Prospective implementation of a nonopioid protocol for patients undergoing robot-assisted radical cystectomy with extracorporeal urinary diversion

Objectives: To evaluate the feasibility and outcomes of a nonopioid (NOP) perioperative pain management protocol for patients undergoing robot-assisted radical cystectomy (RARC). Materials and Methods: We prospectively included 52 consecutive patients undergoing RARC at our institution for bladder cancer. Patients received a multimodal pain management protocol, including a combination of nonopioid pain medications and regional anesthesia. For comparison, we retrospectively included 41 consecutive patients who received the same procedure before implementation of the NOP protocol. Results: There was no significant difference in demographic and perioperative characteristics between the two groups. Patients included in the NOP protocol received a much lower dose of postoperative morphine milligram equivalents (2.5 [IQR: 0–23] vs. 44 [14.5–128], P < 0.001), with no difference in pain scores. In the NOP protocol, the median time to regular diet was significantly shorter (4days [IQR: 3–5] vs. 5days [IQR: 4–8], P = 0.002) and the length of stay was 2days shorter compared to the control group (5days [IQR: 4–7] vs. 7days [IQR: 6–11], P < 0.001). When evaluating the direct costs within 30days after initial surgery, the NOP protocol was associated with an 8.6% reduction as compared to the control group (P = 0.032). In multivariate analysis, the receipt of the NOP protocol was a significant predictor of a length of stay <7days after RARC (OR: 12.09; 95% CI: 1.70–140; P = 0.023). Conclusions: The prospective implementation of a NOP protocol for patients undergoing RARC is feasible, allowing for minimal narcotic usage and provides benefits to patients, institutions, and population.