Implementation of ERAS, PreHab Combo Leads to Improved Patient Recovery After Prostatectomy

August 16, 2020

This study found that implementation of the enhanced recovery after surgery pathway combined with prehabilitation programs can significantly change the postoperative course of patients.

An article published in Cancer indicated that the implementation of the enhanced recovery after surgery (ERAS) pathway combined with prehabilitation (PreHab) programs can significantly change the postoperative course of patients and may also simultaneously aid in optimizing robot-assisted radical prostatectomy (RARP) outcomes.

Overall, researchers indicated that the combination use of these pathways improves patient recovery and is associated with reduced lengths of stay, blood loss, operative times, and costs without creating an increase in the post-discharge readmission rate.

“The aim was to provide a targeted and personalized approach,” the authors wrote. “Overall, the patients perceived a great benefit from these perioperative protocols.”

In total, 507 consecutive patients from a prospective database undergoing RARP from 2014 to 2019 were included in the study. The primary end point was duration of hospital stay and secondary end points included intraoperative blood loss, operative duration, readmission rate, and overall costs.

The ERAS protocol was applied to 350 of the 507 study participants (69%) and the PreHab program was then applied to 194 patients (38.3%). Importantly, only 5.3% of the patients included in the study underwent outpatient surgery.

The cohort of patients assigned to ERAS protocol had shorter hospital stays (P < .001), reduced operative times (P < .001), and decreased blood loss (P < .001) in comparison with those who did not receive ERAS. Moreover, shortened hospital stays were not associated with an increased readmission rate (7.9% [stable over time]; P = .757).

“The readmission rates were in line with the rates of 9% to 11% published in nationwide, population-based studies,” the authors noted. “Readmissions tended to occur earlier for ERAS patients.”

Those who were not assigned to either pathway were found to have a longer hospital stay (4.7 days) than those who only received the ERAS protocol (3.5 days) as well as those who received both ERAS and PreHab (1.6 days; P < .001). Further, in multivariate analysis, operative time and perioperative pathway (odds ratio for ERAS, 0.144; P < .001; odds ratio for ERAS and PreHab, 0.025; P < .001) were independently predictive for a prolonged length of stay (P < .001). Costs also decreased significantly when ERAS and PreHab pathways were combined.

“The key element to the success of all these programs is the multidisciplinary approach, which includes surgeons, nurses, anesthetists, physiotherapists, dieticians, psychologists, and cancer nurse specialists,” the authors wrote. “Our experience also showed that group interviews during the PreHab day were very appreciated by patients because they promoted interactive discussions, but they required large rooms for computer presentations and group audiences, which may represent a limitation for other institutions.”

Of note, the researchers indicated that the improvements seen in terms of operative time and blood loss could also possibly be explained by better procedure performance by all involved surgeons at the time. In addition, no randomization was performed; the programs were just progressively implemented as a part of routine practice.

“The next step would be to randomize patients according to the PreHab status,” the authors wrote. “However, because of the proven benefit, some ethical issues might be discussed before such a trial is launched.”

Reference:

Ploussard G, Almeras C, Beauval J, et al. A Combination of Enhanced Recovery After Surgery and Prehabilitation Pathways Improves Perioperative Outcomes and Costs for Robotic Radical Prostatectomy. Cancer. doi: 10.1002/cncr.33061.