Enhanced Recovery After Surgery in the Urinary Diversion Population: Are Protocols Applied Differently in the Benign Indication Population?

OBJECTIVE: To retrospectively evaluate enhanced recovery after surgery (ERAS) protocol administration, hospital length of stay, 30-day readmission, and complication rates among cystectomy and/or urinary diversion patients with benign or malignant indication. MATERIALS AND METHODS: Data was extracted retrospectively for cystectomy and/or urinary diversion performed at our institution from June 2016 to May 2019. Descriptive statistics, Chi squared, Wilcoxon rank-sum, binary logistic regression, and linear regression functions in R 4.0.4 (R Foundation), R Package "Tidverse" V1.3.0.9, and RStudio V1.44.1106 (RStudio, PBC) were used to analyze data. RESULTS: 102 patients met selection criteria with 36 and 66 patients in the benign and malignant indication cohorts, respectively. Significant differences between cohorts included BMI, age, opioid exposure, and spinal anomalies. The malignant cohort had higher ERAS completion rates for preoperative and intraoperative protocols (41% and 53% vs 14% and 19%). The mean ERAS item administration for benign and malignant indication patients differed significantly (2.9 vs 4.2, P < 0.01). Logistic regression demonstrated benign indication was significantly associated with ERAS failure (OR 4.25, 95% CI 1.18 - 21.03, P = 0.043). Higher ERAS item administration sum was associated with shorter hospitalizations and lower complication rates (P = < 0.01, P = 0.019). No association was observed for 30-day readmission. CONCLUSION: The benign urinary diversion/cystectomy population more frequently possesses characteristics adverse to ERAS protocol completion and in our study received fewer ERAS protocol items. This was associated with longer hospitalizations and higher postoperative complication rates. Population-specific ERAS protocols targeted at increasing ERAS completion could reduce morbidity.

Robotic ureteral reconstruction distal to the ureteropelvic junction: a large single institution clinical series with short-term follow up.

BACKGROUND AND PURPOSE: Use of the robotic platform for urinary reconstructive surgery is growing in popularity since its initial application with pyeloplasty for ureteropelvic junction (UPJ) repair. Although clinical series of adult robotic ureteral reconstruction appear in the literature, these reports tend to be limited in size and scope. We present the largest series to date of patients undergoing surgery for any obstruction distal to the UPJ along with outcomes and short-term follow up. PATIENTS AND METHODS: A retrospective chart review was performed for patients undergoing robotic ureteral reconstructive procedures for any indication at our institution. Patients undergoing pyeloplasty, planned open procedures, and pediatric patients were excluded from the current analysis. Patient demographic data, etiology, procedure performed, and perioperative outcomes were reviewed. Postoperative follow up, imaging, and any re-interventions were also captured. The procedures performed included ureteroneocystostomy, psoas hitch, Boari flap, ureteroureterostomy, ureterolysis, ureterolithotomy, and nephropexy. RESULTS: A total of 55 patients underwent robotic ureteral reconstructive procedures distal to the UPJ. Of these patients, 45 underwent intervention for a benign etiology and 10 for upper tract malignancy. All cases were successfully completed robotically with no open conversions and no intraoperative complications. Concurrent endoscopy was performed in 31 patients. The median operating room time was 221 minutes overall. Median blood loss was 50 ml with no intraoperative transfusions. The average hospital stay was 1.6 days, with 39 patients (71%) discharged on postoperative day 1. All surgical margins were negative for malignancy. The median follow up with imaging was 181 days. There were two serious complications (3.6%) and three failures (5.3%). CONCLUSIONS: Robotic reconstruction of the ureter distal to the UPJ is feasible, safe, effective, and able to replicate techniques of open surgery with equivalent outcomes to large robotic pyeloplasty and smaller distal ureteral reconstruction series.