• The enhanced recovery programme (ERP) is about improving patients’ outcomes and speeding up their post-operative recovery
• The programme starts within primary care and continues throughout the peri-operative period through to post discharge care.
• This guideline provides advice for the anaesthetist, urologist and nursing staff managing patients undergoing laparoscopic/robotic urological procedures on the enhanced recovery programme at Frimley Park Hospital.

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition.

Abbreviations

The enhanced recovery programme (ERP) is about improving patients’ outcomes and speeding up their post-operative recovery. The programme starts within primary care and continues throughout the peri-operative period through to post discharge care. It results in benefits to both patients and medical staff. Patients play a vital role in their own recovery process. ERP also aims to ensure that patients always receive evidence-based care at the right time.

This guideline provides advice for the anaesthetist, urologist and nursing staff managing patients undergoing laparoscopic/robotic urological procedures on the enhanced recovery programme at Frimley Park Hospital. Support is available via the starred anaesthetic consultant on bleep 5639 and also the inpatient/acute pain team on bleep 5252.

2.1 Outcomes of the enhanced recovery programme are

• Better clinical outcomes and reduced length of stay

• Increased numbers of patients being treated (if there is demand) or reduced level of resources necessary

• Improve patient flow

• Better staffing environment

• Greater patient engagement and higher patient satisfaction

There are four elements to the enhanced recovery programme

• Preoperative assessment, planning and preparation before admission

• Reducing the physical stress of the operation

• A structured approach to immediate post-operative and intra-operative management including pain relief

• Early mobilisation

The urological surgeon should identify suitable patients for ERP pre- operatively. This should be confirmed at pre-operative assessment with any issues identified and the anaesthetist consulted if necessary.

The aim of ERP is to continually assess and prepare patients at different steps.

Primary Care

Hospital medical staff are encouraged to work in partnership with primary care. Management of chronic conditions such as diabetes, hypertension and anaemia should start in the community, with optimisation encouraged prior to surgery.

Outpatient clinic

The first outpatient appointment constitutes a key part of the ERP. Patients are usually selected for ERP by the urological surgeon. The procedure is explained to patients verbally. Information leaflets about surgical procedures are available and should be given to all patients. Information about upper urinary tract conditions and video animations of surgical procedures are available on the Frimley Renal Cancer Centre website. Patients are encouraged to visit the webpage

https://www.fhft.nhs.uk/services/renal-cancer-centre/

Patients are introduced to the renal cancer nurse specialist (CNS) at the first outpatient visit. The procedure, timeline for recovery and patient expectations are discussed.

The projected length of stay for most of the patients would be:

• Laparoscopic radical nephrectomy: 1-2 days.

• Robotic assisted partial nephrectomy: 1-2 days.

• Laparoscopic / Robotic assisted nephroureterectomy: 1-2 days. Laparoscopic adrenalectomy: 1 day.

• Robotic assisted pyeloplasty: 1-2 days.

High-risk patients are identified at the first hospital visit. The surgeon should consider referring these patients to high-risk anaesthetic clinic (HRAC).

Patients with cardiac and lungs problems should be referred to cardiopulmonary exercise testing (CPET).

Pre-operative assessment clinic:

The specialist nurses perform pre-operative assessment with anaesthetic support. Patients are encouraged to reflect on their understanding about their condition, their expectations and knowledge about surgery.

Optimisation of chronic diseases should be ensured at this stage. Written advice should be given to patients about fasting instructions, anti- coagulants, oral hypoglycaemic drugs and ACE inhibitors.

2.3 Operative Stage

The principles of the ERP are:

• Optimise analgesia whilst minimising opiate use

• Minimise the stress response

• Use short acting agents where possible

• Effective fluid management

Pre-operatively

• Analgesia: Paracetamol 1g PO (given by a nurse on POD);

• Encourage patient to stay warm

Intra-operatively

• Large bore cannula (significant blood loss is not uncommon)

• General anaesthesia

• Antibiotics as per the Trust peri-operative prophylaxis guideline

• IV analgesia: morphine or oxycodone (if eGFR<60) +/- paracetamol if not given pre-op;

• Avoid NSAIDs

• Neuraxial anaesthesia/wound catheters: NOT routine; if required, to be discussed with surgeon pre-op

• LA infiltration of operative site by surgeons

• Antiemetic drugs

• Warmed fluids / forced air warmer

• 2 to 3 litres of balanced crystalloid solution per case

• Discontinuation of IV fluids before leaving theatre should usually be possible

• Special attention to protecting pressure points due to potentially prolonged nephrectomy position

• Patients catheterised pre-KTS, catheter to stay post op in most cases

2.4 Post-Operative Stage

• Extended VTE prophylaxis: all patients should continue wearing TED stockings for the period of their admission. Extended application of Flowtron boots should be considered for high-risk patients

• Prophylactic low molecular weight heparin should be started for all patients undergoing laparoscopic / robotic assisted radical nephrectomy, nephroureterectomy and pyeloplasty. Patients undergoing robotic assisted partial nephrectomy should avoid receiving low molecular weight heparin for 24 hours post operatively. The surgeon should make clear anticoagulant management plan for high-risk patients

• Mobilisation: early post-operative mobilisation is encouraged. With the support of nurses, patients should be out of bed for 2 hours on the day of surgery and for 6-8 hours on subsequent days. Early mobilisation is essential reduce the risk of

  • Venous thromboembolism (DVT, PE)

  • Chest infection and respiratory compromise

  • Paralytic ileus

  • Loss of muscle strength

  • Insulin resistance

  • Referred shoulder pain

• Patients should be encouraged to eat and drink immediately after surgery

Post-operative medications

• Regular paracetamol 1g PO QDS

• Regular tramadol 50 to 100mg PO QDS (unless contraindicated)

• Avoid codeine + NSAIDs and other nephrotoxic drugs (e.g., ACEi / ARBs etc.)

• PRN opioid for breakthrough pain –either 5-10mg (up to 20mg) morphine sulphate oral solution 2-4 hourly or 2-5mg (up to10mg) oxycodone immediate release liquid 4 hourly depending on eGFR

• PRN cyclizine 50mg + ondansetron 4mg both PO/IV 8 hourly

• Laxatives: Laxido 1 sachet PRN or lactulose 10ml BD and senna 2 tablets nocte

• Note: neuraxial anaesthesia, wound catheters or PCA are NOT standard

• Review of regular medications (e.g., NSAIDS, ACEi, ARBs, etc.)

VTE Prophylaxis

• Post-operative dalteparin is NOT routinely prescribed for RAPN patients

• Post-operative dalteparin is routinely prescribed 4 hours after procedure for patients undergoing robotically assisted pyeloplasty, laparoscopic radical nephrectomy and nephroureterectomy

2.5 Discharge criteria

The aim of ERP is early return to normal function. On discharge, the patient must be tolerating a normal diet, able to mobilise comfortably and have adequate pain control. The renal cancer nurse specialist will routinely arrange for a follow-up telephone consultation within 3 days of discharge.

Patients are advised to contact the renal CNS or surgical assessment unit (24-hour emergency point of contact) in case of any complications.

3.1 This guideline will be monitored through incident reporting. It will also be discussed as required at multidisciplinary team meetings in anaesthetics and urology. Audit work to assess effectiveness of treatment will be undertaken as a separate activity from monitoring of guideline

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