Platinum Opinion

Enhanced Recovery After Surgery: Are We Ready, and Can We Afford Not to Implement These Pathways for Patients Undergoing Radical Cystectomy?

We aimed to appraise the methodological quality of existing guidelines for Enhanced Recovery After Surgery (ERAS) using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument and to identify the concordance of different recommendations.

PubMed, Embase, Google Scholar, Web of Science, and clinical practice guideline websites were systematically searched. Four reviewers independently assessed the guidelines using the AGREE II instrument. The mean score of each AGREE II item, number of recommendations, strength of recommendation, and level of evidence were calculated. Agreement among reviewers was assessed using the intraclass correlation coefficient.

We identified 23 guidelines from 7,127 records. The overall agreement among reviewers was considered good (intraclass correlation coefficient, 0.92; 95% confidence interval [CI], 0.86–0.96). The mean scores of the six AGREE domains were scope and purpose, 60.1% (95% CI, 55.9–64.1); stakeholder involvement, 40.7% (95% CI, 35.4–46.0); rigor of development, 44.7% (95% CI, 42.2–47.2); clarity and presentation, 69.8% (95% CI, 65.3–74.3); applicability, 37.2% (95% CI, 31.8–42.6); and editorial independence, 47.8% (95% CI, 39.0–56.7). Only 2/23 ERAS guidelines were considered applicable without modifications.

The methodological quality of the ERAS management guidelines varied and was generally low. Future guideline development should adhere to the use of the AGREE II instrument and the GRADE system to better guide clinical practice and improve individualized treatment strategies.

The purpose of this narrative review is to summarize existing knowledge and evidence about the establishment of enhanced recovery after surgery (ERAS) pathways with emphasize on radical cystectomy (RC), and the emerging and prominent role of nursing within the ERAS pathway. The current status of implementation and adherence to ERAS protocol in RC is discussed and the impact on primary outcomes according to ERAS is summarized.

The review was conducted based on a focused search in PubMed and CINAHL.

The goal of a modern RC enhanced recovery protocols (ERPs) anno 2022 is to have a positive impact on patient care from diagnosis throughout recovery with focus on the quality, rather than speed, of recovery. This may be more in alignment with the patient's needs and preferences.

Nursing has been in the forefront since the establishment of ERAS, and the nurse-coordinator must be skilled in evidence-based medicine and have excellent communicative competencies to support the patient journey. Implementation of ERAS have reduced hospitalization by improved minimal surgery, optimized anesthetic regimes without increasing readmission rates. It is not known which items can reduce post-operative complications. In the future, nurses should seek a more prominent and leading role during the implementation process and take responsibility for continued education of the staff. Likewise, future nursing interventions will focus on early identification of modifiable risk factors, and a deeper exploration of the patients personally needs and preferences to upcoming surgery could optimize adherence throughout the pathway, which may add to positive outcomes.

To assess the feasibility and safety of same-day discharge (SDD) surgery after robot-assisted partial nephrectomy (RAPN) in patients with small renal tumors.

Observational, monocentric study conducted over a one-year period. Inclusion criteria: good performance status, Charlson score <5, cT1a renal mass and RENAL score <6. Exclusion criteria: coagulopathy or contraindication to outpatient surgery. RAPN was performed as the first case of the day. Anesthesia protocols allowed quick recovery and rapid hospital discharge. Patients were called systematically 1-day post-surgery to enquire about any early complications. Perioperative outcomes and complications were recorded according to Intraoperative adverse incident classification by the European Association of Urology and Clavien classifications 30- and 90-days post-surgery. Follow-up consultations were carried out with assessment of patient satisfaction. Primary outcomes were SDD failure, 30- and 90-day complications and readmission rate. Descriptive data were reported without statistical comparative analysis.

Twenty patients were included (median age: 63 years [interquartile range: 57-64]). All patients were discharged home after a median surveillance time of 350 min (interquartile range: 270-420). One grade 1 intraoperative complication was reported. Two procedures were followed by an unplanned readmission due to early complications within the first 30 days (1 pain and anxiety [Clavien I], one active bleeding requiring embolization [Clavien IIIa]). The majority (85%) of patients were satisfied and would recommend day surgery. SDD failure rate was 10% at 90 days.

RAPN is safe as a SDD procedure without major perioperative morbidity for selected tumors and patients.

To determine current practice patterns and adherence to various components of enhanced recovery after surgery in cystectomy (ERAC) protocol for peri-operative management of radical cystectomy patients through a global survey.

A survey containing 25 questions and addressing 15 of the 22 items of the ERAC protocol was developed and disseminated through Email to the urologists with recent bladder cancer publications. The mailing list was generated by retrieving Email-ids of corresponding authors of articles using the keyword “cystectomy” in Scopus from January 2018 to October 2020.

The survey was completed by 443 respondents across the globe. About 51.5% of respondents used some form of bowel preparation. A minority used carbohydrate loading (29.8%) and Alvimopan (13.3%). A short duration of nil by mouth was practised by 28.9%. For antibiotic prophylaxis, 51.7% used one, and 42% used two antibiotics. Duration of antibiotics was 24 hours, 48 hours, and >48 hours for 47.6%, 16.9%, and 35.4%, respectively. For peri-operative analgesia, 43.6% used non-steroidal anti-inflammatory drugs, 9.3% opioids and 40.6% combination of both. Pharmacological thrombo-prophylaxis was routinely used by 74.7% respondents. There was significant variability in ERAC and non-ERAC components according to region of practice; The open surgical approach was most commonly used in Africa (92%), whereas it was the robotic approach in North America (or America?) (41%). The use of bowel preparation was higher in Asia (58%) and Africa (65%). Alvimopan use was more common in North America (58%). Most used 1 or 2 prophylactic antibiotics but the duration was shorter (<24 hours) in the Americas and European (58%–83%) compared to Asia and Africa (15%–35%).

There is high variability in the use of different ERAC components. Other than the timely removal of the abdominal drain and the use of thromboprophylaxis, the overall adherence of ERAC components is low.

This paper provides an overview of the multifarious role of nursing in enhanced recovery after surgery (ERAS) in advanced bladder cancer surgery with procedure-specific recommendations in radical cystectomy pathways.

Electronic databases including PubMed and CINAHL.

The growing evidence of preoperative, perioperative, and postoperative interventions and the concept of reacting proactively in ERAS, has led to the paradigm shift in the surgical pathway with establishment of nurse-led multi-professional prehabilitation academies. Moreover, although most patients will recover in real-life at home, there is a need for a change in postoperative and discharge management. Thus, a highly skilled discharge nurse is required to secure a comprehensive, safe discharge plan adjusted to the patient's needs in close cooperation with the primary care setting, family, and survivorship clinic if needed. Limited efforts have been made to evaluate rational principles and goals for rehabilitation after radical cystectomy; an important issue with major patient and perhaps socioeconomic consequences, wherein the ERAS nurse may take the future lead.

It has become a governmental demand in many countries to involve the patient and family in treatment decisions and care by using shared decision tools, and to educate and inform each family in concordance with the patient's needs and preferences, and the health care systems must react accordingly. However, to provide person-centeredness care within advanced surgical pathways, there remains a need for thought-leaders, strategic planners, managers, and decision-makers to anchor the process of change and stop “we do it anyway” arguments to defend organizational cultures that are not conducing the evidence-recommend practice.