Webinar | Enhancing Bladder Cancer Surgery Recover: Strategies for Better Patient Outcomes

July 9, 2024

Surgery options, ranging from TURBT (Transurethral Resection of Bladder Tumor) to a radical cystectomy, (bladder removal) play a crucial role in treating bladder cancer. But what happens after surgery? How can we ensure patients recover well and experience better outcomes? Our featured expert, Dr. Saum Ghodoussipour from Rutgers Cancer Institute shares insights into the latest strategies and practices aimed at improving recovery, including physical and mental health and infection prevention following bladder cancer surgeries.

Year: 2024

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Part 1. History of Enhanced Recovery Surgery

Transcript (PDF)

Part 2. Modern Efforts to Improve Outcomes

Transcript (PDF)

Part 3. Enhancing Bladder Cancer Surgery Recovery Q&A

Transcript (PDF)

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Full Transcript on Enhancing Bladder Cancer Surgery Recovery: Strategies for Better Patient Outcomes

Stephanie Chisolm:  

Welcome to Enhancing Bladder Cancer Surgery Recovery, or ERAS, Strategies for Better Patient Outcomes.

I’d like to thank Merck and UroGen for making Patient Insight webinars possible.  Today’s topic is about enhancing bladder cancer surgery recovery strategies for better patient outcomes. Surgery options ranging from a TURBT, a Transurethral Resection of a Bladder Tumor, to a radical cystectomy, actual bladder removal, play a very important part in treating bladder cancer. Enhancing recovery after surgery, or ERAS, is a number of different strategies that can have a significant impact on postoperative recovery.

Our featured speaker tonight, our expert is Dr. Sam Ghodoussipour from Rutgers Cancer Institute, and he’s going to share insights into the latest strategies and practices that are really aimed at improving recovery, including both the physical and mental health, preventing infections, just giving you overall better outcomes after any bladder cancer surgical procedure. Dr. Ghodoussipour is a urologic surgeon, and he focuses on the treatment of men and women with cancers of the genitourinary system. His clinical expertise includes complex open and robotic surgeries of the pelvis and retroperitoneum. This includes removal of the bladder, a radical cystectomy, with reconstruction of the urinary tract to maximize functional recovery, nerve sparing procedures to maintain sexual function and fertility, advanced vascular techniques for invasive tumors, and open extraperitoneal procedures to hasten or speed up your recovery process. He’s done research on techniques to enhance recovery methods, and he’s going to share his latest strategies and practices that are really aimed on improving recovery, including, as I said, the physical and mental health, and infection prevention that you might have risk for following bladder cancer surgeries. I’m now going to direct your attention to Dr. Ghodoussipour. Welcome, I’m really looking forward to your presentation and if you would like to share your screen, you can start your slides.

Dr. Ghodoussipour:

Great. Thank you so much Stephanie, and to BCAN, and really everyone for the opportunity to share our experience here with Enhanced Recovery After Surgery, also known as ERAS, a topic that is near and dear to my heart and what I do every day in taking care of patients.

Dr. Ghodoussipour:

So I also appreciate everyone who was able to fill out the questionnaire prior to this talk, and based off of that, I was able to understand that the majority of responders had never really heard about Enhanced Recovery After Surgery, over 70% of you. And half of you reported not being sure if you had ever been treated with an Enhanced Recovery After Surgery protocol. So my main objectives are to explain what these protocols really are, and in order to accomplish that, I’m going to highlight some of the challenges in recovery that patients with bladder cancer face. I’m going to go over some of the history of Enhanced Recovery After Surgery, how we got to where we are today, and then go over some modern efforts to improve outcomes.

Dr. Ghodoussipour:

So while ERAS may be a somewhat new concept for many of you, I think that the indications, or the reasons patients have surgery for bladder cancer might be a little bit more clear based off of your personal experience. Radical cystectomy is a vital treatment procedure in bladder cancer. The indications for radical cystectomy are patients with muscle invasive bladder cancer, patients with certain high risk non-muscle invasive diseases that might not be good candidates for bladder sparing treatments, patients who failed bladder sparing treatments for non-muscle invasive disease, and then patients who have failed trimodal therapy, which is chemotherapy and radiation for bladder cancer. A lot of the focus in recovering patients after surgery has focused on radical cystectomy, but transurethral resection of bladder tumor is an often overlooked procedure as well.

Dr. Ghodoussipour:

This is a procedure that every patient with bladder cancer has to have as it is indicated for initial diagnosis of bladder cancer at the time of repeat resection, in patients with high risk disease, at any time a patient may have recurrent disease and to ensure a complete resection of bladder tumor to enhance the efficacy of chemotherapy and radiation.

Dr. Ghodoussipour:

Now we’re talking about radical cystectomy now in 2024, but this has really been around for almost a century. In 1950, Professor Leadbetter and Cooper from Tufts Medical School in Boston explained the concept of regional gland dissection, which means lymph node removal, cystectomy and urinary diversion for bladder cancer. At the time of this publication, the urinary diversion that they did was plugging the ureters, which drained the kidneys into the rectum. It was not a separate urinary diversion at the time, and we’ll talk about how we’ve evolved from there.

