Keywords

Bladder Cancer

Bladder cancer is the second most common urologic malignancy and the 6th most common cancer. The majority (93%) of the tumors are classified as urothelial cell carcinoma (UCC), which may be non-muscle invasive (NMIBC) or muscle invasive bladder cancer (MIBC) (Fig. 14.1). The majority of tumors (Ta and T1) and carcinoma in situ (CIS) are flat and noninvasive, but high-grade types can progress to MIBC. NMIBC is treated with transurethral resection of the bladder (TUR-B) often followed by intravesical instillations of chemotherapy or immunotherapy. Intravesical immunotherapy using Bacillus Calmette-Guerin (BCG) is the most common treatment for NMIBC usually administrated by the urology nurse [1].

Fig. 14.1
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Classification of bladder tumors. (Courtesy of DA-BLA-CA ref. Jørgen B. Jensen)

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Radical cystectomy (RC) remains the first-line treatment when diagnosed with MIBC, T2-T4aN0M0, or high-grade NMIBC. Radiation therapy is an alternative approach in, e.g., frail patients not considered candidates for surgery or may be a specific preference from the patient based on informed and shared decision although the survival rate is inferior to RC [2]. RC is one of the most complex procedures in major abdominal oncology surgery and includes removal of the bladder together with prostate and seminal vesicles in men and anterior vaginal wall, uterus, and adnexa in women plus extended lymph node dissection (LND) and subsequently establishment of a urinary diversion [3]. The urinary diversion is mandatory and can be performed as a continent or incontinent diversion. Ileal conduit is the most common incontinent diversion (uro-stoma), whereas the continent diversion (neobladder) is a more complex procedure and depends on the tumor margins and more rarely a continent cutaneous reservoir (Indiana pouch).

At time for surgery, MIBC patients are generally characterized by a mean age around the seventh decade and with a high burden of comorbidity according to the Charlson comorbidity index (CCI) score yielding 33% has a CCI on 3–4 and 31.2% scorer ≥5. There is a 4:1 predominance in men over women. Moreover, approximately 27% are at severe nutritional risk, and approximately 80% are former smokers, whereas 30% are current smokers. Across Europe, approximately 30–40% have undergone neoadjuvant chemotherapy. In total, the MIBC patients are considered a “frail” population, and RC is followed by a high risk of perioperative morbidity. Even high-volume centers report more than 60% of the patients experience at least one complication within the first 3 months postoperatively [4]. Apart from smoking which is attributed to more than 50% of the cases, occupational exposures such as aniline dyes, aromatic amines, and polycyclic aromatic hydrocarbons are associated with high risk of developing bladder cancer (used, e.g., by painters, rubber industry workers, and hairdressers).

Renal Cancer

Renal cell carcinoma (RCC) is the third most common genitourinary tumor, the 7th most common cancer, and one of the most vascular cancers [1]. RCC and urothelial cell carcinoma of the renal pelvis and ureter are different cancers and have different treatments [1]. RCC is not a single malignant neoplasm, but a group of several different tumor subtypes, each with a unique genetic profile; the most common histological pattern is clear cell. RCC is often diagnosed incidentally at the time of radiographic imaging for other complaints.

For localized RCC, surgery is the only curative treatment with high-quality evidence. According to oncological and quality-of-life outcomes, localized tumors are best managed by partial nephrectomy (PN) rather than radical nephrectomy (RN), if technically feasible irrespective of the surgical approach [5]. There is a 1.5:1 predominance in men over women, with peak incidence occurring between sixth and seventh decade of age. According to CCI, the comorbid burden is modest compared to MIBC patients reminding CCI does not encompass hypertension, lung disease, and coronary artery disease in the absence of myocardial infarction. In a large population-based study, only 25% had a CCI score above 1, and more than 51% had no comorbidities [6]. However, postoperative mortality is 2%, and complications are reported in up to 11% in 90 days postoperatively [5, 7]. Regarding lifestyle factors 48% are former smokers, whereas 11% are current smokers, approximately 40% of RCC patients are classified as obese, and about 34% suffers from hypertension [5, 8]. Alcohol is not reported to be an independent risk factor, and moderate consumptions seem to have a protective effect [5]. Having a first-degree relative with kidney cancer is also associated with an increased risk of RCC. A number of other factors have been suggested as being associated with higher or lower risk of RCC, but have not been confirmed. These include specific dietary habits and occupational exposure to specific carcinogens, but the literature is inconclusive.

