Hospital Charges and Length of Stay Following Radical Cystectomy in the Enhanced Recovery After Surgery Era

Published:October 13, 2017DOI:


      To report our center's experience with enhanced recovery after surgery (ERAS) pathway for radical cystectomy (RC), specifically evaluating complications, LOS, 30- and 90-day readmissions, and hospital charges. Pathways of this type have been shown to decrease the length of stay (LOS) and postoperative ileus. However, concerns persist that ERAS is costly and increases readmissions. To date, limited studies have evaluated these concerns.

      Materials and Methods

      Our ERAS protocol was implemented for RC in December 2015. Outcomes in ERAS patients were compared with those in RC patients from the time period before ERAS. Patients were excluded if they underwent concomitant nephroureterectomy.


      Fifty-six consecutive ERAS patients were compared with 54 pre-ERAS patients. The median charge for index hospitalization was $31,090 in the ERAS group and $35,489 in the pre-ERAS group (P = .036). The median LOS was 5.0 days in the ERAS group and 8.5 days in the pre-ERAS group (P = < .001). The pre-ERAS group had a significantly increased use of nasogastric tube (13.8% vs 30.0%) and parenteral nutrition (6.9% vs 20.4%). The overall complication rate (including infectious, renal, deep vein thrombosis and pulmonary embolism, myocardial infarction and stroke, and respiratory and gastrointestinal-related complications) was similar between the 2 groups (51.7% in the ERAS group and 62.0% in the pre-ERAS group, P = .28). Thirty- and 90-day readmissions also remained similar (19.0% vs 14.8%, P = .55, and 31.0% vs 27.7%, P = .64). The most common readmission reason was infection, specifically urinary tract infection.


