Ashish Kamat: It gives me great pleasure to welcome Dr. Sima Porten here today to UroToday. Dr Porten's an expert in bladder cancer and Assistant Professor at UCSF right here in San Francisco. Thank you so much for taking the time from a busy GU ASCO schedule, Sima. Tell me a little bit more about the whole enhanced recovery after surgery paradigm that you've been championing for several years.

Sima Porten: Yeah, thank you for having me. It's a pleasure to be sitting here with you and doing this interview. So enhanced recovery after surgery is something that I learned in fellowship with you and others at MD Anderson and it is a pathway built to help improve outcomes for patients undergoing cystectomy. It has a few core principles, mainly early mobilization, early feeding, some component of preoperative education and optimization, opioid minimization, as well as the goal of attempting to get patients to get through a big operation with minimal side effects, minimal complications and hopefully a shorter length of stay, which ends up being cost saving for the hospital.

Ashish Kamat: Yeah. And clearly radical cystectomy is not a surgery to be taken lightly either by the patients or by the surgeon. And the work that you've done in getting these patients through the ERAS pathway has been really critical in getting it adopted in many places. But in a center that's trying to adopt ERAS, you often hear about people trying to pick and choose certain components. What would your advice be as far as the entire ERAS pathway? Which components are more irrelevant? Is it the entire package? How should someone go about adopting it?

Sima Porten: So I can tell you some errors are made in trying to adopt an ERAS pathway early on at UCSF. When I got there, I figured I'm going to do it the same way that was done at MD Anderson. I'm going to take the same exact medications, what we do intraoperatively postoperatively and I'm just going to say that this is what it's going to be at UCSF. And that didn't go over that well because at every institution ERAS is going to look different as long as you keep certain principles. So I think a few core principles that are very important are number one, you have to engage your anesthesiologist. If you can't start with opioid reduction right when the patient enters the operating room, you've sort of lost a window of opportunity. Meaning there are many different things that you can do during surgery, minimizing fluid, using things like magnesium or I.V. lidocaine to minimize any opioids. And overall that's sort of where it starts.

The other part of that is you really have to engage your anesthesiologist in terms of when are you going to let patients stop drinking liquid? Because in the past we used to do a bowel prep, which I think is another key point in getting rid of the bowel prep and helping bowel recovery after. But also it's about not dehydrating a patient, meaning letting them drink liquids up two hours before the report time or four hours before the start time in surgery. And that definitely requires a culture change. So I would say that's the first important component. In terms of postoperatively, for us, it's been the use of ENTEREG® or alvimopan, which is a mu-two receptor antagonist. That was one of the first key things that we worked with our pharmacy team to get at UCSF, to help minimize ileus or opioid-induced constipation after cystectomy. That I think is a key point.

The other group you really have to engage is your nursing team in terms of getting patients up and moving as soon as possible and also making sure that they utilize multimodal energies after surgery. So what I mean by that is in general people see a patient who've had a really big operation they're like, "Oh, you have to stay in bed for the night," which is sort of the opposite of what ERAS wants to do and again, this is a huge culture change. So it's about finding all those people and teams and sitting with them explaining what you want to do and why and figuring out how you're going to be able to get it done at your particular institution with their rules, regulations and all of the other things that create an entire hospital system that you have to work in.

And so I was a lot more successful in doing all of that after finding an anesthesia champion, finding a perioperative nursing champion, finding a floor nursing champion and also engaging my own colleagues and figuring out what's going to work for us. Starting from the clinic all the way through the whole operative experience to postoperatively.

Ashish Kamat: Right. Now you raised some really important points and I think it's key to recognize that, it's a team effort, right? Because we can do the surgery as best as we can, but if you don't have your anesthesia colleague, your nursing, everyone that's helping the patient on board, then everything kind of falls apart. With that in mind, there has been talk about ERAS and its role in minimally invasive surgery. What are your thoughts on whether ERAS is relevant? If it's relevant, is it more relevant than the route of surgery? Your thoughts?

Sima Porten: So my thoughts on that is how you do your surgery is a tool whether you do it minimally invasive or open. We do both at UCSF and having an ERAS pathway has been beneficial with both types of operations, same operation, just a different way of doing it. When we looked at our data retrospectively and compared both groups, ERAS helped both. We did not see a length of stay difference just inherent to the type of operation you perform, whether minimally invasive and it's robotically at UCSF compared to open. And ERAS did help reduce that length of stay in both groups, but we didn't have a difference between the two at baseline. I think because the surgery to me is a tool and that you use it appropriately for the right patient.

ERAS is more of a, I don't know if it's a bundle or like a patient experience. I don't know what a great way of describing it, but it really is more targeted toward the physiology of what happens when you undergo a massive operation like cystectomy. And it focuses on more of the biologic aspects versus technically what you're doing in the operating room. And so that's kind of how I thought about it and that's what our data seems to support. We see a difference we're using ERAS or not, we don't see a difference in terms of the modality of surgery.

