metabolic trauma caused by surgery [8]. Recently, studies in the field of urological surgery have started with the ERAS protocol. It has been shown that the length of hospital stay (LOS) and the rate of development of ileus are statistically significantly less in patients who underwent the ERAS protocol compared to those using the traditional approach [9–11]. Although more studies are required, no significant difference was observed in terms of anastomotic leaks, peritonitis, or other complications [12].

Our study aimed to compare the start time of enteral feeding (SEF), the first stool time, LOS, duration of postoperative antibiotic use, rates of ileus, and serum albumin values of patients with ileal conduit under the ERAS protocol with those who underwent a traditional protocol.