This chapter focuses on the surgical pathways in RC, PN, and RN.

The Surgical Challenge

Surgery causes a cascade of reactions including release of stress hormones and inflammatory mediators such as cytokines, responsible for the systemic inflammatory response syndrome (SIRS) [9]. SIRS causes catabolism of glycogen, fat, and protein, and the consequences of protein catabolism is the loss of muscle tissue, which is a short- or long-term burden for functional recovery. Surgery remains a cornerstone of oncology treatment, and minimally invasive approaches including robot-assisted procedures have improved safety and patient outcomes. However, despite these advances, resections of the bladder and the kidney have mortality rates of 2–3%, and high postoperative morbidity persists even for lower-risk procedures like nephrectomy.

Enhanced Recovery After Surgery Programs in Urology

Enhanced recovery after surgery (ERAS) programs are based on a multimodal approach usually involving multi-professional healthcare teams including nurses, nurse leaders/nurse coordinators, dieticians, physiotherapist, oncologists, anesthesiologists, and surgeons. The ultimate goal is to reduce SIRS and minimize postoperative organ dysfunction and postoperative morbidity and enhance rehabilitation leading to improved patient outcome and secondly to reduce healthcare costs [10]. The success of ERAS protocols (ERPs) began more than 25 years ago in Denmark within the field of colorectal surgery led by Professor Henrik Kehlet. He challenged old conservative doctrines across perioperative care by letting patients drink clear fluids until 2 hours before surgery and eliminating most bowel preparation before surgery and post-surgery, avoiding drainage/tubes or removing immediately after surgery and having patients drinking and eating as soon as possible after surgery as well as early progressive mobilization by sitting and walking the same day or the day after surgery.

Although the evidence of the ERAS concept has mainly been gained and documented in colorectal surgery, ERAS has successfully improved recovery across surgical specialties, and the concept is internationally recognized as standard of care although interpreted different and lacks full implementation. Especially the urology community has been criticized for reluctant implementation. Enhanced recovery after surgery protocols (ERPs) are continuously refined with respect to surgical procedure since Wilmore and Kehlet described the core evidence-based components in 2008 [11]. The Society of ERAS has procedure-specific ERPs and implementation tools (www.erassociety.org). Today healthcare providers across the world (despite the nature of healthcare services) have transferred the ERAS concept besides colorectal surgeries to several other specialties such as gynecology and head and neck surgery and urology and is now expanding its role into prehabilitation interventions in major cancer surgery and thereby another emerging role of nursing care [12, 13].

In the recent RC-ERP from 2013 by Cerantola, there is a list and an overview of the level of evidence of any of the 22 components included in the guideline [14]. The basic recommendations such as preoperative preparations, reducing SIRS, pain management, early postoperative oral intake, and immediate postoperative progressive mobilization are in general and applicable to both PN and RN pathways.

Nursing Within the Context of ERAS

The genesis of ERAS based on the question “why is the patient still in hospital today?” given the following answer will clearly address the patients’ individual recovery problems [12]. The question clearly indicates that the nursing profession has a pivotal role and a significant opportunity to impact the core surgical cancer care continuum from diagnosis to survivorship (Figs. 14.2 and 14.3).

Fig. 14.2
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Overview of basic perioperative ERAS components in urology

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Fig. 14.3
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The multi-professional cancer care continuum – urology surgery

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Through early patient screening, patient involvement, pre- and postoperative habilitation assessments, and documentation of patient status, the nurse can provide evidence-based interventions designed to improve physical and psychological health and contribute to the efforts of reducing the likelihood of patients developing future chronic impairments (Table 14.1).

