• Stephen B Williams, Marcus G K Cumberbatch, Ashish M Kamat, Ibrahim Jubber, Preston S Kerr, John S McGrath, Hooman Djaladat, Justin W Collins, Vignesh T Packiam, Gary D Steinberg, Eugene Lee, Wassim Kassouf, Peter C Black, Yannick Cerantola, CattoJames W FJWFAcademic Urology Unit, University of Sheffield, Sheffield, UK. Electronic address: j.catto@sheffield.ac.uk., and Siamak Daneshmand.
• Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA.
• Eur. Urol. 2020 Nov 1; 78 (5): 719-730.

ContextEnhanced Recovery After Surgery (ERAS) is a perioperative approach to managing surgical patients. The impact of ERAS on radical cystectomy (RC) outcomes remains understudied.ObjectiveTo review the literature regarding ERAS protocols and RC outcomes. The primary outcome was hospital length of stay (LOS).Evidence AcquisitionA systematic review of the articles published from 1970 through 2018 was conducted. Individual patient data (IPD) were requested and a meta-analysis was performed.Evidence SynthesisA total of 4197 articles were retrieved and 22 (reporting 4048 patients) were selected for the review. LOS followed by 30-d and that followed by 90-d complications were the most common endpoints. ERAS use was associated with reduced morbidity, quicker bowel recovery, and shorter LOS, without affecting mortality. IPD were obtained for 2077 patients from 11 studies. In multivariable models, LOS was associated with ERAS use (regression coefficient: -4.54 [95% confidence interval {CI}: -5.79 to -3.28] d with ERAS p <  0.001) and Charlson Comorbidity Index (+1.64 [1.38-1.90] d for each point increase, p <  0.001), and varied between hospitals (from -1.59 [-3.03 to -0.14] to +4.55 [1.89-7.21] d, p <  0.03). Individual ERAS components associated with shorter LOS included no nasogastric (NG) tube (-8.70 [-11.9 to -5.53] d, p <  0.001) and local anesthesia blocks compared with regional anesthesia (-3.29 [-6.31 to -0.27] d, p =  0.03).ConclusionsERAS protocols were associated with reduced LOS and postoperative complication rate. Avoidance of NG tubes and use of local anesthesia blocks were significantly associated with reduced LOS. These findings reflect different components of recovery, which ERAS can optimize and further support documentation of the use of ERAS components when reporting RC outcomes.Patient SummaryUse of enhanced recovery in patients undergoing surgery to remove the bladder is associated with fewer surgical complications and a shorter hospital stay. Avoidance of nasogastric tubes and use of local anesthesia after the operation were associated with a shorter length of stay.Copyright © 2020 European Association of Urology. All rights reserved.

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