Impact of an enhanced recovery after surgery programme in radical cystectomy. A cohort-comparative study

Implementation of ERAS (Enhanced Recovery After Surgery) protocols for radical cystectomy patients: The pathway to standardization. A systematic review

CONTEXT

The development of ERAS (Enhanced Recovery After Surgery) protocols in patients undergoing major surgery has brought perioperative benefits in several disciplines. Its main application in urology is focused on patients undergoing radical cystectomy.

OBJECTIVE

Systematic review of the available literature on ERAS protocols applied to patients undergoing radical cystectomy in terms of perioperative outcomes as well in the analysis of their implementation.

EVIDENCE ACQUISITION

A bibliographic search was conducted in the electronic databases PubMed, Embase, Cochrane and Scopus, using the terms «Cystectomy», «Enhanced Recovery After Surgery» and «Fast-Track». Randomized and non-randomized studies that compared the implementation of an ERAS protocol versus a traditional protocol in patients undergoing radical cystectomy were selected.

EVIDENCE SYNTHESIS

869 articles were identified; 25 were selected for final analysis: 22 non-randomized and 3 randomized studies. No differences were observed in terms of demographic characteristics between studies. Statistically significant differences were identified in favor of the ERAS protocol: length of hospital stay, major complication rate, time to first ambulation and return of bowel function. In the analysis of protocols, a high variability was detected in the number of items and in the implementation method.

CONCLUSIONS

The multidisciplinary nature and the number of items of the ERAS protocols imply a high heterogeneity in their implementation. Further randomized studies, standardized reporting and analyzing results, as well as a systematic analysis of subsequent adherence are required to increase comparability between groups.

Early recovery after surgery for radical cystectomy: comprehensive assessment and meta-analysis of existing protocols

Purpose

Different enhanced recovery after surgery (ERAS) protocols (EP) for radical cystectomy (RC) have been published. Protocols highly differ in number of included items and specific measures.

Materials and methods

A systematic review and meta-analysis on EPs in RC were performed using the databases MedLine, Cochrane Library, Web of science, and Google Scholar. The specific ERAS measures of the protocols were extracted, analyzed, and compared. Pooling of available outcome data was performed for length of stay, complications, readmission rate, and time to defecation.

Results

The search yielded a total of 860 studies of which 25 studies were included in qualitative and 22 in quantitative analysis. Oral bowel preparation (BP) was omitted in 24/25 (96%) EPs, optimized fluid management was administered in 22/25 (88%) EPs and early mobilization (postoperative day 1) in 21/25 (84%). Gum chewing (n = 12, 46%), metoclopramide (n = 11, 44%), and alvimopan (n = 6, 24%) were the most common measures to prevent postoperative ileus. Our meta-analysis revealed a significant benefit in favor of EPs for the outcome parameters length of stay [mean difference (MD) − 3.46 d, 95% confidence interval (CI) − 4.94 to − 1.98, p < 0.01], complications [Odds ratio (OR) = 0.76, 95% CI 0.61–0.94, p = 0.01] and time to defecation (MD − 1.37 d, 95% CI − 2.06 to − 0.69, p < 0.01). Readmission rate did not show a significant difference (OR = 0.73, 95% CI 0.52–1.03, p = 0.07).

Conclusion

Current EPs focus on omitting oral BP, early mobilization, and optimized fluid management while they differ in methods preventing postoperative ileus. Our meta-analysis revealed a benefit in introducing these protocols into clinical practice.