Archivio Italiano di Urologia e Andrologia 2019; 91, 4230 ORIGINAL PAPER Is Fast Track protocol a safe tool to reduce hospitalization time after radical cystectomy with ileal urinary diversion? Initial results from a single high-volume centre Daniele Romagnoli 1, Riccardo Schiavina 2, Lorenzo Bianchi 2, Marco Borghesi 2, Francesco Chessa 2, Federico Mineo Bianchi 2, Andrea Angiolini 2, Carlo Casablanca 2, Marco Giampaoli 1, Paolo Corsi 1, Daniele D’Agostino 1, Eugenio Brunocilla 2, Angelo Porreca 1 1 Abano Terme Hospital, Abano Terme (PD), Italy; 2 St. Orsola Malpighi Universitary Urology Clinic, Bologna (BO), Italy. Introduction and aim: Radical Cystectomy (RC) with ileal urinary diversion is one of the most complex urological surgical procedure, and many Fast Track (FT) protocols have been described to reduce hos- pitalization, without increasing postoperatory complications. We present the one-year results of a dedicated protocol devel- oped at a high volume centre. Materials and methods: The FT protocol was designed after a review of the literature and a multidisciplinary collegiate dis- cussion, and it was applied to patients scheduled to open RC with intestinal urinary diversion. To validate its feasibility, we compared its results with data collected from a 1:1 matched population of patients who had undergone the same surgical procedure, without the implementation of the FT protocol. Results: We enrolled in the FT group 11 (55%) patients sched- uled to RC with ileal conduit diversion, and 9 patients (45%) scheduled to orthotopic neobladder (Studer) substitution, while a numerically equivalent population was enrolled in the con- trol group, matched according to age at surgery, BMI, gender, ASA score, CCI, preoperative stage and type of urinary diver- sion. No statistically significant difference was found in terms of pre-operatory and intra-operatory domains. Median overall age was 71 years (Inter Quartile Range - IQR: 63-76) and mean operatory time was 276 ± 57 minutes. Hospitalization time was significantly reduced in the FT group, considering oralization and canalization items we found a significant advantage in the FT group. No statistically significant differ- ence was found in the control of the post-operatory pain. We found no difference, in terms of both early and late complica- tions ratio, among the two populations. Complications graded Clavien ≥ 3 were found in 4 patients of the control group (20%), while in only one patient (5%) in the Fast Track group, though this difference was not statistically significant. Conclusions: The Fast Track protocol developed in this study has proven to be effective in significantly reducing hospitaliza- tion time in patients submitted to RC with intestinal urinary diversion, without increasing post-operatory complications ratio. KEY WORDS: Radical cystectomy; Fast Track; Enhanced recovery; After surgery. Submitted 4 June 2019; Accepted 26 June 2019 Summary No conflict of interest declared. DOI: 10.4081/aiua.2019.4.230 INTRODUCTION Bladder cancer (BC) represents the 7th most common can- cer in male population and the 11th considering both sexes (1). Open RC remains the gold standard for the surgical treatment of localized muscle invasive bladder cancer (MIBC) or non-muscle invasive bladder cancer (NMIBC) resistant to topic chemo- and immunologic therapy (2, 3). RC with urinary diversion is considered one of the most complex urological surgery and is char- acterized by long hospital stay and high rate of postop- erative morbidity and mortality. Complication rate could be up to 34.4% (and to 50% in some series) for mild- moderate grade (Clavien Dindo < 3), and up to 17.5% for severe grade (4, 5) (Clavien Dindo ≥ 3). Even if improvements in surgical procedure have reduced inci- dence of postoperative complication, it remains impor- tant to minimise surgical trauma and optimise perioper- ative care. The term “Fast Track” refers to a group of perioperative protocols aimed to standardise perioperative cares, shorten hospital stay, maintain optimal surgical treat- ment quality without increasing postoperative complica- tion rate (6). They are also commonly known as Enhanced Recovery After Surgery (ERAS) protocols, as they were firstly described in general surgery. FT schemes are standardised, multimodal and multidiscipli- nary developed protocols aimed to enhance surgical out- comes referring to perioperative “best clinical practice” (7). The origins of ERAS protocols date back to the early 90s with the experiences of Dahl et al., with bupivacaine intratecal analgesia (8), and Kehlet et al. with epidural anaesthesia, high preoperative glucose intake and early mobilization and starting of oral diet, applied on col- orectal surgery with a mean reduction of 2 days in terms of hospital stay (9). From the urologist’s point of view, FT protocols can be applied mainly to RC with ileal diver- sion, considering the complex operation technique, high complication rate and long mean hospital stay. Distinctive tract of the FT protocols is that they can be adapted on patient’s needs depending on perioperative management phase. Key features of FT protocols are: perioperative diet management, advanced anesthesiolog- ical technique, specific antalgic postoperative care (based on non-opioid drugs), early oral diet intake and mobilization (10). We developed a FT protocol with the aim of reducing mean hospitalization time in patients sub- Romagnoli_Stesura Seveso 10/01/20 08:50 Pagina 230 231Archivio Italiano di Urologia e Andrologia 2019; 91, 4 Fast Track protocol after radical cystectomy with ileal urinary diversion mitted to RC with ileal urinary diversion in our centre, without increasing the complications ratio. MATERIALS AND METHODS After an extensive review of literature and a multidisciplinary team consult consisting of urologists, anesthesiologists, nurses and nutri- tionists, we developed an ERAS protocol (see Appendix). To test the effect of this protocol, we designed a pilot observational prospective cohort study, in accordance with the principles and practice of our Review Board. The proto- col focused on the reduction of postoperative nausea and vomiting, early canalization, naso- gastric tube (NGT) removal, enteral feeding and mobilization, shorter hospitalization time, without significant worsening in terms of com- plication rate or pain management. We enrolled 20 consecutive patients candidate to open RC with ileal urinary diversion from January 2016 to April 2017 at a single high volume centre. Each operation was performed by surgeons at the end of the learning curve and with extensive experience. The indica- tions for RC included muscle-invasive bladder carcinoma or high-grade non-muscle invasive bladder carcinoma refractory to topic intraves- ical immunotherapy in fit-for-surgery patients (2, 3). Preoperative radiological assessment was realized via a toraco-abdominal computed tomography with urographic reconstructions and contrast enhanced magnetic resonance of the pelvis (we adopted this accessory tech- nique in order to have a precise and detailed study of the pelvis, as previously described) (11). Data were prospectively collected from medical records. For each patient of the study population a one-to-one propensity score- matched analysis was performed with a popu- lation selected among 64 patients who under- went RC with ileal urinary diversion, without application of the FT protocol. Each patient received detailed instructions about FT proto- col at preoperative evaluation. Adherence to instructions was verified at the time of the hospital admittance. Data were prospectively collected for patients in the FT group, while, for patients of the control group, each item was retrospectively collected. Preoperative data were collected about age, Body Mass Index (BMI), American Society of Anesthesiology score (ASA Score), Charlson Comorbidity Index (CCI), smoking habits, clinical stage, grading (defined sec. WHO 2016 classification) or neoadiuvant therapy. We collected data regarding surgical approach, urinary diversion used, pelvic lymphadenecto- my template, number of removed lymph nodes, global operation time (minutes) and intraoperative transfusion rate. Postoperative data collection comprehended histological tumor features (such as stage, grading, lymph node status), hospital stay time, NGT removal Table 1. Preoperative and intraoperative items. Overall Fast Track group Control group P value Number of patients, n (%) 40 (100%) 20 (50%) 20 (50%) - Gender, n (%) Male 31 (77.5) 16 (80) 15 (75) 0.7 Female 49 (22.5) 4 (20) 5 (25) Age Median (IQR) 71 (63-76) 70 (60-76) 72 (66-75) 0.6 ASA score, n (%) 1-2 16 (40) 9 (45) 7 (35) 0.5 3-4 24 (60) 11 (55) 13 (65) CCI, n (%) 0 0 (0) 0 (0) 0 (0) 0.8 1-2 7 (17.5) 4 (20) 3 (15) 3-4 15 (37.5) 8 (40) 7 (35) > 4 18 (45) 8 (40) 10 (50) BMI (Kg/m2) Mean ± SD 28 ± 4.8 28 ± 4.9 28 ± 5 0.9 Smoking attitude, n (%) No 16 (40) 11 (55) 5 (25) 0.05 Yes 24 (60) 9 (45) 15 (75) Clinical stage, n (%) T0 1 (2.5) 0 (0) 1 (5) 0.7 Ta-pT1 12 (30) 7 (35) 5 (25) T2 23 (57.5) 11 (55) 12 (60) T3 4 (10) 2 (10) 2 (10) Preoperative grade, n (%) G1 1 (2.5) 0 (0) 1 (5) 0.6 G2 5 (5) 1 (5) 1 (5) G3 37 (92.5) 19 (95) 18 (90) Neoadjuvant chemotherapy, n (%) No 40 (100) 40 (100) 40 (100) - Yes 0 (0) 0 (0) 0 (0) Surgical approach, n (%) Open 39 (97.5) 19 (95) 20 (100) 0.3 Laparoscopic 1 (2.5) 1 (5) 0 (0) PLND template, n (%) Not performed 2 (5) 1 (5) 1 (5) 0.2 Standard 22 (55) 13 (65) 9 (45) Extended 14 (35) 4 (20) 10 (50) Super-extended 2 (5) 2 (10) 0 (0) Lymph node retrieved Median (IQR) 14 (10-23) 14 (12-21) 14 (8-24) 0.3 Urinary diversion, n (%) Ileal conduit 23 (57.5) 11 (55) 12 (60) 0.7 Ileal ortotopic neobladder (Studer neobladder) 17 (42.5) 9 (45) 8 (40) Surgical time (minutes) Mean ± SD 276 ± 57 260 ± 56 293 ± 54 0.06 Intraoperative transfusion, n (%) No 27 (67.5) 15 (75) 12 (60) 0.3 Yes 13 (32.5) 5 (25) 8 (40) Pathologic stage, n (%) pT0 2 (5) 1 (5) 1 (5) 0.8 pT1-pTis 9 (22.5) 6 (30) 3 (15) pT2a-pT2b 7 (17.5) 3 (15) 4 (20) pT3a-pT3b 15 (37.5) 6 (30) 9 (45) pT4 7 (17.5) 4 (20) 3 (15) Pathologic grade, n (%) G1 2 (5 ) 1 (5) 1 (5) 0.8 G2 2 (5) 1 (5) 1 (5) G3 35 (87.5) 17 (85) 18 (90) G4 1 (2.5) 1 (5) 0 (0) LNI, n (%) No 26 (65) 13 (65) 13 (65) 1 Yes 14 (35) 7 (35) 7 (35) IQR: Inter Quartile Range; VAS: Visual Analogue Scale; ASA: American Society Of Anesthesiologists; CCI: Charlson Comorbidity Index; BMI: Body Mass Index; SD: Standard Deviation; PLND: Pelvic Lymph Node Dissection; LNI: Lymph Node Invasion. Romagnoli_Stesura Seveso 10/01/20 08:50 Pagina 231 Archivio Italiano di Urologia e Andrologia 2019; 91, 4 D. Romagnoli, R. Schiavina, L. Bianchi, et al. 232 (time and repositioning), pain control (coded by visual analogic scale [VAS] standard), time to flatus and time to defecation, lymphorrea amount, time of the start of a light diet and time to drain removal. Postoperative compli- cations were stratified as early (before 30 days from surgery) and late complications (between 30 and 90 days from surgery). All complications were graded following the Clavien-Dindo classication. To compare results between the study popula- tion and the control group a one-to-one propensity score-matched analysis was com- puted by modelling a logistic regression, with the dependent variable as the odds of under- going Fast Track protocol and independent variables such as age at surgery, BMI, gender, ASA score, CCI, preoperative stage and uri- nary diversion in course of surgery. Subsequently, covariate balance between the matched groups was examined. Covariates between the two groups were considered equivalent, providing a standardised mean dif- ference ≤ 10%. The primary objective was the evaluation of the eventual