      Implementation of the ERAS pathway at our center resulted in significantly reduced LOS and total hospital charge, with comparable rates of complication and readmission, highlighting the need for ERAS pathways in patients undergoing RC.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Urology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Daneshmand S.
        • Ahmadi H.
        • Schuckman A.K.
        • et al.
        Enhanced recovery protocol after radical cystectomy for bladder cancer.
        J Urol. 2014; 192: 50-56
        • Shabsigh A.
        • Korets R.
        • Vora K.C.
        • et al.
        Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology.
        Eur Urol. 2009; 55: 164-174
        • Patel H.D.
        • Ball M.W.
        • Cohen J.E.
        • et al.
        Morbidity of urologic surgical procedures: an analysis of rates, risk factors, and outcomes.
        Urology. 2015; 85: 552-560
        • Djalat H.
        • Daneshmand S.
        Gastrointestinal complications in patients who undergo radical cystectomy with enhanced recovery protocol.
        Curr Urol Rep. 2016; 17: 50
        • Lohsiriwat V.
        Impact of enhanced recovery program on colorectal cancer surgery.
        Asian Pac J Cancer Prev. 2014; 15: 3825-3828
        • Rawlinson A.
        • Kang P.
        • Evans J.
        • et al.
        A systematic review of enhanced recovery protocols in colorectal surgery.
        Ann R Coll Surg Engl. 2011; 93: 583-588
        • Azhar R.A.
        • Bochner B.
        • Catto J.
        • et al.
        Enhanced recovery after urological surgery: a contemporary systematic review of outcomes, key elements, and research needs.
        Eur Urol. 2016; 70: 176-187
        • Tyson M.D.
        • Chang S.S.
        Enhanced recovery pathways versus standard care after cystectomy: a meta-analysis of the effect of perioperative outcomes.
        Eur Urol. 2016;
        • Cerantola Y.
        • Valerio M.
        • Persson B.
        • et al.
        Guidelines for perioperative care after radical cystectomy for bladder cancer: enhanced recovery after surgery (ERAS) society recommendations.
        Clin Nutr. 2013; 32: 879
        • Pruthi R.S.
        • Nielson M.
        • Smith A.
        • et al.
        Reducing time to oral diet and hospital discharge in patients undergoing radical cystectomy using a perioperative care plan.
        Urology. 2003; 62: 661
        • Arumainayagam N.
        • McGrath J.
        • Jefferson K.P.
        • et al.
        Introduction of an enhanced recovery protocol for radical cystectomy.
        BJU Int. 2008; 101: 698
        • Karl A.
        • Buchner A.
        • Becker A.
        • et al.
        A new concept for early recovery after surgery in patients undergoing radical cystectomy for bladder cancer: results of a prospective randomized study.
        J Urol. 2014; 191: 335
        • Lemanu D.P.
        • Singh P.P.
        • Stowers M.D.
        • et al.
        A systematic review to assess cost effectiveness of enhanced recovery after surgery programs in colorectal surgery.
        Colorectal Dis. 2014; 16: 338-346
        • Nabhani J.
        • Ahmadi H.
        • Schuckman A.K.
        • et al.
        Cost analysis of the enhanced recovery after surgery protocol in patients undergoing radical cystectomy for bladder cancer.
        Eur Urol Focus. 2016; 2: 92-96
        • Page A.J.
        • Ejaz A.
        • Spolverato G.
        • et al.
        Enhanced recovery after surgery protocols for hepatectomy—physiology, immunomodulation, and implementation.
        J Gastrointest Surg. 2015; 19: 387-399
        • Muller S.
        • Zalunardo M.P.
        • Hubner M.
        • et al.
        A fast-track program reduces complications and length of hospital stay after open colonic surgery.
        Gastroenterology. 2009; 136: 842-847
        • Kehlet H.
        • Wilmore D.W.
        Evidence-based surgical care and the evolution of fast-track surgery.
        Ann Surg. 2008; 248: 189-198
        • Pruthi R.S.
        • Nielsen M.
        • Smith A.
        • et al.
        Fast track program in patients undergoing radical cystectomy: results in 362 consecutive patients.
        J Am Coll Surg. 2010; 210: 93-99
        • Stimson C.J.
        • Chang S.S.
        • Barocas D.A.
        • et al.
        Early and late perioperative outcomes following radical cystectomy: 90-day readmissions, morbidity and mortality in a contemporary series.
        J Urol. 2010; 184: 1296-1300
        • Ja R.
        • McIntosh A.G.
        • Strehlow R.
        • et al.
        Definition, incidence, risk factors, and prevention of paralytic ileus following radical cystectomy: a systematic review.
        Eur Urol. 2013; 64: 588-597
        • Maffezzini M.
        • Campodonico F.
        • Canepa G.
        • et al.
        Current perioperative management of radical cystectomy with intestinal urinary reconstruction for muscle-invasive bladder cancer and reduction of the incidence of postoperative ileus.
        Surg Oncol. 2008; 17: 41-48
        • Persson B.
        • Carriger M.
        • Andren O.
        • et al.
        Initial experiences with the enhanced recovery after surgery (ERAS) protocol in open radical cystectomy.
        Scand J Urol. 2015; 49: 302-307
        • Guenaga K.F.
        • Matos D.
        • Wille-Jorgensen P.
        Mechanical bowel preparation for elective colorectal surgery.
        Cochrane Database Syst Rev. 2011; (CD001544)
        • Carney D.E.
        • Nicolette L.A.
        • Ratner M.H.
        • et al.
        Ketorolax reduces postoperative narcotic requirements.
        J Pediatr Surg. 2001; 36: 76-79
        • Xu W.
        • Daneshmand S.
        • Bazargani S.T.
        • et al.
        Postoperative pain management after radical cystectomy: comparing traditional versus enhanced recovery protocol pathway.
        J Urol. 2015; 194: 1209-1213
        • Goettsch W.G.
        • Sukel M.P.
        • van der Peet D.L.
        • et al.
        In-hospital use of opioids increases rate of coded postoperative paralytic ileus.
        Pharmacoepidemiol Drug Saf. 2007; 16: 688
        • Lee C.T.
        • Chang S.S.
        • Kamat A.M.
        • et al.
        Alvimopan accelerates gastrointestinal recovery after radical cystectomy: a multicenter randomized placebo-controlled trial.
        Eur Urol. 2014; 66: 265-272
        • Kauf T.L.
        • Svatek R.S.
        • Amiel G.
        • et al.
        Alvimopan, a peripherally acting µ-opioid receptor antagonist, is associated with reduced costs after radical cystectomy: economic analysis of a phase 4 randomized, control trial.
        J Urol. 2014; 191: 1721-1727
        • Djaladat H.
        • Katebian B.
        • Bazargani S.T.
        • et al.
        90-Day complication rate in patients undergoing radical cystectomy with enhanced recovery protocol: a prospective cohort study.
        World J Urol. 2016;
        • Chappidi M.R.
        • Kates M.
        • Stimson C.J.
        • et al.
        Quantifying nonindex hospital readmissions and care fragmentation after major urological oncology surgeries in a nationally representative sample.
        J Urol. 2017; 197: 235-240