Dr. Ghodoussipour:

So really this surgery has been a standard since 1950. At that time, similar to now, the surgery in men involved removal of the bladder, prostate and seminal vesicles, and in female patients it involved removal of the bladder, uterus, fallopian tubes, ovaries, the anterior or top wall of the vagina, and in both sexes, removal of the regional lymph nodes.

Now this was done to cure patients of bladder cancer, but at the time of this publication in 1950, the mortality rate or risk of death after surgery was 40%, and the survival at that time was 35%. But these results were what we had at that time.

Dr. Ghodoussipour:

But Professor Leadbetter was sort of an innovative thinker, and in that publication he said, “The place that cystectomy will ultimately occupy in the treatment of carcinoma of the bladder, depends on its success as a palliative procedure, and on the cure rate following operation on significant numbers of patients by competent surgeons.” So in the remainder of this talk I’m going to talk about how we’ve evolved from this statement, and how he really was able to be a visionary in this statement here. The success of cystectomy as a palliative procedure refers to its ability to improve symptoms and potentially maintain quality of life. Cure I think is a little bit more clear, it’s to rid patients of this so that they can live their life. And competent surgeons, I think he was putting the onus on us to continue to improve outcomes for patients.

Dr. Ghodoussipour:

Well, I think that we’ve done Professor Leadbetter proud in many ways since the time of that publication. When it comes to cure, we have made significant progress in treating patients with bladder cancer, but it’s not necessarily by improving our technique of surgery, it’s more so with the perioperative management. This was a publication in the New England Journal of Medicine from 2009 from the SWOG 8710 trial, where patients with muscle invasive bladder cancer were treated with chemotherapy before surgery, versus surgery alone, and we saw that we were able to really move that needle towards cure when patients had a great response to chemotherapy.

Dr. Ghodoussipour:

I promised Stephanie that I would stay away from Kaplan-Meier curves in this talk, and I really want this to be more of a practical conversation, less so about the science. But if you see this top curve here, and the 100 markup here, we’re showing that patients who have a great response to chemotherapy are essentially cured of this disease, 95% chance of cure.

Dr. Ghodoussipour:

When it comes to maintaining quality of life, there’s been a lot of variability in the data on quality of life after cystectomy, and the quality of life as it pertains to research has really centered around the focus of urinary diversion. There’s a lot of different types of urinary diversion including ileal conduit, which is the most common. That’s the one where you have a bag on the abdomen, versus continent urinary diversions, the most common being a neobladder or an Indiana pouch. A lot of studies have shown that you can preserve quality of life.

Dr. Ghodoussipour:

One of the most well done studies I think was this one, that included 411 patients with bladder cancer who were treated with cystectomy, and they looked at 14 different patient reported quality of life measures. And you can see in all of these figures that the quality of life from baseline, meaning before surgery here on the left, to after surgery up to two years, the numbers actually were pretty good. After two months of surgery, most of these measures returned to where they were before surgery and some of them get even better. In these top three figures, higher numbers are better, and in this bottom one, body image, higher numbers tend to be a little bit worse, so that you can see that with ileal conduit compared to continent diversion, body image does get slightly worse, but it’s not dramatically far off from baseline. So we now understand that patients are going through a major operation, but if we’re able to preserve quality of life, then that’s a significant effort that we want to make.

Dr. Ghodoussipour:

I have to throw this slide up here as another one of my main areas of interest is continent diversion after radical cystectomy. The man in this figure is Donald Skinner, who is one of the grandfathers of urologic oncology, and champions of continent diversions. At the time of this presentation, this slide of his, he said that any patient who’s an appropriate surgical candidate for a cystectomy is also a

potential candidate for continent urinary diversion. I think this is a talk unto itself.

Dr. Ghodoussipour:

so we can move on understanding that we’ve been able to move the curative needle as well as the palliative needle in cystectomy for bladder cancer. Now this is a really important paper that was published in 2009, that looked at complications or challenges in recovery after a cystectomy, and over 1,000 patients treated over a 10-year period. These results I think were sobering to a lot of urologists and patients.

In this study, we found that in these patients who had cystectomy, though there was excellent cure rates and preserved quality of life, the 90-day complication rate approached 64%, meaning the majority of patients are having some complication. Now, the rate of high grade complications, meaning complications that really required treatment in the hospital, that was lower, that was around 13%. But a lot of these complications even happen after discharge from the hospital. The most common complications that occurred were GI related, or gastrointestinal related complications, things like having nausea or vomiting after surgery, or having a hard time moving your bowels after surgery, the bowels sort of get paralyzed. There’s a concept called paralytic ileus where the intestines slow down, infectious complications like urinary tract infections, and wound infections happen in a quarter of patients, and other noninfectious wound related complications happen in 15% of patients.

On top of this, the average hospital length of stay was nine days. That’s a long time to stay in the hospital for a lot of patients, but that varies by location. I’m going to get into that a little bit later. Re-admissions to the hospital were also a significant concern. A quarter of patients, 26%, would have to come back to the hospital for treatment. Mortality rate was low, 1.5%, but you may say that we want it to be even lower. And there were several predictors of complications, but really had a hard time predicting who was going to have a complication, and these numbers were not really where we would want them to be, and as a field we sought ways to improve this.