reduction in hospi- talization ratio, while the secondary objective was the evaluation of any difference in the early (< 30 days) and late (< 90 days) postop- erative complication ratio. Statistic software R (The R Foundation) was used for statistical analysis. Chi-square test and t test were used for binomial and continuous variables, respec- tively. RESULTS 11 (55%) patients of FT groups underwent ureteroileocutaneostomy, while 9 (45%) patients underwent urinary diversion with orthotopic neobladder (according to the Studer technique), while, in the control group, 12 (60%) patients received ureteroileocuta- neostomy and 8 patients (40%) were submit- ted to orthotopic urinary diversion according to the Studer technique. Table 1 shows preop- erative and intraoperative characteristics of the two study groups. The two groups were statis- tically homogenous, with no significant differ- ence among them. Considering intraoperative parameters, mean operative time was 260 ± 56 min in FT group, while was 293 ± 54 min in the control group, with a difference at the limit of the statistical difference (p = 0.06). Table 2 depicts Fast Track outcomes. NGT was removed earlier in the FT group than in the control group, with a median of 20 hours ver- sus 48 hours, respectively (p < 0.001). Just one patient (5%) of the FT group had SNG removed after the first 24 hours. No signifi- cant difference was noted in NGT reposition- ing rates between the two groups (15% in FT group and 5% in control group, p = 0.3). Table 2. Postoperative datas. Overall Fast Track group Control group P value Number of patients, n (%) 40 (100%) 20 (50%) 20 (50%) - NGT removal ( hours) Median (IQR) 24 (20-48) 20 (18-20) 48 (48-72) < 0.001 NGT removal after POD 1, n (%) 18 (42.5) 1 (5) 16 (80) < 0.001 NGT repositioning, n (%) 4 (10) 3 (15) 1 (5) 0.3 Mobilization (hours postoperatively) Mean ± SD 66 ± 43 21 ± 12 106 ± 26 < 0.001 Postoperative nausea episodes, n (%) None 25 (62.5) 13 (65) 12 (60) 0.02 1 7 (17.5) 6 (30) 1 (5) > 1 8 (20) 1 (5) 7 (35) Postoperative VAS Score Median (IQR) 4 (3-4) 3 (3-4) 4 (3-4) 0.2 Time to flatus (POD) Median (IQR) 2 (1-3) 1.5 (1-2.75) 3 (2-3.75) 0.004 Time to defecation (POD) Median (IQR) 5 (3-6) 4 (3-5.75) 6 (4.5-6) 0.02 Start of a light diet (POD) Median (IQR) 5 (2-8) 2 (2-4.5) 6.5 (6-8) < 0.001 Last drain removal (POD) Median (IQR) 8 (6-9) 7 (6-9.75) 8.3 (7-9) 0.5 Lymphorrea amount (ml) Mean ± SD 1720 ± 1534 1776 ± 1710 1665 ± 1380 0.8 Hospital stay (days) Median (IQR) 12 (9-14) 10 (8-12) 13 (11-14) 0.005 NGT: Naso Gastric Tube; POD: Post Operatory Day; SD: Standard Deviation; IQR: Inter Quartile Range. Table 3. Postoperative complications. Overall Fast Track group Control group P value Number of patients, n (%) 40 (100%) 20 (50%) 20 (50%) - Overall perioperative (< 30 days) complications, n (%) No 31 (77.5) 14 (70) 17 (85) 0.3 Yes 9 (22.5) 6 (30) 3 (15) Clavien-Dindo classification, n (%) Grade 1 6 (66.6) 5 (83.3) 1 (33.3) 0.3 Grade 2 2 (22.2) 1 (16.7) 1 (33.3) Grade 3 1 (11.1) 0 (0) 1 (33.3) Grade 4 0 (0) 0 (0) 0 (0) Grade 5 0 (0) 0 (0) 0 (0) Type of complication (< 30 days), n (%) Dynamic Ileus 6 (66.6) 5 (83.3) 1 (33.3) 0.3 Anemization 1 (11.1) 1 (16.7) 0 (0) Wound Infection 1 (11.1) 0 (0) 1 (33.3) Deep Venous Thrombosis 1 (11.1) 0 (0) 1 (33.3) Overall postoperative (< 90 days) complications, n (%) No 36 (90) 19 (95) 17 (85) 0.3 Yes 4 (10) 1 (5) 3 (15) Clavien-Dindo classification, n (%) Grade 1 0 (0) 0 (0) 0 (0) 0.3 Grade 2 0 (0) 0 (0) 0 (0) Grade 3 4 (100) 1 (100) 2 (100) Grade 4 0 (0) 0 (0) 0 (0) Grade 5 0 (0) 0 (0) 0 (0) Type of complication (< 90 days), n (%) Lymphocele (Right Iliac Fossa) 1 (25) 1 (100) 0 0.2 Uretero-Ileal Anastomosis Stricture 2 (50) 0 2 (66.7) Laparocele 1 (25) 0 1 (33.3) Readmission within 90 days, n (%) 4 (10) 1 (5) 3 (15) 0.3 Romagnoli_Stesura Seveso 10/01/20 08:50 Pagina 232 233Archivio Italiano di Urologia e Andrologia 2019; 91, 4 