Introduction:

Enhanced Recovery After Surgery (ERAS) has significantly decreased morbidity associated with radical cystectomy. However, infectious complications including sepsis, urinary tract (UTI), wound (WI), and intraabdominal infections (AI) remain common. We aimed to assess if intracorporeal urinary diversion (ICUD) and antibiogram-directed antimicrobial prophylaxis would decrease infections after robotic-assisted radical cystectomy (RARC).

Methods:

We performed a retrospective analysis of a prospectively maintained database of patients undergoing RARC between 2014-2022 at our institution, identifying two groups based on adherence to a prospectively implemented modified-ERAS protocol for RARC (Figure 1). Unmodified-ERAS: patients receiving extracorporeal UD and guideline recommended cephalosporin-based prophylaxis regimen (November 2014-June 2018). Modified-ERAS: patients after a prospectively implemented protocol including ICUD and antibiogram-directed ampicillin-sulbactam, gentamicin, and fluconazole prophylaxis (January 2019-present). Patients receiving other prophylaxis regimens were excluded. The antibiogram was created after institutional review of postoperative urine culture data for all patients receiving RARC at our hospital from May 2018 to November of 2018 in collaboration with the Mount Sinai Hospital Antibiotic Stewardship Program. Primary outcome was UTI, WI, AI, and sepsis within 30 and 90-days postoperatively. Secondary outcome: Clostridioides difficile infection (CDI) within 90 days postoperatively.

Results:

396 patients were studied (unmodified-ERAS: 138 [34.8%], modified-ERAS: 258 [65.2%]). UD via neobladder was more common in the modified-ERAS cohort; all other inter-cohort demographic differences were not statistically different. Comparing cohorts, modified-ERAS had significantly reduced rates of 30- (7.8% vs. 15.9%, p=0.027) and 90-day UTIs (11.2% vs. 25.4%, p=0.001), and 30-day WI (1.2% vs. 8.7%, p<0.001); neither group had a WI after 30 days. Rates of AI, sepsis, and CDI did not differ between groups. On multivariate regression, modified-ERAS protocol correlated with reduced risk of UTI and WI (all p<0.01). 

Conclusion:

Implementation of a modified ERAS protocol featuring ICUD and antibiogram-based prophylaxis for RARC correlated with reduced 30- and 90-day UTI and WI rates. Further prospective trials are necessary to corroborate these findings and come to consensus regarding optimal perioperative prophylaxis and diversion approach for reducing infectious complications after RARC.

Funding: N/A