Postoperative Pain Management after Radical Cystectomy: Comparing Traditional versus Enhanced Recovery Protocol Pathway

Purpose: Opioids have traditionally been the mainstay of pain management after radical cystectomy for bladder cancer but they have many side effects. The efficacy of opioid sparing analgesics after cystectomy as part of a protocol of enhanced recovery after surgery has yet to be proved. We compared opioid use, pain score and postoperative ileus in consecutive patients on a protocol of enhanced recovery after surgery and those on a traditional protocol after radical cystectomy. Materials and Methods: Using our institutional review board approved bladder cancer database we retrospectively reviewed the records of patients who underwent open radical cystectomy using a traditional protocol or a protocol of enhanced recovery after surgery for pain management. A total of 205 patients were ultimately enrolled in study, including 81 on a traditional protocol and 124 on the enhanced protocol. Opioid use and pain scores were analyzed and compared up to postoperative day 4. All routes of opioid use were recorded and converted to the morphine equivalent dose for comparison. Postoperative pain was recorded using a visual analog scale. Postoperative records were reviewed for the incidence of ileus. Results: Patients on the enhanced recovery after surgery protocol and those on a traditional protocol were similar demographically. When analyzing data up to the median hospital stay on the case group, patients on enhanced recovery used significantly less opioids per day (4.9 mg vs 20.67 mg morphine equivalents, p < 0.001) and reported more pain (visual analog scale 3.1 vs 1.14, p < 0.001). They also experienced a significantly lesser incidence of postoperative ileus (7.3% vs 22.2%, p = 0.003) and had a significantly shorter median length of hospital stay (4 vs 8 days, p < 0.001). Conclusions: Patients on the protocol of enhanced recovery after surgery used significantly less opioid analgesics, possibly contributing to decreased postoperative ileus and shorter length of hospital stay.