Enhanced Recovery After Surgery Principles and How They Apply to Pediatric Urology
By: Kristen M. Meier, MD; Kyle O. Rove, MD | Posted on: 01 Feb 2022
Enhanced Recovery After Surgery (ERAS®) is a perioperative framework that uses evidence-based strategies to reduce physiologic stress from anesthesia and surgery via standardized care before, during and after surgery. The protocol has increasingly become the standard of care for many adult specialties, yet its uptake in pediatric urology has been behind the adult curve. This is not entirely surprising; as a subspecialty within urology, we practice and train differently and increasingly separately from our adult counterparts. Dissemination of innovation in medicine occurs over long timespans, and ERAS’s entry into pediatric urology is no different, trailing approximately 10 years behind its introduction in adult surgical practice in North America. Early pediatric ERAS outcomes have shown positive effects similar to their adult counterparts, namely reduced length of stay, reduced opioid use in and out of the operating room, reduced complications, and improved time to return to baseline function. Although data in pediatric urology are limited, there are efforts underway to remedy this as outlined below.
First, several studies in pediatric surgery and pediatric urology have been published recently that demonstrate improved outcomes and raise the level of knowledge regarding ERAS. A literature review from Shinnick et al in 2016 demonstrated that there were, at that time, only a small number of studies examining ERAS protocols in children.1 Many of these showed a hodgepodge implementation of portions of key ERAS concepts. Despite only adopting parts of ERAS principles, these studies still demonstrate benefits in reducing opioid use and inpatient length of stay. Another small pilot study involving pediatric urology patients undergoing reconstruction requiring a bowel anastomosis demonstrated significantly fewer complications in patients who received ERAS care vs standard practice (1.3 vs 2.1 events per patient, OR 0.71, 95% CI 0.51–0.97),2 which is in line with results from numerous adult studies. Another study from Purcell et al showed ERAS pathways decreased opioid usage in their pediatric patients undergoing colorectal surgery.3
Second, societal efforts have come to bear recently to improve the representation of pediatric surgical specialties. The first World Congress on Enhanced Recovery After Surgery in Pediatrics convened on November 30, 2018 at Virginia Commonwealth University in Richmond, Virginia. Global experts gathered here to bring the key concepts of ERAS to the pediatric community. This was a major step in acknowledging the future of pediatric care and catapulting ERAS into this new arena. In 2019, ERAS USA agreed to create a formal subsection for pediatrics, where leaders in surgical specialties and anesthesiology are working to develop new protocols, put forth best practice statements and curate resources to aid in improving ERAS knowledge and experience. As members of ERAS USA and ERAS Pediatrics, we encourage providers interested in pediatric ERAS to get involved and consider attending a meeting to learn more and hear from national experts.
And third, prospective multicenter studies are underway that relate to pediatric urology. PURSUE, or Pediatric Urology Recovery after SUrgery, is an observational, prospective, propensity-matched study comparing patients who have lower urinary tract reconstructive operations (including bladder augmentation, creation of catheterizable channels and bladder neck surgeries) to patients not under an ERAS pathway.4 Investigators are examining protocol compliance, length of stay, complications, opioid usage and patient-reported outcomes. Results are expected in the next year or so. ENRICH-US (ENhanced Recovery In CHildren Undergoing Surgery) is a pediatric surgery multicenter collaboration with a stepped-wedge cluster randomized design examining ERAS implementation and outcomes for pediatric patients undergoing colonic resection.5 While not directly relevant to urology, understanding implementation of pediatric ERAS in a variety of centers and settings lends itself to new, more efficient implementations within our specialty. Finally, PORTS (Pediatric Oncology Recovery Trial after Surgery) is a multicenter effort to examine surgical and oncologic outcomes for pediatric cancer patients after surgical resection.6
Appendix. ERAS process measures with applicability in pediatric urology. Adaptation to specific operations is common, allowing for more precise definitions that lend themselves to auditing a protocol or pathway implementation to allow for constructive feedback to a clinical team to continue to improve care. These elements are also not meant to be rigidly adhered to, as clinical circumstances of a patient may take precedent. However, we encourage providers to apply as many other principles as possible, even if 1 or more are not or cannot be applied.
|Phase of Care||Process Measure|
|Preoperative/clinic||Counsel about ERAS|
|Clear-liquid complex carbohydrate load|
|Avoid prolonged fasting|
|No bowel preparation|
|Avoid excess drains|
|Minimally invasive assisted (if feasible, safe)|
|Venous thromboembolism prophylaxis|
|Postoperative||No nasogastric tube|
|Scheduled nonopioid pain meds|
|Discontinue intravenous fluids early|
|Early removal of excess drains|
We believe the time is now to make ERAS the standard of care for pediatric urology. Any patient can benefit from a framework of standardized practices to reduce physiologic stress, but pediatrics has many factors that lend itself well to adoption. For example, having patients who are generally healthy and a high proportion of procedures that are relatively short ambulatory cases make things like minimizing nil per os (NPO) times, standardizing anesthetic and surgical care, minimizing opioids accomplishable, and accruing additional benefits to patients. In a time when we are seeing record numbers of mortalities in the opioid epidemic, protecting our youth by using multimodal pain control and minimizing opioid exposure is all the more important.
At our center, ERAS has become the standard for all urological procedures, and we are championing incorporation into other pediatric subspecialties. With urology leading the way, we are incorporating ERAS-driven care into the electronic medical record, rendering adoption by others easier and removing as many barriers as possible to expand ERAS to more pediatric surgical patients. All patients who undergo major urological reconstructive surgeries are seen in the ERAS preoperative clinic where expectations are addressed by a multidisciplinary group including a surgeon, anesthesiologist, nurse, psychologist and research personnel. Order sets have been developed to standardize orders, provide intraoperative guidelines and streamline postoperative care. The Appendix demonstrates key measures that are focused on in our system.
In closing, ERAS provides a strong framework to standardize perioperative care that can benefit pediatric patients. ERAS protocols have been proven effective in adult urology, and there are numerous factors that make it ideal for incorporation into the pediatric realm. In our experience, ERAS has been welcomed by patients, families and providers alike. In an era were high-quality evidence and data-driven research is key, ERAS provides an ideal platform for the future of perioperative care, especially in a time when compensation is becoming increasingly tied to outcomes and protocol adherence.
- Shinnick JK, Short HL, Heiss KF et al: Enhancing recovery in pediatric surgery: a review of the literature. J Surg Res 2016; 202: 165.
- Rove KO, Brockel MA, Saltzman AF et al: Prospective study of enhanced recovery after surgery protocol in children undergoing reconstructive operations. J Pediatr Urol 2018; 14: 252.e1.
- Purcell LN, Marulanda K, Egberg M et al: An enhanced recovery after surgery pathway in pediatric colorectal surgery improves patient outcomes. J Pediatr Surg 2021; 56: 115.
- National Institutes of Health: Clinical trial NCT03245242: pediatric urology recovery after surgery endeavor (PURSUE). ClinicalTrials.gov 2018. Available at https://clinicaltrials.gov/ct2/show/NCT03245242. Accessed December 3, 2021.
- National Institutes of Health: Clinical trial NCT04060303: enhancing recovery in children undergoing surgery for IBD (ENRICH-US). ClinicalTrials.gov 2019. Available at https://clinicaltrials.gov/ct2/show/NCT04060303. Accessed December 3, 2021.
- National Institutes of Health: Clinical trial NCT04344899: Pediatric Oncology Recovery Trial After Surgery (PORTS). ClinicalTrials.gov 2020. Available at https://clinicaltrials.gov/ct2/show/NCT04344899. Accessed December 3, 2021.