Ashish Kamat: You know like the way you put that because you're using ERAS and it's a good way to think about it is as to address the physiological status and the physiology of the patient and going through the journey of the surgery and then how you do the surgery is just another tool that you're using, but it's just a way to do the surgery. I like the way of thinking of that. Tell me a little bit more about what you would see as some of the pitfalls of ERAS and not just the adoption but during the actual process.

Sima Porten: So I think during the actual process, I think one of the hardest things to do is set up a system where you're able to look back at your data. And what actually ERAS is doing are all the different components being implemented and if yes, great. Is it making the changes that you want it to make? Are you seeing a reduced length of stay? Are you seeing an earlier return of bowel function? Are patients actually being walked on postoperative day zero? Are all of the things that you set out actually happening? And then what the followup to that is. And when we started our auditing process, we actually found some interesting things. We had an initial decrease in length of stay from 7.9 days to about 5.5 days and then it remains stable for a year. And when we looked back at patients undergoing cystectomy on ERAS, what we were actually finding was they were getting a very large amount of morphine equivalence in the first two postoperative days.

So postoperative day zero, one, and two and based on how much they got during that period, it was directly associated with length of stay. And we were able to kind of tease out that, it's really this early opioid exposure. And for us, that was opioid exposure through the epidural because we were an institution that used an epidural as a way of reducing pain and minimizing systemic or oral opioids. But it turned out that getting opioids in the spinal area was just as impactful. And so when we looked at that, we decided we went through a few iterations of how we're going to minimize that early opioid exposure and we settled on using liposomal bupivacaine or EXPAREL.

Ashish Kamat: So you've moved away from epidurals to tap blocks or EXPAREL essentially?

Sima Porten: Essentially yes. Basically injecting it directly in its incision versus a tap block at all the different layers. And we just looked at our data after starting liposomal bupivacaine and we had our morphine equivalents fall to almost nothing. About 40% of patients are going through cystectomy entirely opioid-free and our length of stay has decreased by about a day and a half.

Ashish Kamat: That's great. That's great. Now you often hear some of the critics of ERAS say well you're just transferring the care of the patient over to the outpatient side and you're going to negate the cost savings with readmission rates. What's your view on that?

Sima Porten: Our readmission rates have stayed stable, comparable to around the country. It kind of ebbs and flows between 10 to 20% depending on the month and so that has remained fairly stable in terms of our 30-day readmission rates, so we're not seeing that. In terms of what we do after surgery that's been a more difficult journey. There are some institutions that implement regular hydration. We haven't been able to do that routinely. We are targeting patients more who don't have great PO intake and so we use, if you aren't able to take 1.2 liters of PO intake in the last two days before discharge, we're using that as a metric of saying this person's at risk of possible dehydration could we transfer a little of the care in the outpatient setting. Which is still cheaper than keeping someone in-house and give those patients hydration twice a week for two weeks.

And so we've kind of moved our resources that way. And that was because we got a lot of feedback from our case managers, social workers and discharge planners based on our pair mix that trying to get the outpatient hydration was actually from a logistic and reimbursement perspective, not possible. And so if we could focus on people who are most at risk, we would likely be able to be more successful in that. And so that's what we've done in that aspect.

I think you asked a question about, the other thing that kind of comes up is are we also telling patients to suck it up a little and deal with more pain? So what our patients' pain scores when we changed this and we did notice that patients' pain scores were a little higher during their stay than the group that had an epidural. And it was an overall pain score of between like 2.5 for epidural and at somewhere around four for the non-epidural group, our liposomal bupivacaine group. That hasn't translated into a patient-reported outcome. That has shown that people are dissatisfied with pain management on the floor. So we have these patient surveys of the floors, in general, looking at that and so we haven't seen that translate in a patient-reported outcome but I think it's an important thing to ask. We don't want to focus so much on the length of stay that people are suffering unnecessarily during this. There might be a length of stay day or a minimum that it might not be worth it to try to discharge a patient that early just based on their patient-reported experience I would say. And then some of the issues that bring up, but right now we haven't really gotten into that territory. Meaning people aren't leaving on post-op day two, we're kind of around four, four and a half days.

Ashish Kamat: And that's sort of where we are too, four or four and a half days. I feel uncomfortable even if a patient feels great on day three actually letting them go after such a major procedure. This has been very informative for our viewers. I mean this is really great. In wrapping up, any last thoughts or points that you want to leave our viewers with?

Sima Porten: Yeah, I would say that the most important things about enhanced recovery after surgery is really setting up a system to help a patient have a better experience through surgery and hopefully fewer complications and a more favorable outcome. And I would say the only way that you can do that is with a team. And also you've really got to look back at what you're doing and making sure that there's number one, no unintended consequences and number two, that you're not seeing a drift back toward an older culture. Because then you really have to work toward bringing that culture change back and keeping your pathway active. Otherwise, for the long run, it's not going to be successful.

Ashish Kamat: Very well said. Once again, thank you so much for taking time off your busy schedule for being with us here, Sima, I really enjoyed it.

Sima Porten: Thanks for having me.