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Table 1 List of components in Rigshospitalet’s Enhanced Recovery After Surgery protocol for radical cystectomy

From: Robot-assisted laparoscopic radical cystectomy with intracorporeal ileal conduit diversion versus open radical cystectomy with ileal conduit for bladder cancer in an ERAS setup (BORARC): protocol for a single-centre, double-blinded, randomised feasibility study

Preoperatively

 - Pre-operative education and counselling: surgical details, hospital stay, and discharge criteria

 - Stoma education with a specialised stoma nurse

 - Preoperative medical evaluation and optimization

 - Advice and support for smoking cessation and reduction of alcohol intake

 - Instruction on postoperative mobilisation and physiotherapy

 - Anesthesiologic assessment

Day before operation

 - Admission to hospital

 - Normal diet with no restrictions

 - Rectal enema the night before surgery; omission of mechanical bowel preparation

 - Pharmacological thrombosis prophylaxis with LMWH (Tinzaparin 4500 IE)

POD 0: preoperatively

 - Preoperative fasting: normal diet until 6 h and clear fluids until 2 h before anaesthesia

 - Preoperative pain medication: Gabapentin 600 mg + Paracetamol 1 g.

 - No long-acting sedatives

 - Elastic compression stockings for thrombosis prophylaxis

POD 0: intraoperatively

 - Antimicrobial prophylaxis: i.v. Cefuroxime 3 g intraoperative and skin preparation

 - Anaesthesia is similar between groups, including orotracheal intubation, total intravenous anaesthesia (Cisatracurium, Remifentanil, and Propofol), Ondansetron 4mg, Dexamethasone 24 mg, Tranexamic acid 1000mg, i.v. oxycodone and regional anaesthesia using rectus sheath blocks (2 mg bupivacaine/kg body weight) at the end of surgery without epidural

 - Central venous catheter (vena jugularis interna dexter)

 - Radial arterial line

 - Prevention of intraoperative hypothermia (Bair Hugger)

 - Nasogastric tube inserted and removed before extubating

 - No resection site drainage

 - Bilateral ureteric stents

POD 0: postoperatively

 - Admission to the postoperative care unit until POD1

 - Chewing gum (throughout admission to hospital)

 - Antibiotics Cefuroxime 1500 mg x 3 i.v. (continued for 3 days)

 - Thrombosis prophylaxis: LMWH (continuing 4 weeks postoperatively) and compression stockings (until discharge)

 - Analgesics: Gabapentin 600mg+300 mg (continued for 3 days) + Paracetamol 1 g x 4 (continued throughout admission), short-acting opioids (oxycodone or morphine) if necessary

 - Laxatives: macrogol 1 sachet x 2

 - Antiemetics: Metoclopramide 10 mg if needed

 - Mobilisation: sitting and standing in the evening

 - Oral nutrition: maximum 1 L I fluid, no solids

 - Fluid strategy: Goal directed fluid therapy by stroke volume optimization

 - Continuous Positive Airway Pressure (CPAP) every second hour except during nighttime (24–06)

POD 1

 - Admission to the urological ward

 - Medication and thrombosis prophylaxis: see “POD 0 postoperatively”

 - Oral nutrition: solids as tolerated, maximum of 1 L of fluids

 - Mobilisation: sitting as much as possible in a chair, walk minimum 2 x 60 m with a walking frame with wheels

 - Self-administration of thromboprophylaxis injections and individually adapted level of self-sufficient care for ileal conduit throughout their hospital stay in preparation for discharge

POD 2

 - Medication and thrombosis prophylaxis: see “POD 0 postoperatively”

 - Oral nutrition: no restrictions

 - Mobilisation: out of bed minimum 2 x 3 h, walk minimum 3 x 60 m

POD 3

 - Medication: see “POD 0 postoperatively”

 - Oral nutrition: no restrictions

 - Mobilisation: out of bed minimum 8 h, walk minimum 3 x 60 m

 - Discharge if fulfilling discharge criteria

POD 4 and until discharge

 - Medication: Paracetamol 1 g x 4, macrogol 1 sachet x 2. Metoclopramide and short-lasting opioids if needed.

 - Mobilisation: as POD 3

Discharge criteria

 - Adequate pain control

 - Independently mobilised

 - Instructed in stoma care, and establishment of post-discharge specialised assistance if needed

 - No sign of ileus

 - Adequate oral intake

Discharge

 - Unblinding

 - Provision of support network including district nurse and urology nurse

 - Information on signs and symptoms of complications. Informed to contact the department by telephone at all hours in case of signs of complications for consultation with a urological nurse or doctor on further actions.

Post discharge

 - Removal of ureteric stents and skin suture on POD 10 with creatinine blood sample on POD 11

 - Contact with a nurse by telephone the first Thursday after discharge

 - Follow-up after discharge will adhere to local and national guidelines with planned outpatient visit (1) 3 weeks postoperatively for the result of pathology report and planning of oncologic follow-up, and (2) 8 weeks postoperatively for a 99m Technetium-mercaptoacetyltriglycine renography control.

  1. POD postoperative day, LMWH low molecular weight heparin