Study design
We retrospectively identified 143 patients who underwent RC with ileal conduit creation between June 2010 and December 2021 at a single institution. We excluded patients who underwent additional procedures related to concomitant malignancies, such as upper tract urothelial carcinoma and colorectal cancer, and those with surgical complications. ERAS was adopted in July 2017, and eRARC in June 2018 [15]. ERAS was used in all patients undergoing eRARC. Fig. 1 depicts the timing of the changes in perioperative protocol and surgical approach.
We allocated the patients to the following three groups: group A comprised 75 patients who underwent ORC with conventional recovery after surgery (CRAS) between June 2010 and June 2017, group B comprised 47 patients who underwent ORC with ERAS starting in July 2017, and group C comprised 21 patients who underwent eRARC with ERAS starting in June 2018. The institutional review board approved the study (approval number 712).
Surgical procedures
ORC
After a suprapubic to infraumbilical skin incision, a retrograde and retroperitoneal approach was taken, with the peritoneum being opened just before specimen removal. The prostate and seminal vesicles in men and the uterus and anterior vaginal wall in women were also extracted. Pelvic lymph node dissection, whose extent was determined at the surgeon’s discretion, was ordinarily performed below the level of the common iliac artery. The surgeon’s experience varied from fellowship to expert, but at least one well-experienced surgeon attended each operation.
RARC
RARC was performed with a da Vinci Si, X, or Xi surgical robot (Intuitive Surgical, Sunnyvale, CA, USA) and six ports. The surgical maneuvers were identical to those in ORC, but an antegrade and transperitoneal approach was used. Before attempting RARC, every surgeon had performed over 30 robot-assisted radical prostatectomies. All patients were operated on consecutively starting with the initial implementation of RARC.
Urinary diversion
To construct an ileal conduit, a 60 mm Endo GIA stapler (Covidien, Dublin, Ireland) was used to isolate a 15–20 cm segment of the ileum 10–15 cm from the oral side of the cecum valve. The stapler was also used to create the functional end-to-end ileal–ileal anastomosis; the Nesbit or Wallace method with ureteral stents was used to create the ureteroileal anastomosis. In RARC, an extra 5 cm skin incision was added to extirpate the specimen and construct the ileal conduit.
Perioperative protocol
ERAS was formally introduced in July 2017 [15]. However, parts of its preoperative counseling, education, and medical optimization had been applied before that. No anesthesiologist was dedicated to RC procedures; therefore, intraoperative anesthesia was managed by the attending anesthesiologist in each case. Table 1 lists the changeover from conventional recovery to ERAS.
Data extraction
The demographic data collected for patients included age, sex, body mass index (BMI), American Society of Anesthesiologist physical status (ASAPS), prior abdominal surgery, prior pelvic radiotherapy, and neoadjuvant chemotherapy. Operative data, such as operation time and use of transfusion were also extracted.
Complications were graded using the Clavien–Dindo classification version 2.0, with a complication greater than grade 3 defined as a major complication. All patients were followed postoperatively for at least 90 days.
Outcome measures
The primary endpoint was LOS. The secondary endpoint was the 90-day postoperative complication rate, including overall complications, major complications, paralytic ileus, and miscellaneous gastrointestinal (GI) complications, such as bowel obstruction and anastomosis failure.
Statistical analysis
The Fisher exact test was used to compare categorical variables. Whereas, the Kruskal–Wallis test was used to compare continuous variables. Categorical variables are reported as frequencies and percentages, and continuous variables are reported as medians with an interquartile range.
In outcome analyses, LOS and complication rates were first compared between the groups.
Next, pairs of groups were compared (group A vs. group B and group B vs. group C) to estimate the outcome improvement resulting from ERAS and eRARC individually. Specifically, the differences in LOS after ERAS or eRARC were evaluated in a linear regression model. The odds ratios (OR) for complications were evaluated in logistic regression models, comparing values from, before, and after implementing ERAS or eRARC. Finally, univariate and multivariate analyses were performed to assess the contributions of ERAS and eRARC to outcomes.
All statistical analyses were performed using the EZR software (Saitama Medical Center, Jichi Medical University, Saitama, Japan), a graphical user interface for R software (The R Foundation for Statistical Computing, Vienna, Austria) [16]. All P values are two-sided, and P < 0.05 was considered statistically significant.