Dr. Ghodoussipour:

So what was the first thing that we did to try to improve outcomes when it comes to recovery after a radical cystectomy? Well, the first thing we did was we looked to our colleagues. In colorectal surgery, there had been this concept in place called fast track surgery, where there was these perioperative care pathways that included multiple different interventions or steps that would speed up recovery. In 1995, there was a publication that included the use of epidurals to decrease pain after surgery, omission of a nasogastric tube, that’s a tube going down the nose to drain the stomach, which up until that time had been sort of a dogmatic standard of care. Early oral feeding was used, and in the past we used to not give patients any food until they passed flatus, and they would sit there hungry in the hospital. And intensive mobilization was used, meaning patients were encouraged to walk right after surgery. Up until this time we were still in the era of bed rest. If you had a major operation, you were instructed to stay in bed all the time, but now we know that the more you move, the more your body starts to move, the faster you’ll recover. But by implementing all these changes, they were able to have patients stay in the hospital for a median of five days.

Now these are not patients having cystectomy for bladder cancer, but there’s a lot of similarities between colorectal surgeries and bladder cancer surgeries. There’s still bowel resections and bowel anastomosis, but the urinary diversion does make cystectomy a little bit unique. In 2000, they were able to update some of the experience with fast track for colorectal surgery, and saw that patients were able to stay in the hospital two days, which is a significant improvement. This ultimately led to the development of Enhanced Recovery After Surgery protocols. So what are ERAS protocols? The sort of topic of the evening tonight? So ERAS protocols are multimodal pathways that optimize all elements of perioperative care. This includes interventions that happen before surgery, before you ever come to the operating room, interventions inside of the operating room that we perform to improve your recovery, and then interventions after surgery to speed things up.

These are really multidisciplinary efforts as well. It’s not just us surgeons who are involved with ERAS, it involves nursing, it involves nutritionists, physical therapists before surgery, it involves our anesthesiology colleagues intraoperatively, and then postoperatively, it’s still the whole team as well. The ERAS society is an international society that was created in 2001. I’m very fortunate to be a part of this group, and along with some other very distinguished colleagues who are focusing on bladder cancer surgery. But the mission of the ERAS Society was to develop perioperative care to improve recovery through research, education, audit and implementation of evidence-based practice. The ERAS Society employed specialty specific guidelines to make specific recommendations. Because as I said, though colorectal surgery and bladder cancer surgery have some similarities, each is very unique, as is trauma surgery, gynecologic surgery.

Dr. Ghodoussipour:

So that is what the ERAS Society set out to do. One of the first reports of an ERAS pathway, or a perioperative care plan in bladder cancer came from this study published in 2003 by Dr. Pruthi, that looked at 40 consecutive patients who were treated with this modified care plan. Their care plan included a limited bowel preparation. Up until that time, all patients who went to cystectomy for bladder cancer had a bowel preparation, which sort of cleaned out the intestines. Then the thought was that it could decrease infection rates. However, there were some studies to show that there’s no benefit, and there’s potentially harm if you do a bowel preparation, patients can get dehydrated. Preoperative education was standardized in their protocol. Incisions were made smaller. Preperitoneal dissection means that we stayed outside of the abdominal cavity for as long as we could, and stapling devices were used to make the surgery faster. Again, nasogastric tube, which is the tube going down the nose, was emitted from ERAS protocols for a cystectomy, and non-narcotic pain medications were used. We now know that there’s a lot of side effects from narcotic pain medications, and if you use things like Tylenol or anti-inflammatories, you can avoid a lot of those undesired side effects, and early feeding has been and remains to be an important tenet of ERAS after a radical cystectomy.

So with all of these measures, they were able to have a median hospital stay of five days. Only one patient out of these 40 had an ileus, which is where the bowels don’t really quite wake up right after surgery, and that patient had to stay in the hospital for seven days.

Dr. Ghodoussipour:

This study and other small studies similar to it, led the ERAS Society to create specialty specific recommendations for a radical cystectomy. Now these guidelines were published in 2013, and they’re the last version of guidelines for enhanced recovery after a cystectomy for bladder cancer, and they included these 22 different measures. Now, as part of our questionnaire, we got some feedback from you all on what measures you thought might be important in the preoperative area. All of you thought that counseling and education was extremely effective, and I would agree with you. However, I feel that all of these other interventions are similarly effective, and that includes medical optimization, making sure that you’re healthy enough for surgery, that your heart, and your lungs, and your diabetes if you have it, are under control. Other things involved in medical optimization include smoking cessation and alcohol cessation, which can negatively impact your recovery after surgery. Avoiding bowel preparation, giving you carbohydrates and avoiding fasting before surgery.

We have to get your body ready for the stress of surgery, and fasting can really impair your ability to recover right away, we now know, so we avoid those things. Giving medications to prevent the nausea related to anesthesia, and thromboprophylaxis, means giving medication to prevent blood clots, which is something that can happen in any patient who’s having any operation, and especially so in patients who are having operations for cancer. Intraoperative interventions included in this guideline series epidurals to avoid narcotics after surgery. They recommended minimally invasive approaches using drains to avoid lymphatic collections and urine collections using antibiotics to prevent infections from ever happening, starting them before you have an infection rather than waiting for an infection, having a standardized anesthetic protocol, and one of the most important parts of that is fluid management. You don’t want to be overloaded with fluid, which can make you feel boggy after surgery and patients can really feel that, but you also don’t want to be dry. Your kidneys need fluid, and overall you need fluid to recover after surgery. Maintaining your body temperature, preventing hypothermia, and avoiding that NG tube.

