Complications and high readmission rates are a persistent challenge following radical cystectomy for the treatment of bladder cancer. The complex, intrabdominal operation, which includes replacement of the bladder or creation of a stoma, and often includes removal of reproductive organs as well, is associated with a high rate of morbidity. Patients undergoing the procedure often have additional risk factors for venous thromboembolism (VTE), such as pre-operative chemotherapy, older age and a history of smoking, and VTE is estimated to occur in 5.5 to 8.5 percent of patients and cost more than $10,000 per event. In a comprehensive effort to reduce risk of VTE, reduce length of stay and improve other measures of quality of care, Brigham and Women’s Hospital urologists have implemented a perioperative VTE prophylaxis program and analyzed its results, reporting key quality of care improvements. In addition, in collaboration with nurses, anesthesiologists, pharmacists and other members of patients’ care teams, clinicians in the Division of Urology are exploring innovative initiatives to continue to make strides in improving patient care.
“Given the Brigham’s high volume of radical cystectomies—we perform approximately 120 procedures each year—we’re in a unique position to be able to focus on improvements, institute process changes and perform randomized clinical trials to inform evidence-based practice,” said Mark Preston, MD, MPH, a Brigham urologic surgeon. “Our strengths have attracted interest from collaborators both within and outside of the hospital and we’re actively engaged in ongoing quality improvement efforts for this operation to improve patient outcomes.”
Comprehensive Prophylaxis
The perioperative VTE prophylaxis program adopted at the Brigham includes both an enhanced recovery after surgery (ERAS) protocol and an extended post-discharge pharmacologic prophylaxis for at-risk postsurgical patients. The Brigham’s ERAS protocol includes a preoperative carbohydrate drink, prophylactic antibiotics, multi-modal pain control to minimize narcotic use, anesthesia goal-directed volume management; and clear liquid diet and ambulation beginning on postoperative day 1.
Implemented in 2015, the program has yielded a rich dataset that Preston and colleagues analyzed and describe in a paper recently published in European Urology Focus. Using patient and outcome data prospectively collected as part of the American College of Surgeons National Surgical Quality Improvement Program, the team found that the VTE rate was significantly lower, decreasing from 6.2 percent among the 319 patients in the pre-intervention cohort to 0.9 percent among the 109 patients in the post-intervention cohort. Length of stay was also reduced from an average of 7 days to 6 days.
From Prehab to Rehab
Urologist Matthew Mossanen, MD, and others in the division recognize that process improvement opportunities begin long before surgery and have launched a prehabilitation program for radical cystectomy patients.
“We’re building a program to help prepare patients before the operation,” said Mossanen. “I like to tell patients, ‘Think of a mountain that you’re about to hike. We want to train you now, before the hike begins, rather than give you instructions once you’re already on the trail.’”
The Brigham’s radical cystectomy prehabilitation program focuses on bolstering patients’ nutritional, functional, and psychological well-being before surgery. Smoking cessation is also a key focus. While trials are ongoing, preliminary data suggest that these efforts may reduce readmission rates and improve patient recovery.
More to Explore
In October, Preston and colleagues launched a randomized trial sponsored by Merck, Inc., to test whether Entereg (alvimopan), a gastrointestinal opioid-receptor blocker developed to counteract bowel-related complications, adds benefit when combined with an established ERAS protocol. The trial is expected to finish sometime in the next two years.
The division is also exploring the use of intravenous acetaminophen and the effects of its administration on length of stay. So far, the team has evaluated and published results in the Journal of Pain & Palliative Care Pharmacotherapy for its use among patients undergoing robotic-assisted laparoscopic prostatectomy, finding that patients receiving IV acetaminophen showed a 32 percent decrease in length of stay when compared with placebo. Length of stay for radical cystectomy is far longer—typically 7 to 10 days—and additional study will be needed to determine if use of IV acetaminophen can translate to similar benefits for patients undergoing this procedure.
Adam Kibel, MD, chief of the Division of Urology, sees value in collecting hard data to quantify and assess improvements.
“Our goal is to help our patients rehabilitate faster with fewer complications. The work of Dr. Preston and colleagues to implement the perioperative VTE prophylaxis program represents a huge step forward as does Dr. Mossanen’s pioneering work on prehabilitation,” said Kibel. “We’ve seen exciting results already from these changes, but we’re not stopping there. We’ll continue to foster and explore innovative ideas and find new evidence for how to improve the experiences of our patients.”