Fast Track protocol after radical cystectomy with ileal urinary diversion Mobilization time was significantly shorter in the FT group than in the control group (mean 21 ± 12 hours vs 106 ± 26 hours, respectively, p < 0.001). We observed one (5%) patient in the FT group who had more than one nau- sea episode postoperatively, while we noted 7 (35%) of such events in the control group (p = 0.02). Median time to flatus was 1,5 (IQR 1-3) days in the FT group and 3 (IQR: 2-3.75) days in the control group, with a statistical- ly significant difference (p = 0.004). We also observed a significant shorter time to defecation in the FT group (4 days IQR: 3-5.75) than in the control group (6 days, IQR 4.5-6) with p = 0.02. No statistically significant difference was noted in terms of VAS scale, duration and entity of lymphorrea between the two groups. We observed a sta- tistically significant shorter median hospital stay time in the FT group (10 days, IQR: 8-12) than in the control group (13 days, IQR: 11-14, p = 0.005). As depicted in Table 3, no statistically significant differ- ence was noted in terms of early and late complication rate among the two groups (p = 0.3 for each type of com- plication, respectively). Considering early complications, only one event graded as Clavien 3 was reported (11.1%), and it was a wound infection surgically treated in the con- trol group. Considering late complications ratio, 4 events graded as Clavien 3 were documented, 1 in the FT group (right iliac fossa lymphocele percutaneously drained), and 3 in the control group (2 cases of uretero-ileal anas- tomosis stricture surgically corrected, and 1 case of laparocele surgically repaired), though this difference was not statistically significant (p = 0.2). No statistically sig- nificant difference was found in terms of readmission rate within 90 days among the two groups (p = 0.3) DISCUSSION RC with ileal urinary diversion is a surgery historically affected by a high rate of perioperative morbidity and mortality. With the starting point set in intervention on bowel in general surgery, ERAS protocols were described in order to improve postoperative outcomes. Although a number of ERAS protocols have been built over the years, all of them found their key features on strategies to improve postoperative recovery rate and reduction of hospital stay time, without worsening postoperative complication rate. After extensive literature review and multidisciplinary meeting between urologists, anaes- thetists, nurses and nutritionists, we designed a tailored ERAS protocol to be adopted at a high volume institu- tion. In order to validate the FT protocol we designed a case-control prospective study, matching patients who underwent RC with ileal urinary diversion and who applied the protocol with patients who underwent the same kind of surgery but without implementation of the protocol. In our cohorts of RC with ileal urinary diver- sion, the adherence to the FT protocol permitted to obtain a significant shorter hospitalization time, without a significant increase in term of perioperative complica- tions rate. An interesting fact is that no preoperative bowel preparation was adopted, because, as demon- strated by Shafii et al., it does not give any significant advantage (12). Moreover, the early removal of the NGT tube, in adjunction with a continuous prokinetic stimu- lus, has proven to be feasible, in accordance to the expe- rience of Braga (13), who demonstrated that decom- pression with NGT in all patients is not necessary ad is associated with an increased incidence of pulmonary complications. An important contribute to this result is represented by the perioperative dietary regimen and by the intra- and postoperative pain management. The hypercaloric and hyperglucidic preoperative dietary reg- imen of the FT protocol allows to create a preoperative supply of proteins and glucose in order to