Table 14.1 Overview of nursing interventions in prehabilitation
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Organization

In any ERAS pathway, anchor-based leadership and consensus on treatment and care pathways are key factors and a necessity for successful implementation, medical performance, clinical outcome, and patient satisfaction. In multimodal pathways it is essential to define the responsibilities of all healthcare professionals involved and requires commitment and team approach driven by the hospital, departments, and nurse leaders. Nursing standard of care pathways and algorithm must be clearly described in ERPs for pre- and postoperative interventions including everyday goals, nursing documentation aspects, patient-education material pre- and postoperatively, and tools for shared decision. The growing evidence of prehabilitation interventions has high-volume cancer centers (e.g. the Netherlands and Denmark) in Europe initiated multi-model prehabilitation academies which systematically involve, educate, and inform the patients and families when scheduled for surgery.

On the ERAS website, tools are provided to facilitate and support the implementation process. Moreover, manuals including evidence-based elements to include in the ERAS program are available as well as programs to support documentation of assessments and achievements. Of note, ERAS is not a “one-size-fits-all” program beyond the surgery itself but rather spans specific individualized assessments and interventions that are likely to improve or maintain health status along the cancer care continuum.

Nursing Interventions

Prehabilitation

Prehabilitation is defined “as the process of enhancing an individual’s functional capacity before scheduled surgery.” The aim is to withstand the tolerance for the upcoming physical challenge and the surgical metabolic stress response caused by tissue trauma, periodically starvation reduced physical activity and anxiety, which in total contribute to a rapid decline in functional capacity [16, 17]. Poor preoperative performance has been shown to increase risk of mortality and prolong recovery suggesting that the preoperative period may be the most favorable time to optimize the overall condition and proactively involve the patients in own recovery [18,19,20]. Although significant advances in diagnostic procedures, surgical technique (minilaparotomy and robot-assisted RC), anesthesia, and perioperative care, the continuously high burden of postoperative morbidity and long-term impairments indicates that the urological patients remain candidates for further optimization beyond the surgical procedure. ERAS has until recently primarily focused on perioperative period. However, the “unutilized window” of time from diagnosis to surgery has gained increasing attention in the effort to enhance recovery and reduce postoperative impairments.

Currently, prehabilitation in major surgical cancer is considered as an integrated part of the core cancer continuum of care [21] (Fig. 14.3) and can be seen as an extension of the original ERAS concept. The prehabilitation concept includes physical and psychological assessments that accommodate a baseline functional capacity, identify impairments, and provide interventions to support physical and psychological health aiming to reduce the incidence and severity of per- and postoperative impairments [21, 22]. The scope of prehabilitation is yet expanding from the original single physical interventions to multi-professional complex programs including both double and triple modalities (see below). The evidence base on prehabilitation and the impact on recovery and health-related quality of life (HRQoL) has until recent years mainly been accomplished in orthopedic and cardiovascular and colorectal surgery contrary to the relatively few procedure-specific clinical studies in uro-oncology cancer surgery [23,24,25,26,27]. However, prehabilitation is moving forward and slowly being recognized by national health boards as a key player in both MIBC and RCC pathways (www.sst.dk). The multimodal team offers a platform of different competencies, which works synergistically and includes all key factors in prehabilitation of the patient (Table 14.1).

The Role of Physical Prehabilitation Intervention

Poor preoperative fitness and physical status are well-known risk factors for serious postoperative complications and prolonged disability. Neoadjuvant oncologic therapies may be associated with additional degradations of physical fitness before surgery. Again, prehabilitation is not a “one-size-fits-all” program before surgery but rather involves specific individualized assessments and interventions that are likely to improve outcomes for each patient.

This expanding scope of prehabilitation is likely due to the acknowledgment that non-exercise interventions may be beneficial as well as that prescribing exercise as a single modality shortly before surgery may actually be detrimental to some patients who lack physiologic reserves. For example, frail elderly patients known to be at high risk for postoperative complications often present with decreased muscle mass and low protein reserves, and they may not tolerate an increase in exercise before surgery without protein supplementation. Although there is a rising movement in Europe and Canada acknowledging the potential unutilized resources and benefits prehabilitation may add to optimize the recovery in cancer surgery, much remains to be implemented and further studied. Currently there is no dose/response evidence-based recommendation regarding duration and intensity adjusted to the individual cancer patient. Thus, recommendations of the level of activity and exercises are derived from general sports medicine although encouraging high evidence in the field supports the ongoing efforts of prehabilitation in cancer surgery. Currently, patients are recommended to be physically active (aerobic element) with moderate intensity for 30 minutes every day combined with exercises to empower muscle strength and endurance targeting the major muscle groups involved in mobilization, in and out of bed, chair-raise performance, stair climbing, and gait speed.