Postoperative, I think you all agreed that early mobilization and early diet are important. Those remain cornerstones of ERAS for a cystectomy, but avoiding postoperative narcotics, preventing ileus with medications that stimulate the gut are all important. And the last one on this measure is audit. That means tracking our outcomes, learning what we can do better and making modifications. And we’ve done a lot of that since 2013, and there’s been a lot of evidence which we’ll get into.

Dr. Ghodoussipour:

One of the first reports of ERAS, one of the first large series reports of ERAS for a radical cystectomy came from the University of Southern California in 2014. In this series they included 126 patients who were treated with an ERAS pathway that included the interventions I had on the last slide. They were able to decrease hospital stay from eight days after surgery to four days. That eight days was before the use of ERAS protocols. Complication rates remained unchanged, still 68% complication rates, 14% major. And again, the most common complications were anemia, which is a low blood count requiring transfusion in 20% of patients, infection in 13% of patients, and dehydration in 10%. Readmissions were 21%.

So you can look at all of these outcomes and say, “Yeah, we were able to knock down hospital stay, which can get patients home, not because we’re getting them out of the hospital quicker, just because they’re ready to go quicker without negatively impacting complications and readmissions.”

Dr. Ghodoussipour:

Since that publication, there have been many, many, many studies done on ERAS for cystectomy. We’ve shown that we can decrease the rate of gastrointestinal complications, things like ileus, ability to eat, rates have been knocked down to 7% with the use of ERAS. Pain has been significantly decreased by having standardized pathways to give pain medication, specifically non-narcotics, after a radical cystectomy. Costs have actually come down. There might be an initial increase in cost because of all these different interventions that are done, but in the long run, if patients do better costs come down. And there’s been a lot of studies to suggest that patient reported quality of life, how you feel about your recovery is improved after an Enhanced Recovery After Surgery for a cystectomy.

Dr. Ghodoussipour:

So that’s a history of how we got to where we are today. But where are we really? Where do we stand today?

Dr. Ghodoussipour:

Have we moved the needle in complications?

Well, this is a recent study from the NSQIP, which is the National Surgical Quality Improvement Program, that includes patients who had surgery in the United States. This database included 11,000 patients, over 11,000 patients who had surgery from 2006 to 2018. This includes smaller hospitals, not necessarily academic centers. So the length of stay went down from 10 to eight days, not necessarily four days everywhere. But complication rates, we were able to see a significant decrease from over 50% to just at about 50%. The major complication rates however were unchanged. Readmissions are unchanged, specifically urinary tract infections and sepsis, which is severe infection remaining prevalent after the operation, at about 9%.

Dr. Ghodoussipour:

So why are we able to improve some things but not everything? I think it requires us to take a look at the literature, the studies that have been reported, and get a better understanding of how we are implementing ERAS protocols. And if we’re not implementing them all the way, then why not? So this was a study put out a couple of years ago that looked at all of the studies on ERAS, and how did they report and use all of those 22 measures that we talked about a couple of slides ago? And what they found was, after they searched the whole literature, they found 48 published series that reported on an average of 16 of the 22 steps, meaning six of the steps were never even mentioned in most of the studies. The adherence to the steps that were mentioned was about 80%, which does make sense. You can’t do every single one of these interventions in every patient, and these pathways do have to be personalized, but we would still like it to be closer to 100%. And I think that we need to understand what might be holding us back from that.

Dr. Ghodoussipour:

Another nice study that looked at variations or heterogeneity of implementation of ERAS pathways, was this study that looked at the association between antibiotic prophylaxis, which is preventative antibiotics, before a cystectomy, and at the time of stent removal, which is the stents that connect the kidneys to the urinary diversion, and infectious complications. This was another systematic review that looked at all published studies, and included 20 studies of 55,000 patients. They found that the rate of any infection after a cystectomy was 40%, urinary tract infection, 20, and bacteremia, which is a significant infection in the bloodstream, was 6%. What was important in this study, was that there was very heterogeneous or diverse use of antibiotics, and duration of antibiotics, and time of stent removal. On this figure here you can see that this red line is the time, the duration that patients were on antibiotics, preventative antibiotics. So at the top line here, you can see that antibiotics were given continuously for 30 days, and some studies here just gave it for 24 hours right after surgery, and they didn’t continue this long dose of antibiotics. These blue triangles here, are showing the time that the stents were removed from the urinary diversion. So you can see that it’s all over the place.

So though we are all doing our best to take care of patients, everyone has a different method, a different protocol, and really best practice comes when we’re all aligned and we have a good understanding of what really is best care for patients.