react to the operative stress without significantly compromise the homeostasis and improving the natural healing process. This fact seems to be the possible base for the observa- tion that no wound infections were reported in the FT group. As a matter of fact, wound repair depends on the disponibility of adequate protein and glucose supply, which could be insufficient after a prolonged periopera- tive fasting period. We observed no statistically significant difference in VAS scale evaluation between the two groups, so we might affirm the non-inferiority of an opioid-free pain control regimen (based on FANS and continuous infusion via epidural catheter), in comparison with the pain control obtained with opioid drugs. Moreover, the absence of opioid administration allows to avoid typical side effects, such as a prolonged intestinal transit, which could hesi- tate in delayed time to flatus and time to defecation. Other aspects of our FT protocol aimed to improve intestinal function, such as administration of prokinetic drugs (metoclopramide) and of chewing-gum, as already been prove successful by Kouba et al. (14). We observed a statistically significant reduction of canalization time in FT group compared to control group, either considering median time to flatus (respectively in POD 1,5 vs POD 3, p = 0.004) and median time to defecation (respective- ly on POD 4 vs POD 6, p = 0.02). Moreover we observed that patients of the FT group could tolerate a solid diet regimen on POD 2, significantly sooner in comparison with patients of the control group (median POD 6.5, p < 0.001). These results could be explained by the fact that metoclopramide administration is able to reduce the incidence of nausea and vomiting episodes, and also gas- trointestinal complications, as described by Pruthi (15). Another explanation for this matter could be the fact that faster bowel activity recovery might be reached also with early mobilization and early feeding, as postulated by Cerruto et al. (10). Internal peristalsis is moreover facilitated by the blocking of visceral afferents and seg- mental efferences, which is realized by the epidural anal- gesia (16). The importance of a T11 epidural catheter as a useful tool to increase microvessels perfusion (thus reducing interference with the cardiopulmonary sys- tem), has been underlined by Friedrich-Freksa, who suc- cessfully applied this technique to high-risk patients submitted to RC (17). The result of the aforementioned considerations allows patients in the FT group to be discharged 3 days before, in comparison with patients of the control group (mean 10 days vs 13 days, p = 0.005). This result is in line with the Literature, though there are discordant experiences, as the one described by Cerruto (10), who reported no statistically significant difference in mean hospital stay Romagnoli_Stesura Seveso 10/01/20 08:50 Pagina 233 Archivio Italiano di Urologia e Andrologia 2019; 91, 4 D. Romagnoli, R. Schiavina, L. Bianchi, et al. 234 time in patients submitted to RC with implementation of a dedicated FT protocol. A promising synergy is represented by FT protocols applied to mini-invasive surgery, a technique which is usually already characterized by a short hospital stay (18). As demonstrated by Saar et al. (19), the imple- mentation of a FT protocol in case of robotic approach to RC provides a significant advantage in terms of return to a regular diet and use of postoperative morphine equivalents. The efficacy of FT protocols applied to mini-invasive surgery has led to the recommendation to always adopt them in case of robot assisted radical cystectomy, as written in the paper published by Wilson (20). Moreover, the use of barbed sutures (21), a typical fea- ture of the robotic approach, might improve the postop- eratory continence ratio, as described in case of robot- assisted radical prostatectomy (22, 23). Another point of interest