Enhanced Recovery After Surgery Pathways Improve Hospital Efficiency and Outcomes for Cystectomy Patients

Enhanced recovery after surgery (ERAS) pathways after cystectomy can reduce patients’ length of stay and improve quality of care, according to a study published in European Urology.

ERAS pathways in urologic care have emerged as an effective tool for reducing care variation, decreasing costs, accelerating postoperative convalescence, and maintaining quality. However, despite enthusiasm for their use, there is little evidence supporting ERAS pathways in cystectomy patients. 
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Therefore, researchers led by Mark D Tyson, MD, Mayo Clinic Hospital (Phoenix, AZ), performed a systematic literature review and meta-analysis to compare the effectiveness of ERAS pathways with standard care on a number of perioperative outcomes relevant after cystectomy and urinary diversion, namely length of stay, complications, readmission, and time-to-bowel activity.  

A literature search of observational studies and randomized controlled trials was first conducted in the electronic databases of Medline (PubMed), EMBASE, Web of Science, Google Scholar, the Cochrane Library, and an index of abstracts from the American Urological Association and the European Urological Association for the past 5 years. To be included in the review, studies had to have data comparing ERAS pathways with standard postoperative pathways after cystectomy; ERAS protocols with standardized preoperative, intraoperative, and postoperative pathways that included patient education, goal-directed fluid management, prevention of nausea and vomiting, early ambulation, early oral nutrition, and early hospital discharge; and at least one of the main outcomes of interest. Statistical analyses were then performed to analyze the effect of ERAS pathways on care after cystectomy.

Thirteen studies were deemed eligible for study inclusion, with data on 801 ERAS participants and 692 controls who received standard care. Overall, patients in the ERAS group were less likely to be readmitted after cystectomy compared with those who received standard care, though the difference was not significant (14.9% vs 15.9%, respectively). However, the other critical factors were all significantly improved in patients treated on ERAS pathways. Raw results showed that just 39.9% of patients in the ERAS group experienced complications while more than half (51%) of patients did in the standard care group. Additionally, the mean length of stay was approximately 5.4 days shorter in the ERAS group than those receiving standard care. Return of bowl function between the two groups also favored ERAS by 1.1 days.

Thus, researchers concluded that ERAS pathways for patients undergoing cystectomy could help them to transition out of institutions more quickly with less complications and a faster return to normal bowel function. 

However, they did also note some limitations associated with their study. First, all studies included in their review were observational and most used historical controls. Additionally, due to a lack of available data, they did not evaluate costs or patient-reported outcomes, which could have provided useful insight on ERAS utilization.

“Despite these limitations, we believe these data are clinically relevant for quality improvement efforts for organizations that care for cystectomy patients,” the researchers wrote. “The data support the development of integrated, multidisciplinary clinical pathways in an effort to improve patient outcomes, reduce errors, and increase patient and provider satisfaction.”—Sean McGuire

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Tyson MD, Chang SS. Enhanced recovery pathways versus standard care after cystectomy: a meta-analysis of the effect on perioperative outcomes [published online ahead of print June 10, 2016]. Eur
Urol
. doi: 10.1016/j.eururo.2016.05.031.