The functional capacity of patients encompasses aerobic endurance capacity and muscular strength and can be considered a central element in the preparation of patients for surgery [28, 29]. Three studies in MIBC patients preparing for RC have shown that a short-term-home-based exercise program consisting of simplistic exercises is feasible and effective and can increase physical capacity and cardiopulmonary fitness. Thus there is an increased ability for early mobilization which again may improve postoperative outcome [23, 25, 27]. A RCT study introducing a short-term home-based exercise-based prehabilitation program of a 2-week period showed a patient adherence of 66% fulfilling ≥75% of the standardized exercise program [25]. All patients in the study received oral supplements according to guidelines [9]. The physical program consisted of exercises to empower muscle strength and endurance targeting the major muscle groups involved in mobilization, in and out of bed, chair-raise performance, stair climbing, and gait speed. Muscle capacity was expressed as muscle power (W/kg) in the lower extremities which correlates with the ability to perform physical activities [30, 31]. The program significantly improved leg extension power of 18% in the intervention group compared to standard (no intervention). Postoperatively, an everyday progressing physical program followed up the prehabilitation program (look postoperative care). LOS or complications were not reduced, whereas time to independently perform activities of daily living was significantly improved as well as HRQoL after 4 months in domains relevant to recovery [32]. The same level of adherence of 65% was shown in another study implementing a prehabilitation program consisting of both a nutritional and a physical component over a 2-week period. In this study all patients were instructed by the clinical nurse specialist to a standardized exercise program composed by the comprehensive cancer center survivorship program for all types of cancer patients awaiting or undergoing treatment [33]. Highly specialized physiotherapists from the survivorship clinic educated the specialized nurses allocated to the program. The program consisted of both endurance and resistance training. Capacity was measured using the 6-minute walking test [34]. A significant mean increase of 10.6% in functional capacity was measured from baseline to 6-week follow-up. Moreover, bone mass was also significantly improved from baseline [23]. Another pilot study reports promising results regarding the impact of cardiopulmonary fitness on postoperative complications although not significant [27]. All three studies document that a home-based short-term physical prehabilitation is feasible and effective.

The nurse role: The specialized nurse can under supervision by the physiotherapy team assess baseline status and instruct the patients to a basic standardized exercise program when referred to surgery (RC, PN, RN). The nurse will after the instruction handle out a personal manual where the patient can log everyday achievements including contact details in case of problems and or need of reassurance (Table 14.1 and Fig. 14.4).

Fig. 14.4
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The synergistic association between physical activity and nutrients

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The Role of Nutritional Intervention

The indication for nutritional therapy in the prehabilitation phase is prevention and treatment of catabolism and possible malnutrition before urological surgery (RC, PN, RN). The intention is essentially maintenance of nutritional status aiming to reduce the risk of postoperative complications and mortality [9]. In clinical practice the goal is to identify patients at risk and provide sufficient support for protein intake to achieve anabolism and energy to maintain body composition [9, 21, 35]. Nutrition interventions may be indicated even in patients without clear disease-related malnutrition if it is anticipated that the patient will be unable to eat or cannot maintain oral intake for a relative long period postoperatively [9, 36]. The amount of dietary protein or supplemental protein needed depends on the disease severity and the patient’s actual nutritional status [9, 19, 37]. Limited evidence supports preoperative nutritional interventions although evidence suggests that the outcome is improved if malnourished individuals are adequately fed for at least 7–10 days before surgery [38]. In the case of severely malnourished patients who cannot be adequately fed orally or enterally, preoperative enteral treatment is indicated, and surgery may be postponed although seldom because of the oncological risk.