Dr. Ghodoussipour:

Since those guidelines were published in 2013, we have had a lot of evidence come into the field that has influenced our ability to make recommendations for patients for what we think is best. In 2013, the guidelines identified 804 studies in ERAS and included 11 of them in their guideline report. And when they synthesized or put all the data together, they saw that the evidence level was low for 21 of those recommendations. So a lot of the recommendation was just expert opinion. Again, as I said, I’m very fortunate to be part of a group of really impressive physicians from all different backgrounds, nurses, nutritionists, who are updating these guidelines. And in our most recent update we identified over 3,000 studies including 182 clinical trials, which clinical trials we generally think are a higher level of evidence than just retrospective reports where people are just talking about their experience. So the evidence level today is better, but I will admit to you that it’s not perfect even though perfection is what we are always going for.

Dr. Ghodoussipour:

So how do we use the existing data to improve outcomes moving forward, and how do we get better data to improve outcomes moving forward?

Dr. Ghodoussipour:

Well, I think that one of the most important things is that we develop more evidence-based measures, meaning we have more study to understand if things are truly better, we need to be away from all of the dogmatic practice. In the past, like I said, everyone would get an NG tube, no one would eat until they passed gas, and no one would get out of bed after surgery. Bedrest was the dogma at the time. We need more evidence-based measures to eliminate dogma from our perioperative care. Also, we need to look at outcomes beyond the index admission. In our survey, you all stated that the rate of any complication is the most important outcome after surgery. And I agree with you that it’s an extremely important outcome, but we need to look at other things including late complications, readmissions, costs, and I think more and more important every day is getting a better understanding of the patient experience as reported by the patient, not by us physicians. To really be honest about things, we need to understand how our interventions affect you.

Dr. Ghodoussipour:

So this is just a short list, not a comprehensive list, of recently completed or ongoing clinical trials in ERAS specifically for radical cystectomy. This list shows that it is possible to do clinical trials in surgery, and to really try to get the best evidence possible for our patients. If you look here, you can see that a lot of these trials are centered around something called pre-habilitation, education and a lot of trials here on nutrition. So what is pre-habilitation,

Dr. Ghodoussipour:

and how does nutrition play a role?

Well, pre-habilitation is essentially, the most simple way to think about it is, exercise before surgery to try to improve your fitness for surgery. In order to understand who is going to benefit from that, we need to have an ability to preoperatively assess functional status or fitness before surgery. If we’re able to do that, we can intervene.

You can see here this red line is where we were before the widespread use of pre-habilitation, or recommendation of exercise before surgery. In the early preoperative period, patients are at a certain level of fitness. When you have surgery, there is inherently a hit. This is a stressor and you have to recover. So there is a period of recovery in the postoperative period, and as I showed in one of my first slides, patients do get back to a baseline level of function and quality of life, but it can take two months, and that’s just the honest truth. Six to eight weeks is what you should expect in your recovery. But there’s a lot of research, and there’s people doing things now to try to improve your recovery. If you do prehabilitation before surgery, or exercise, or do special nutrition supplements, things like immuno-nutrition, you can improve that level of fitness so that there’s a gap, so that when the time comes for surgery, you’re at a higher level of fitness.

When that inherent drop comes, you can have a faster recovery, and get back to a higher level of functional recovery after surgery. So that’s really pre-habilitation, preoperative nutrition in a nutshell.

Dr. Ghodoussipour:

Another important outcome that I think up until recently we have not been giving enough attention to, is the importance of mental health in the patient experience. So patients with bladder cancer have disproportionately high rates of depression and anxiety. Depression rates can be up to 23% before treatment, and 71% after treatment, and anxiety can go up to 78% after treatment. We do note from retrospective series looking back at how patients did, that preoperative mental health is associated with your risk of developing a high grade complication after a cystectomy. And again, I think it’s very healthy and good that we’re talking about this more and more in society as a whole. But individuals with cancer, including those with bladder cancer, are at a two times increased risk of death from suicide compared to the general population. So these mental health risk factors for depression, anxiety, and suicidal ideation need to be screened before surgery. And if identified, patients should see a specialist, whether that be a mental health specialist, a psychiatrist or whatnot, but it’s not something that should be ignored.

And as competent surgeons, as Professor Leadbetter urged back in 1950, I want it to be clear that this is something that we think about, and we make sure is addressed in our patients who are undergoing surgery for bladder cancer.

Dr. Ghodoussipour:

Now, everything I’ve talked about so far has been recovery after a radical cystectomy, because that is the more complex and major operation that we perform. However, recovery after TURBT has been overlooked and neglected, and it shouldn’t be, because this is the most common procedure done, and most common surgical procedure in bladder cancer. Over 100,000 transurethral resections are performed in the United States each year, and patients do experience things like ED visits. They have pain, they have hematuria or blood in the urine, and they can have issues with their catheters that require them to come to the ED or come back to clinic. The rates of all these things are not nearly as well studied or reported as the rate of complications after a cystectomy. So just as that paper in 2009 sobered us to the challenges in recovery after a cystectomy, I think that we’re being honest in looking at these outcomes after TURBT, and thinking about how we can improve the patient experience. And ERAS is certainly a way that we can improve the patient experience.

ERAS, standardized pathways have been used for other endoscopic surgeries. For example, in kidney stone surgery using an enhanced recovery after surgery protocol decreased the use of postoperative opioid use, narcotics like Percocet, Vicodin, Oxycontin decreased from 93% to 0% in one study. In another study of endoscopic surgery for benign prostate disease, ERAS protocols were able to lead to earlier catheter removals and better pain control.

