Activating patients is key to enhanced recovery
Prof. James Catto (GB) was one of the closing speakers of the third Plenary Session at EAU17, speaking with great enthusiasm about the post-cystectomy ‘ERAS’ approach to patient care. Plenary Session 3 was mainly focused on bladder cancer and featured case discussions, debates and state-of- the-art lectures.
Enhanced Recovery After Surgery, or ERAS, is a pragmatic approach to patient care that can be summarised in three core philosophies: “Do as much as possible outside of the hospital; do as little as possible to the patient; and activate the patient,” Catto summarised. “Cystectomy patients are generally elderly, not in good shape, and smokers. By encouraging ‘pre-habilitation’, we prepare patients for surgery and a better recovery, for instance by getting them to walk for one to two hours every day.”
“Following surgery, patients are also activated relatively soon. To reduce discomfort, use of nasogastric tubes and non-essential drainage should be minimised. Even by dressing patients in their regular clothes after a few days, they already feel more empowered and they will move around more. Our data shows that ERAS can make massive changes to patient care with no change to the cancer outcome.”
Win-win
Speaking after the session, Catto explained that another key part of this approach has to do with challenging dogmas. “In some cases we do more harm than good. Things like bowel preparation, traditional pain relief techniques, changes in fluid intake: these are big changes for the patient without any clear benefit. I tell my patients that their body will be running a marathon. We want a well-fed and fit patient, not one that is already tired and weak from fasting going into surgery.”
This approach is certainly not limited to Sheffield: “We might have started with this approach relatively early some 10 years ago, and we’ve perhaps applied it more systematically. Generally speaking we’re all on the same page, worldwide. There was a randomised trial in Germany five years ago, and in turn we learned lessons from other surgical disciplines. A lot of the early lessons were learned from Swedish colorectal surgeons.”
Aside from having fitter patients who are more comfortable due to less invasive recovery, there are advantages for hospitals too. Particularly in the UK, where budgets are limited in the NHS, urologists can do more work with the same resources.
Guidelines on BCa: EAU or NICE?
The realities of costs were also a big theme in the debate about follow-up beyond 12 months for low-grade bladder tumours. Prof. Maximilian Burger (DE) defended the EAU Guidelines’ recommendations for a five-year follow-up period, arguing that cystoscopy doesn’t harm patients, it is the safest way to avoid recurrence, and crucially, pathologists’ assessments are sometimes wildly divergent and cannot always be trusted blindly.
Mr. Hugh Mostafid (GB) in turn defended the NICE recommendations, stating that they take cost into account from the outset, achieving maximum results with limited resources: “Whereas the EAU Guidelines are about achieving ideal medical results, NICE deals with the realities of the NHS.” Mostafid also pointed to data showing that follow-up may also be useful beyond five years, arguing that the five-year cut-off could be considered arbitrary, being based on retrospective, non-randomised data.
Questions by moderator Prof. Brausi (IT) about specific hypothetical cases (for instance, a heavy smoker) caused both debaters to agree that their respective guidelines were just that: guidelines that leave enough space for urologists to make exceptions at their discretion on a case-by-case basis.