Enhanced Recovery After Surgery (ERAS) Pathway in Patients Undergoing Robot-Assisted Laparoscopic Radical Prostatectomy

Enhanced Recovery After Surgery (ERAS) Pathway in Patients Undergoing Robot-Assisted Laparoscopic Radical Prostatectomy

Impact of Enhanced Recovery After Surgery (ERAS) Pathway on Outcomes in Patients Undergoing Robot-Assisted Laparoscopic Radical Prostatectomy: A Randomized Controlled Trial

Prostate cancer ranks second among all malignances in men and has become a significant threat to men's health. Robot-assisted laparoscopic radical prostatectomy (RARP) has become a standard treatment for prostate cancer. How to improve recovery following RARP surgery is worth investigating. The enhanced recovery after surgery (ERAS) pathway involves a series of evidence-based procedures. It is aimed to reduce the systemic stress response to surgery and shorten the length of hospital stay. This randomized trial aims to investigate the impact of Enhanced Recovery After Surgery (ERAS) Pathway on early outcomes after RARP surgery.

Prostate cancer ranks second among all malignancies in men and has become a significant threat to men's health. Surgical resection is the main treatment for patients with early and locally advanced prostate cancer. With the progress of technology, robot-assisted laparoscopic radical prostatectomy (RARP) is gradually accepted by surgeons and become the first line treatment for prostate cancer. How to improve recovery after RARP surgery is worth investigating. The concept of enhanced recovery after surgery (ERAS) was first reported by Dr. Kehlet. The ERAS pathway involves a series of evidence-based managements to accelerate patients' rehabilitation, including selective bowel preparation, nutritional therapy, fluid management, multimodal analgesia, early mobilization, etc. It has been applied to many patient populations including those undergoing gastrointestinal surgery, cardiothoracic surgery, and urological surgery. Previous studies showed that practicing ERAS in patients undergoing laparoscopic prostate surgery shortened the time to flatus and defecate and the length of hospital stay. Specifically, prehabilitation including aerobic exercise and pelvic floor training may be beneficial and improve physical wellbeing in patients undergoing prostatectomy. However, little is known regarding the effects of ERAS in patients undergoing RARP surgery. The purpose of this randomized controlled trial is to investigate the impact of ERAS management, including prehabilitation, on early outcomes in patients undergoing RARP surgery.

Prostate Cancer, Prostatectomy, Enhanced Recovery After Surgery, Prehabilitation, Length of Hospital Stay

Prostate Cancer, Robot-Assisted Laparoscopic Radical Prostatectomy, Enhanced Recovery After Surgery, Prehabilitation, Length of hospital stay

Routine information provided before surgery. No nutritional therapy. No aerobic exercise. No pelvic floor muscle training. No psychiatrist intervention. Bowel preparation with oral cathartic agent. Fasting for over 8 hours; no oral carbohydrate solution (OCS) loading before surgery. Hypothermia prevention not emphasized. General anesthesia; regional block not emphasized. Routine blood pressure management. Mobilization from postoperative day 1. Start oral feeding from postoperative day 1. Patient-controlled analgesia with opioids. Thromboembolism prophylaxis with low-molecular-weight heparin (LMWH). Routine pelvic drainage tube removal (usually at postoperative day 4). Routine urinary catheterization removal (usually at postoperative day 14).

Patient consultation and education before surgery. Nutritional intervention for patients whose BMI<18.5 or BMI>24 kg/m2. Aerobic exercise for 2 weeks before surgery. Pelvic floor muscle training for 2 weeks before surgery. Psychiatrist intervention for patients with severe depression and anxiety. No bowel preparation before surgery. Provide oral carbohydrate solution 2 hours before surgery. Hypothermia prevention. General anesthesia combined with regional block. Goal-directed fluid infusion and targeted blood pressure management. Early mobilization. Early oral feeding. Multimodal analgesia, including opioids and non-steroid anti-inflammatory drugs. Thromboembolism prophylaxis with low-molecular-weight heparin; rivaroxaban for high-risk patients. Early pelvic drainage tube removal (at postoperative day 2) unless contraindicated. Early urinary catheterization removal (at postoperative day 7) unless contraindicated.

The score of anxiety is assessed by using the Self-Rating Anxiety Scale (SAS). This is a 20-item self-report questionnaire; each item is rated from 1 to 4 denoting the increasing severity or frequency of anxiety; the sum score times 1.25 as a standard score, ranging from 25 to 100, with higher score indicating more severe anxiety.

The score of depression is assessed by using the Self-Rating Depression Scale (SDS). This is a 20-item self-report questionnaire; each item is rated from 1 to 4 denoting the increasing severity or frequency of depression; the sum score times 1.25 as a standard score, ranging from 25 to 100, with higher score indicating more severe depression.

Pain score is assessed twice daily (8:00-10:00 am, and 18:00-20:00 pm) with the Numeric Rating Scale (NRS), an 11-point scale ranging from 0 to 10, with 0=no pain and 10=the worst pain.

Postoperative complications are defined as new-onset medical events that are harmful to patients' recovery and required therapeutic intervention, that is grade II or higher on the Clavien-Dindo classification.

Readmission is defined as hospitalization for the second time after discharge within 30 days after surgery.

Total hospitalization cost is defined as the sum cost of hospitalization from admission up to 30 days after surgery, including re-hospitalization within 30 days.

Inclusion Criteria: Aged 60 years or over but below 90 years. Scheduled to undergo robot-assisted laparoscopic radical prostatectomy (RARP) for prostate cancer. Agree to participate in this study and give written informed consent. Exclusion Criteria: Scheduled to undergo combined surgery, including RARP combined with pelvic lymph node dissection or other procedures. American Society of Anesthesiologists (ASA) physical classification ≥IV. Inability to receive preoperative aerobic exercise because of severe cardiovascular disease, motor system diseases (arthritis, lumbar vertebrae disease), or central nervous system diseases (epilepsy, parkinsonism). Inability to communicate in the preoperative period because of profound dementia, deafness, or language barriers. History of schizophrenia, anxiety or depressive disorders, or other mental disorders.

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