Reporting Radical Cystectomy Outcomes Following Implementation of Enhanced Recovery After Surgery Protocols: A Systematic Review and Individual Patient Data Meta-analysis

Context: Enhanced Recovery After Surgery (ERAS) is a perioperative approach to managing surgical patients. The impact of ERAS on radical cystectomy (RC) outcomes remains understudied. Objective: To review the literature regarding ERAS protocols and RC outcomes. The primary outcome was hospital length of stay (LOS). Evidence acquisition: A 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 synthesis: A 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). Conclusions: ERAS 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 summary: Use 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. In this systematic review, we found the inclusion of Enhanced Recovery After Surgery (ERAS) components when reporting radical cystectomy outcomes and found that only 0.5% studies control for ERAS when reporting outcomes. In the individual patient data meta-analysis, elimination of bowel preparation and nasogastric tube, and use of regional anesthesia were significantly associated with decreased hospital length of stay. These findings reflect different components of recovery that ERAS can optimize and further support documentation of the use of ERAS components when reporting radical cystectomy outcomes.