Dr. Ghodoussipour:

I wanted to give a well-deserved shout-out to one of my friends and colleagues, Max Kates, for initiating the effort in ERAS after TURBT in an ongoing clinical trial called Embrace. And you can see in these three groups here, it’s not too dissimilar from the guidelines for a cystectomy. There are a lot of preoperative, intraoperative and postoperative measures that can be done to enhance recovery after transurethral resection. Whether that’s just better counseling and education of how to care for a catheter at home, avoiding fasting before a TURBT could be just as important as before cystectomy, standardizing anesthesia protocols during TURBT, using non-narcotic pain medicines, and then other things to make the catheter care if needed a little bit more comfortable after a transurethral resection. So this is ongoing work, and I think that we’re going to see a lot more study in this in the future.

Dr. Ghodoussipour:

So with all of these efforts going on for ERAS, and all of the new data coming out, how do we ensure that we’re implementing these to the best of our ability to improve outcomes for our patients? Well, the society guidelines I think are important in my biased opinion, as I said, being able to be involved in the development of these guidelines, but these guidelines do represent best practice. It doesn’t mean that every single measure has to be performed, but they provide a checklist that’s essential for execution of a care plan that can very often-times be very complex, and coordination among multiple different treatment teams is needed. It’s not just the urologist, urological oncologist taking care of these patients, it’s the nurses, it’s the anesthesiologist, the physical therapist, the nutritionist. So having a checklist helps everyone stay on the same page. These checklists do not replace expertise or responsibility, but the existence of checklists and existing care pathways really facilitate the conversation amongst all the stakeholders to improve care for patients.

And one very important stakeholder is the patients themselves, and that’s why the patient reported outcomes I think are going to be essential to look at moving forward.

Dr. Ghodoussipour:

This is just an example of how we have created checklists to try to improve outcomes at my institution. We make it readily available to patients. These may be a little bit outdated at this point, but this is an example of a flier that we give to patients.

Dr. Ghodoussipour:

This is a checklist that patients get before surgery and after surgery, to keep track of what’s happening with us in their care journey, and this I’m very happy to see up on the wall in our unit at the hospital. These are laminated posters that we put on the wall of every patient who’s had a cystectomy. But you can see that cystectomy is just one of the operations that has an ERAS checklist. We’ve got colectomy here, gastrectomy, pancreatectomy, hepatectomy. So it’s not unique to patients undergoing bladder cancer to want to enhance recovery after surgery, but radical cystectomy, transurethral resection of bladder tumor, these are very unique procedures and we should have unique and dedicated care pathways.

Dr. Ghodoussipour:

I think my most important take home points are that bladder cancer is an aggressive malignancy requiring aggressive therapy. I think we’ve done Professor Leadbetter proud in moving that cure rate to almost 100%, we’re doing a great job there, but transurethral resection of bladder tumor and radical cystectomy are still essential treatment modalities in patients with bladder cancer. Not every patient needs a cystectomy. Every patient does need TURBT. We’re able to preserve quality of life with meticulous surgeries, appropriate selection of urinary diversions, but challenges in recovery do exist. Perioperative care pathways, ERAS has revolutionized the patient recovery and the patient experience after surgery, they’re well accepted, but implementation is inconsistent. But I think that continued multidisciplinary collaboration will result in improvement both in the implementation of these pathways, but in the recovery of patients with bladder cancer. So I’ll stop there. I really look forward to hearing what questions you guys might have, and to having a little back and forth.

Stephanie Chisolm: 

Thank you so much. That was an amazing presentation. I think all the people that were on the call will agree with me that bladder cancer treatment, whether it’s a TURBT, or a radical cystectomy, has really evolved in a good way over the last 70 years. So again, I think that your reference of putting it in a historical perspective has been really helpful. I want to encourage people to submit any questions that they may have for you into the Q&A box. But I wanted to start out, what would you think, if you were just going to give a best guesstimate, what percentage of practitioners that might not be at a large academic center like what Rutgers University are implementing all of these procedures? Are people more likely to receive ERAS protocols if they go to a large academic center? Or is this something that has trickled down to community practice at say a small community cancer center?

Dr. Ghodoussipour: 

I think that’s an excellent question, and the truth is, that there’s a lot of evidence to support the fact that patients do better at centers that are experienced and have a high volume in taking of patients with bladder cancer. And that’s a fact, and I think it comes from the experience, and the discussions, and understanding of all these measures, but I know that not everyone has access to an institution like that. And you can still get good outcomes in the community so long as best practice is adhered to, and you’re avoiding dogmatic practices that may be harmful. A lot of the interventions that I said on their own are now considered standard of care. Getting up and out of bed after surgery, I think everyone would agree it is a good thing, but having a standardized pathway to take care of this complex operation, it’s a little bit harder to do, if you don’t have support. It’s not just up to one person, it really is a team effort and you want to make sure you have that team in place.

Stephanie Chisolm: 

Sure. So if you’re looking at maybe somebody is not asking, or somebody’s not giving information about what they should do prior to their surgical procedure, how would you suggest somebody bring it up? If they’re on this call and they’re facing a cystectomy, or even a TURBT, and they’re thinking, “Wow, my doctor never does this or hasn’t told me about it.” How should they bring it up?