of FT protocols is the eventual reduction of both postoperative complications ratio and 90-days readmission rates. On a previous publication by Cerruto et al. on the effect of a FT protocol in patients candidates to robot-assisted RC with Padovana ileal neobladder, the authors reported a lower global rate of postoperative complications (p = 0.004) in patients adherent to the protocol (10). In our study we did not record a statistically significant difference between the two groups in terms of compli- cations or readmission rate. Such observation is in part- ly due to the scarce numerosity of the group of our study. It is important to underline that no major early complication (grade 3 or superior according to the Clavien-Dindo classification) was observed in the FT group. Moreover, of the 4 (10%) major late complica- tions observed, only 1 (5%) was in FT group, while 3 (15%) were in control group. The complication of the FT group was a lymphocele treated with ultrasound-guided percutaneous drainage, which seemed unrelated to FT protocol implementation. On the control group we observed one early and three late complications Clavien ≥ 3, consisting of wound infection (early complication), two uretero-ileal anasto- motic strictures (a well-documented complication of this kind of surgery) (24) and a laparocele, all of them treat- ed with surgical revision on general anaesthesia. A limitation of the present study is the limited number of patients enrolled, though the scarce numerosity seems to be a common feature in studies concerning FT protocols applied to RC, as confirmed by a recent paper published by Freeks et al. (25). CONCLUSIONS The implementation of the FT protocol to patients sub- mitted to RC with urinary ileal diversion is a safe and effective procedure, which allows to reduce hospitaliza- tion time without increasing postoperatory complica- tions ratio. Further studies are needed, with larger pop- ulations, in order to definitively confirm the superiority of FT protocols over standard protocols in the perioper- ative management of patients submitted to this surgical procedure. REFERENCES 1. Ferlay J, et al. Cancer incidence and mortality patterns in Europe: Estimates for 40 countries in 2012. Eur J Cancer. 2013; 49:1374- 1403. 2. Babijuk M, et al. EAU Guidelines: Non-muscle-invasive Bladder Cancer, 2019. 3. Witjes JA, et al. 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Romagnoli_Stesura Seveso 10/01/20 08:50 Pagina 234 235Archivio Italiano di Urologia e Andrologia 2019; 91, 4 Fast Track protocol after radical cystectomy with ileal urinary diversion 20. Wilson TG, et al. Best practices in robot-assisted radical cystec- tomy and urinary reconstruction: recommendations of the Pasadena Consensus Panel, Eur Urol. 2015; 67:363-75. 21. Mineo Bianchi F, et al. Posterior muscle-fascial reconstruction and knotless urethro-neo bladder anastomosis during robot-assisted radical cystectomy: Description of the technique and its impact on urinary continence, Arch Ital Urol Androl. 2019; 91:5-10. 22. Porreca A, et al. Robotic-Assisted Radical Prostatectomy with the Use of Barbed Sutures, Surg Technol Int. 2017; 30:39-43. 23. Porreca A, et al. Bidirectional barbed suture for posterior mus- Appendix Enhanced Recovery Protocol Preoperative clinical setting: within 7 days before surgery - Anestehesiological assessment - Written dietary recommendations - Diet with no restrictions Preoperative days - 24 hours before RC - Hospital admittance - Unrestricted clear fluids - Normal breakfast - No bowel preparation Perioperative phase - day of RC - Clear fluids allowed up to 2 hours before RC - Nutritional supply 2 hours before surgery (400 mL/200 calories) - Elastic compressive stockings - Ceftriaxone 2 g i.v as prophylaxis for infection Intraoperative phase - day of RC - Combined general and epidural anesthesia with intrathecal catheter left in place for the