The nurse role: All patients undergo nutritional screening when referred for surgery performed by the nursing staff using the local recommended screening tool, and in some centers handgrip strength or bio-impedance measurements are standard baseline assessments (Table 14.1). All patients referred for RC are as per default considered at moderate risk due to the upcoming surgical challenge and will routinely be offered oral protein supplements three times a day in at least 1 week before surgery. The nurse or dietician (if available) informs by pixies or other material the patients and their families on how to eat and cook smart based on their current eating habits. All patients are educated and informed of the impact and the “wicked” association between physical activity, nutrition, and sedentary lifestyle on postoperative recovery. Moreover, the importance of eating 1 hour after being physically active and before bedtime ensures maximal absorption. Finally, the patients are encouraged to monitor total energy and protein intake in the personal logbook using the nutritional module. In case of the screening reveals the patient is at high risk or challenged by any comorbid condition, the dietician and the surgeon will advise further.

The Role of Smoking and Alcohol

High alcohol consumption and daily smoking reduce the immune capacity leading to an increased risk of infection and impaired wound healing [39, 40]. In addition risky drinking increases the endocrine stress response to surgery, leading to deterioration of existing conditions which thus increases the risk of postoperative morbidity [41]. The effect of smoking and risky alcohol drinking on outcomes after radical cystectomy remains debated [42]. Most observational studies show that the risk of readmission for an infectious complication, recurrence, and cancer-related death after radical cystectomy are associated with continued smoking, whereas others have questioned this [43,44,45,46,47,48]. In surgery daily smokers and people drinking above 2 units (24 g ethanol) a day are at increased risk of developing wound complications, general infections, and pulmonary complications [41, 49]. Intensive smoking and alcohol cessation intervention 6–8 weeks before elective surgery reduces the incidence of postoperative complications with approximately 50% [50, 51], but cancer surgery like RC often takes place within 2 weeks. The hypothesis is that interventions within this timeframe may improve recovery (pathophysiological mechanisms, such as tissue perfusion and oxygen delivery, ciliary, and immune function) and reduce SIRS, arrhythmias, and bleeding time [39, 41, 49]. Until now no RCTs have evaluated the effect of smoking or alcohol cessation interventions on complications and HRQoL in RC or any specific urologic procedure. An ongoing multicenter study expects to present results in 2019 [52]. Despite the fact that more studies show that patients were satisfied by being offered support in hospital to quit smoking prior to surgery and that the majority were motivated by the possible health gain following, the belief that smoking relieves stress serves as a major barrier for smokers to quit and for healthcare professionals to recommend quitting [53, 54]. A systematic review shows that smoking cessation is associated with reduced depression, anxiety, and stress and abstainers improve positive mood and quality of life compared with smokers who continue to smoke [55]. The risk of alcohol drinking in relation to surgery is now reflected in the American Society of Anesthesiologists (ASA) physical status classification system score (https://www.asahq.org/resources/clinical-information/asa-physical-status-classification-system), meaning that it is important to identify patients drinking more than 2 units of alcohol per day.

The nurse role: Addressing smoking cessation will help all patients. Nurses should use the validated instrument “The 5 A’s” [56]. The nurse should assess smoking habits – ask if they smoke and assess nicotine dependency – use Fagerström score, advice to stop smoking, assist to stop smoking by counseling, or arrange referral to quit lines/clinics. During hospitalization the nurse should provide the patient with nicotine replacement therapy according to the Fagerström score. The nurse should assess the alcohol drinking pattern of the patient and support patients who drink more than 2 units per day to stop drinking as soon as possible in relation to surgery. If the patient is drinking more than 5 units per day, the patient should be offered supportive medical treatment against development of withdrawal symptoms.

The Role of Preoperative Stoma Education

Urostomy care requires manual skills and emotional adaption in order to secure self-efficacy [57], and there is mounting evidence that stoma care ability is the most important variable predicting positive adjustment to life with a stoma and increase the perception of HRQoL [58,59,60,61]. Survivors have described significant unmet needs such as lack of early stoma education and patient involvement [62, 63]. Positive impact of preoperative stoma marking on clinical- and patient-reported outcome (PRO) has been reported [64, 65]. Consensus for good clinical practice have until recently been based on expert knowledge suggesting preoperative stoma care education may be beneficial [66, 67]. In a recent RCT, a significant effect on self-care skills was seen after integrating stoma education into the prehabilitation program. The intervention consisted of 1.5-hour hands-on-training stepwise introducing skills necessary to independently change a stoma appliance. Stoma-kit was handed out for home-based training, and progress was measured using the quantitative Urostomy Education Scale. The significant level of self-care skills was maintained throughout the study period of 1 year postoperatively [68,69,70].