Dr. Ghodoussipour: 

I think that your clinic visit, obviously it’s overwhelming to hear that you have bladder cancer, or to hear that you may need a cystectomy, or honestly even a transurethral resection of bladder tumor. So it’s hard to think of these questions on the fly, but patients, you always want to try to be an advocate for yourself, and if you ask questions of your care team, no one’s ever going to be offended. You should feel comfortable asking questions. But there are a lot of resources out there if for whatever reason, you may not feel comfortable bringing things up in the clinic. And I think that the BCAN website is an amazing resource for patients. I direct a lot of my patients that way.

There’s a lot of easily digestible material and videos like this that you can watch. But one of my favorite recommendations, because I give a lot of stats and numbers in clinic, and I talk about things from my perspective as the physician, but you’re never going to get a true understanding of what your experience is going to be like when you hear it from another patient. Survivor to survivor programs are really important. There’s a great phone number for that through BCAN that you can call. And if you’re at your home institution where you’re receiving treatment, you can ask most of the time to speak with someone who’s been through this before. And I honestly think that might be the most important way to get information.

Stephanie Chisolm: 

Great. And thank you for the infomercial about the survivor to survivor program. Visit bcan.org and look on the top tab for caregivers or finding some support, and you’ll find the link to ask for a patient to call you and speak with you about treatment. We do have a few questions that have come in. First, Annie said, thank you for a great talk, and asked, “Does the implementation of ERAS have any impact on the recurrence rate following a TURBT? Or is that completely separate?”

Dr. Ghodoussipour: 

Well, I think it might be a little bit too early to say. There’s no evidence in that regard, and there isn’t a lot of evidence that ERAS improves cancer outcomes after radical cystectomy. But much of the focus has been on physical, emotional and recovery as we talked about. But in other surgical fields, like in colorectal surgery, there is data that ERAS protocols after colorectal surgery for colorectal cancers improve outcomes, specifically recurrence rates and survival rates after colorectal surgery. And that’s not because necessarily pain medicine influences your cancer recovery, but it’s the little nitty-gritty details that you alluded to with where you receive care matters. But if you have a standardized pathway, nothing is missed, everything is done to the highest level. And if you are able to recover quickly after surgery, you might be able to get on more life-saving therapies afterwards. I just talked about neoadjuvant chemotherapy as an example in here, but adjuvant therapies, immunotherapy, biomarker testing that we have nowadays, that’s sort of in the future for bladder cancer. And if you’re able to recover quicker and get to subsequent therapies, you’re going to do better. And I think that that’s probably the same for TURBT and going on to intravesical and bladder sparing therapies afterwards.

Stephanie Chisolm: 

Right. Yeah. So one of our participants said they’ve never heard of ERAS in the TURBT setting. “The issue I had was an extremely sore throat due to the intubating in my first one, sending me to the emergency department. The second one was done without in-tubing, and both have had equal results, and both were done in academic centers. Why is this not being addressed? Why is it inconsistent?”

Dr. Ghodoussipour: 

Yeah, and again, a lot of credit to my colleague Max Kates for starting ERAS and TURBT, but it’s not something that has been talked about. I think that we have really overlooked TURBT, saying, “Oh, it’s just a quick outpatient procedure. There’s no incisions. We just got to do it and you’ll be fine. And when we come back, we’ll talk about the pathology.” But as time goes on, and we become a little bit more reflective as Leadbetter encouraged back in 1950, we understand that all these little things matter. I can’t speak to everyone, but for example, when I do transurethral resections, I really try to avoid intubations. In the past, everyone was intubated for TURBT so that they could have muscle paralysis so that there was no leg kicks, which can happen during a bladder tumor resection. But there’s a lot of different techniques and whatnot that you can do to avoid that. And if you avoid the need for muscle relaxation, you don’t need intubation. You can just use a mask airway. But that’s a little bit controversial, and I think that as we study this more and more, we can try to avoid things like that.

Stephanie Chisolm: 

Great. Question, are your Rutgers checklists that you showed briefly, available online?

Dr. Ghodoussipour: 

We do not have it available online quite yet because we’re making some modifications. If you go back and look at this video, some of the measures on there, we no longer do. We’ve evolved in a lot of things, but ERAS is continually evolving. For example, thromboprophylaxis medications to prevent blood clots after surgery. We used to send everyone home after a cystectomy on blood thinning injections, we’ve switched to pills. Those checklists that I showed you say that we use injections, but we avoid that. So hopefully in the near future they will be.

Stephanie Chisolm:  

One of the projects that BCAN has been doing a lot of work on is really developing survivorship resources. And perhaps this is something that can be added specifically about bladder cancer procedures, something similar that we can work on together to help really develop a whole checklist that could be really used either for the TURBT, or for a radical cystectomy that patients might be able to download to bring to their doctors and ask questions about. I think that would be really helpful.

Dr. Ghodoussipour: 

I think that’s a great idea, and I do look forward to having the specialty specific guidelines updated. And once that happens, I think we can put forward a little bit more clear consensus checklists. I don’t want to just highlight what I do. I want to highlight what’s best practice, that varies from state to state within the US, but also from country to country. The guidelines that we’re trying to put forth are international, so patients in Europe have a very different experience and desire to get out of the hospital, for example, after surgery.