first PODs - Optimized intraoperative intravenous fluid administration - NGT insertion preoperatively ad removal at the end of surgery - Reducing intraoperative blood loss - Antiemetic prophylaxis - Infiltration of the surgical wound with local anesthetic Postoperative phase - day of RC - Ranitidine 150 mg i.v. - Metoclopramide 25 mg i.v. every 8 hours - Intravenous analgesia (paracetamol, ketorolac) - Epidural analgesia (elastomeric pump loaded with naropine) - Low molecular weight heparin (LMWH) as prophylaxis for thromboembolic events - Intravenous hydration (100 mL/h) of 10% glucose solution and electrolyte solution - Mobilization 6 hours after surgery - Free clear fluids as tolerated Postoperative phase - POD 1 - Female patients: remove vaginal pack - Active mobilization - Respiratory rehabilitation exercises - 1100 calories diet as tolerated - Free clear liquids as tolerated - Analgesia if needed (ropivacaine, paracetamol, ketorolac) - Metoclopramide 25 mg i.v. every 8 hours - Ranitidine 150 mg 1 tab/die - LMWH as prophilaxys - Chewing gum (1 piece very 2-4 hours), as tolerated Postoperative phase - POD 2 - 1500 calories diet as tolerated - Free clear fluids - Active mobilization - Drain removal (if drained < 50 mL/24 hours) culofascial reconstruction and knotless vesicourethral anastomosis during robot-assisted radical prostatectomy. Minerva Urol Nefrol. 2018; 70:319-325. 24. Schiavina R, et al. Laparoscopic and robotic ureteral stenosis repair: a multi-institutional experience with a long-term follow-up. J Robot Surg. 2016; 10:323-330. 25. Freeks SK, et al. A prospective randomized pilot study evaluat- ing an ERAS protocol versus a standard protocol for patients treat- ed with radical cystectomy and urinary diversion for bladder can- cer, World J Urol. 2018; 36:215-220. Romagnoli_Stesura Seveso 10/01/20 08:50 Pagina 235 Archivio Italiano di Urologia e Andrologia 2019; 91, 4 D. Romagnoli, R. Schiavina, L. Bianchi, et al. 236 - Epidural catheter removal - Neobladder flushes 3 trimes a day (every 8 hours) - Analgesia if required (paracetamol, ketorolac) - LMWH as prophylaxis - Metoclopramide 25 mg i.v. every 8 hours - Continue ranitidine Postoperative phase - POD 3 - Active mobilization - 1650 calories diet - Analgesia if needed (paracetamol, ketorolac) - Metoclopramide 25 mg i.v. every 8 hours - LMWH as prophylaxis - Continue ranitidine - Continue neobladder flushing Postoperative phase - POD 4 - Active mobilization - 2000 calories diet as tolerated - Analgesia if needed (paracetamol, ketorolac) - Metoclopramide 25 mg i.v. every 8 hours - LMWH as prophylaxis - Continue ranitidine - Continue neobladder flushing Postoperative phase - PODs 5 to 7 - Free diet - Active mobilization - If absence of canalization and oralization after 5 days from surgery, start total parenteral nutrition (TPN) and search for any cause - Continue neobladder flushing - LMWH as prophylaxis - Continue ranitidine Postoperative phase - PODs 8 and 9 - Ureteral stents removal - Clips removal - LMWH as prophylaxis Postoperative phase - PODs 10 and 11 - Schedule for return to home - LMWH as prophylaxis (up to 18 days after RC) Postoperative phase - POD 30 - Catheter removal (without neocystogram) Correspondence Daniele Romagnoli, MD (Corresponding Author) danieleromagnoli87@gmail.com Marco Giampaoli, MD Paolo Corsi, MD Daniele D’Agostino, MD Angelo Porreca, MD Robotic Urology and Mini Invasive Urologic Surgery Unit Abano Terme Hospital, Piazza Cristoforo Colombo 2 - Abano Terme (PD), Italy Riccardo Schiavina, MD Lorenzo Bianchi, MD Marco Borghesi, MD Federico Mineo Bianchi, MD Andrea Angiolini, MD Eugenio Brunocilla, MD Urology Unit, S. Orsola Malpighi University Hospital - Alma Mater Studiorum Via Pelagio Palagi, 9 Bologna (Italy) Francesco Chessa Carlo Casablanca St. Orsola Malpighi Universitary Urology Clinic, Bologna (BO), Italy Romagnoli_Stesura Seveso 10/01/20 08:50 Pagina 236