The nurse role: all nurses at the department can perform standardized uro-stoma care. However, in most departments highly educated stoma nurses introduce the patient to the future life living with a uro-stoma and educates the patient and family. As an integrated part of the prehabilitation program, the stoma nurse explains the procedure of how the stoma will be created, shows pictures or videos of patients with a stoma at different stage postoperatively, introduces stoma material, and performs a basic change of a stoma appliance together with the patient. The stoma nurse takes the patient through each step in the procedure by using a stoma mock-up. The patients are encouraged to perform a full change of appliance at least twice during the prehabilitation period using the stoma-kit. The nurse can measure progress in self-efficacy by using the validated Urostomy Education Scale from baseline throughout the follow-up period, and the patient can notice the developments.

The Role of Sexual Health

RC is commonly associated with treatment-related sexual dysfunction and varies from mild to severe impact on the individual in both genders. However, common concerns are seen in all types of cancer requiring major surgery in the pelvic floor like PN and RN [71, 72]. Sexual health is related to anatomic, physiologic, medical, psychological, and interpersonal components [73, 74]. Female sexual dysfunction are reported to surpass that of male dysfunction, and less attention has been paid to identify and treat sexual problems of females; moreover, there is a lack of treatment options compared to that for comparable conditions of the male [73]. Although poorly identified, impaired sexual function has been recognized as the primary source of self-assessed distress among patients undergoing RC [75]. A review examining unmet needs in MIBC patients preparing for RC found only 6 patients of the 30 patients surveyed reported efforts to educate them on the possibility of sexual dysfunction following treatment [63, 76]. The patients requested preoperative supportive information focusing on future sexual function in relation to treatment modalities, involvement of partners, and the ability to have sexual intercourse and orgasm.

The nurse role: a nurse educated in the field of sexuality is a necessity when approaching the patient (or partner). Information of future sexual health and what can be expected is clearly an unmet need requested by the patients. The importance of talking about sexual health may not be so obvious for the clinical staff compared to the oncological risk. There is, however, a need for articulating the aspect before surgery and assuring that we continuously will be aware of their sexual health. Sex may still be a relatively high taboo for healthcare staff, patient, and the partner. Thus it is pivotal to provide specialized competencies, stepwise move forward, and indicate that we will take the lead in this conversation and/or consultations unless the patient has other preferences.

Psychological Well-Being and Shared Decision-Making

Although the literature is sparse, new evidence in colorectal surgery (ERAS program) points toward psychological well-being is a pivotal aspect in the prehabilitation phase due to the association with short- and long-term impairments [77]. Two recent qualitative studies have explored MIBC patients’ experience preparing for surgery: First, a 6-week smoking and alcohol cessation intervention was well received, and it was perceived as an integral part of preparing for surgery [54]. Second, a patient-centered approach using the shared care decision model is important with respect to gender preferences for surgery, understanding treatment options, risks, family aspects, and own involvement in care [78, 79]. Nurses have for years known some patients have a high level of anxiety before surgery. However, recently anxiety has been reported by patients as an unmet need in major cancer pathways and now recognized as important factor in preparations for surgery. There is no clear recommendations in the field, although recent research have introduced new approaches to work with the patients/families and provide strategies to reduce the level of anxiety and not only react upon symptoms postoperatively.

The nurse role: the multimodal team is aware that anxiety in the prehabilitation phase may have major implications for being motived for optimization and preparations for surgery. It is however important to confront the patient and explain we recognize and understand the situation. On the other hand, it is likewise important to explain that other patients have shared the same experience but reported that they somehow were manageable when involve in own care. Clearly more evidence is needed in this underreported field.