Stephanie Chisolm:  

I will definitely introduce you. Speaking of having you talk again, you’re going to be coming to our fall summit in November in Philadelphia, and everyone on this call will be getting an invitation to attend. And there’ll also be a session where we’re going to have Mary Dunn, nurse practitioner who is down at UNC, and is focused on our survivorship task force. I will introduce you if you don’t already know Mary, and perhaps we can think about how we can collaborate to work together on that. A couple more quick questions. I just want to try to get to them while we still have some time. You mentioned the removal of ureteral stents. Is that something that occurs after all radical cystectomies? If yes, what is the typical timing post-surgery?

Dr. Ghodoussipour:

Yeah, good question. And that’s something that we’re trying to have in the guidelines. Ureteral stents are used when we sew the ureters to the bowel that is used for the urinary diversion, whether it be an ileal conduit, neobladder or Indiana pouch. The majority of surgeons do use ureteral stents. But there is emerging evidence now that you can avoid the use of ureteral stents, so long as you do a meticulous repair. Traditionally, we’ve used these stents to prevent scarring or stricture formation, which can happen in the long run in up to 10% of patients, and it can prevent things like urine leakage from where we sew everything together.

But as of now, I would say that most people use ureteral stents. There might be a few high volume places that don’t use ureteral stents. We try to remove them as early as possible. There have been studies where they’re removed immediately after the sewing is done, where they’re removed a day after surgery, where they’re removed three weeks after surgery. For ileal conduits, I try to remove them before patients leave the hospital, which with our ERAS protocols is about four days now. So we try to remove those on post-op day four. But when we make neobladders, that’s a little bit more complex and there’s more time required for the neobladder to heal. I have the urethral stents attached to a urethral catheter, which comes out three weeks after surgery. But there’s a lot of variation, I’ll admit to you, in how people do that. That’s just my practice, but the earlier, the better.

Stephanie Chisolm:  

Sure. Okay. Well, one of the things you talked a lot about was this issue of rehabilitation, almost getting yourself ready for the very significant procedures that are involved in a radical cystectomy. The question came in asking, are there guidelines for pre-habilitation that are available?

Dr. Ghodoussipour:

No, there are not guidelines. So the American Society of Clinical Oncology does recommend preoperative exercise before surgery, but the specific details of that exercise are not clear. So it could be small things like hand strength exercises, just push/pull exercises that you can do at home, versus going on a 20-minute walk every day before surgery, versus getting your heart rate up to a certain level. There aren’t specific guideline recommendations because I think it’s such a new and emerging topic, but there are ongoing clinical trials. I think Sarah Psutka from the University of Washington has a really exciting trial coming up that is tailored to specific patients based off of their heart rate monitors. I forget the name of it, you may remember that. It’s the Get Up and Move trial?

Stephanie Chisolm:   

Yes.

Dr. Ghodoussipour:

But I think once all this data comes out, then maybe we’ll have guidelines on specifically what there should be. But until then, at this point, I think it’s just important to stay active before surgery, and try to implement as we all should be doing every day, I’ll admit that I don’t do it myself. We should have some amount of exercise and every day, or at least the majority of days of the week. And if you think about it, surgery is a physical battle that you’re going through almost like a marathon. So the fitter you are going into it, the better you’ll do, and exercise before can get you to that point.

Stephanie Chisolm:  

Absolutely. And I am very proud to say that BCAN supported Dr. Sarah Psutka research. We gave her a $1.5 million grant to do the Get Up and Move protocol, and really do a clinical trial looking at whether patients can really build their stamina and do all of these other things. And so there is information about that on our website, including some webinars by Dr. Psutka. So again, visit bcan.org and look at all of our previously recorded videos. Dr. Psutka is a favorite for BCAN. She’s done a lot of amazing work on the issue of pre-habilitation. So that and many other topics, including Dr. Bernie Bochner did a wonderful program, both as a webinar and a podcast, looking at some of the quality of life measures that they took after doing radical cystectomies in a number of patients.

So there’s a lot of good resources available, and I think it’s something that you’ll all agree with me on that when you’ve got a surgeon like Dr. Ghodoussipour, who’s also a talented researcher who’s documenting all of these things, the future is really bright and a comprehensive overview of ERAS was incredibly helpful. I know that it’s inspired, I hope, many of you to talk to your doctors about that. I’d like to just end with one more question. First of all, I’d like to thank you, because I think this is a wonderful program. But the last question I’m going to ask is, what would be the single most important message you want our listeners to leave with today?

Dr. Ghodoussipour:

I think the single most important message is probably to look at the whole picture of what I presented today. Almost a century’s worth of work. We’re really in a much better place than we used to be in the management of patients with bladder cancer, but there’s a lot of physicians, not just like me, but better than me, who are doing this work, and I think that we’re going to be in a really great place. But the most important voice that we need to hear more from, and incorporate more into these studies in this research, is you the patients. So I look forward to face-to-face meetings in the future at the summit through our work, and to see how we can really move the needle even further.

Stephanie Chisolm:  

Well, again, this has been a phenomenal program. That’s all we have time for today. I want to just again, thank our sponsors, Merck and UroGen for making this webinar possible. Thank you so much, Dr. Ghodoussipour, and thank you to all of the listeners for joining us.