Enhanced Recovery After Surgery for the Complete Primary Repair of Bladder Exstrophy
Andrea K. Balthazar, MD1, Vivian Williams, MSN, RN, CPNP1, Ted Lee, MD, MPH1, Tanya Logvinenko, Ph.D.1, Ozge Yetistirici, Ph.D.2, Saaafia Massoom, BA1, Julia B. Finkelstein, MD, MPH3, Lauren Cullen, MSN, CPNP1, Debra Lajoie, Ph.D., MSN, RN4, Sabeena K. Chacko, MD5, Joseph G. Borer, MD1, Richard S. Lee, MD1.
1Boston Children's Hospital, Department of Urology, Boston, MA, USA, 2Boston Children's Hospital, Boston, MA, USA, 3Columbia University Department of Urology, New York City, NY, USA, 4Boston Children's Hospital, Surgical Programs, Boston, MA, USA, 5Boston Children's Hospital, Department of Anesthesiology, Boston, MA, USA.
Introduction: Enhanced recovery after surgery (ERAS) is a multidisciplinary set of tools implemented to optimize perioperative care and expedite surgical recovery. ERAS protocols have been successfully applied in adult and pediatric urology as well as numerous other surgical specialties with reductions in length of stay (LOS), decreased rates of complications, reduced narcotic use, and improved patient-reported outcomes. However, there are no current guidelines or existing studies addressing the use of ERAS in the complete primary repair of bladder exstrophy (CPRE), which is a very complex, low-frequency surgical procedure. Management of bladder exstrophy (BE) involves complex multidisciplinary surgical and perioperative care. Historically, at our institution, these cases entailed lengthy operative time requiring central access, postoperative recovery in the ICU, high narcotic requirements, risk of ileus, and prolonged LOS. Therefore, we hypothesized that instituting a consistent surgical team and ERAS principles would significantly benefit the delivery of BE care. We aimed to describe the implementation and evolution of an ERAS program for CPRE.
Methods:A consistent multidisciplinary team developed an ERAS program for CPRE, which defines inclusion and exclusion criteria as well as preoperative, intraoperative, and postoperative protocols. Simultaneously, a new surgical approach was instituted by dividing the surgical procedures into two consecutive days. During the first operative day, orthoperiodic surgery performs bilateral iliac osteotomies and SPICA cast placement, and anesthesia performs insertion of the epidural. On the second operative day, the urology team performs the CPRE surgery with subsequent transfer to non-ICU level care. ERAS standards of care were incorporated throughout to maximize evidence-based strategies during the perioperative period. Mann Whitney test was used to compare the total anesthesia time and length of stay between the two groups.
Results:Before implementation, our center performed between 2 to 6 (median 4 [IQR 3.5,5]) CPRE cases per year (2013-2020). Generally, these patients had a peripherally inserted central catheter (PICC) and postoperative recovery in the ICU. We launched the ERAS for CPRE pathway in June of 2020 and have successfully completed 8 cases. The post-ERAS combined median general anesthesia time was 13.5 (IQR: 12.3-15.2) hours and did not differ significantly (p=0.85) from the pre-ERAS time, median 13.5 (IQR: 12.5-14.4) hours of GA. Since the initiation of ERAS, the median ICU LOS significantly decreased from 2.25 (IQR:2-4) to 0.5 (IQR: 0,2.5) days (p=0.0042), and median overall LOS significantly decreased from 15 (IQR:13-20) to 9.5 (IQR: 7.5-12) days(p=0.0335). Other changes include limited periods of fasting, minimized narcotic use, initiated early feeding, reduced utilization of oral antibiotics, and transitioned from PICC to peripheral IV access. Postoperatively, no patient required transfer to a higher level of care, and all patients were safely discharged to home with no complication within 30-days.
Conclusions:The development of a consistent surgical team and applying ERAS principles to CPRE can decrease variations in care. This led to improvements in surgical care through optimization of
patient outcomes and effective resource utilization. Although ERAS has typically been utilized for high-volume procedures, our program highlights that ERAS is both feasible and adaptable to less common, complex surgical procedures.
Back to 2021 Abstracts