Recovery and Rehabilitation

Currently, the most common outcome measure used to measure the success of an ERP is the hospital length of stay (LOS). Although it was an outcome of interest when ERAS was launched, it is in fact only a surrogate marker of recovery and may be a too elastic parameter without clearly defined discharge criteria. Importantly, LOS does not necessarily reflect the true recovery of a patient who has to convalesce at home. It is important to focus our efforts during the postoperative period beyond the LOS and readmission rate, by understanding the factors that influence return to normal daily living after discharge from the hospital. Moreover, LOS is not a goal in itself. The implementation of ERAS in the past decade has evidently cut down LOS from weeks to only a few days in many surgical pathways including RC, PN, and RN. The question “why is the patient still in the hospital today?” remains interesting and clearly addresses the actual condition of the day and still support a goal-directed postoperative care program to prevent further complications or impairments. The ultimate goal is to minimize postoperative organ dysfunction and enhance rehabilitation.

Within an ERAS context, the postoperative period or recovery phase has quite a few endeavors which must be carefully administrated by the nurse. In clinical practice the nurse usually act as the anchor of the multimodal care team (bladder or kidney). Therefore, it is a prerequisite the nursing staff are aware of recent evidence of care. The nurse will accordantly to ERP`S plan todays activities in cooperation with the patient and support and encourage the patients to fulfill everyday goals in the best possible way. Moreover, she will often be positioned as the coordinator between the collaborators such as physiotherapist, surgeons, dieticians, and case managers. Every key player carefully documents today’s achievements in a personal patient-log together with the patient or if not available in the medical record.

In Fig. 14.2, the well-known and most important postoperative focus areas for ERP are listed. There are of course local differences although most elements in the ERPs should be considered and possible to accomplish despite local differences and challenges. The areas that need to be addressed are several: nasogastric tubes, catheters, drains, stents, early oral nutrition, stoma care, enhanced progressive mobilization, smoking cessation, etc. It can be argued that a properly informed patient with no pain, nausea, or vomiting and without drains and tubes, as well as free from postoperative complications, should be willing to eat and ambulate. However, a patient with any of these issues will or may not necessarily be able to eat and/or ambulate. Therefore, early mobilization, early oral intake, and bowel function should be considered and monitored as outcome measures similar to LOS and being key components of ERP. When all discharge criteria are accomplished, the patient is ready to be discharged and start-up the rehabilitation program with or without support from primary care. At discharge all key players have updated the actual status of the patient, and suggestions for rehabilitation activities are individually addressed such as exercise recommendation to further improve functional and nutritional status and continued smoking cessation. The ability to independently change a stoma appliance is not a discharge criterion, and most patients may have a follow-up visit in a stoma clinic 5 weeks postoperatively. All patients have follow-up appointments according to national guidelines. At any consultation, all aspects included in prehabilitation program and problems during admission are addressed. In order to enhance rehabilitation, the multimodal team is an integrated part of the cancer follow-up program and the rehabilitation program, and besides the oncological state, the team will assess and address any unmet needs or impairments the patient may report.

Survivorship

Because of the demographic development and the eldering population, an increasing number of patients will be diagnosed with a cancer. Improved treatment of cancer has changed the view on cancer from a deadly disease to a chronic disease for the majority of patients. Concurrently, the patients are discharged as soon as possible because of lack of capacity in many countries. In total, we may live longer due to early diagnosis and treatment, and many patients may have long-term impairments. Often there is a gap between the rehabilitation periods and when entering the survivorship period (no matter how a survivor is defined). Sequela after oncological cancer treatment is well known but surgical patients may have add-on due to removal of organs and permanently loss of bodily functions and difficulty to adapt. Fortunately, there is a growing interest to establish cancer sequelae clinic focusing on organ-related functional impairment following pelvic cancer treatment. In acknowledgment of the patient-reported long-term impairments and the impact on HRQoL, several cancer centers are committed to focus on developing survivorship programs. Nurses will again take a leading role in delivering evidence-based care and proactively initiate and develop a research environment providing new evidence for survivorship care. The objectives of survivorship clinics are to improve clinical- and patient-reported outcome, empower patients in taking control of their illness by using new technologies and methods to inform them, develop self-management skills to support needs, and prevent long-term problems. In addition health professional’s competencies in managing long-term effects of cancer treatment with the use of clinical tools to support and inform health services. Within the aforementioned objectives, an outstanding possibility has arisen combining academic and clinical nursing skills and hopefully provides a strong interdisciplinary approach to health science and applied nursing research in practicing uro-oncological nursing care.