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JU INSIGHT Enhanced Recovery After Surgery for Complete Primary Repair of Bladder Exstrophy
By: Andrea K. Balthazar, MD, MPH*, Boston Children’s Hospital, Massachusetts; Julia B. Finkelstein, MD, MPH*, Boston Children’s Hospital, Massachusetts; Vivian Williams, MSN, RN, CPNP, Boston Children’s Hospital, Massachusetts; Ted Lee, MD, MSc, Boston Children’s Hospital, Massachusetts; Debra Lajoie, JD, PhD, MSN, RN, Boston Children’s Hospital, Massachusetts; Tanya Logvinenko, PhD, Boston Children’s Hospital, Massachusetts; Young-Jo Kim, MD, PhD, Boston Children’s Hospital, Massachusetts; Sabeena Chacko, MD, Boston Children’s Hospital, Massachusetts; Joseph G. Borer, MD, Boston Children’s Hospital, Massachusetts; Richard S. Lee, MD, Boston Children’s Hospital, Massachusetts | Posted on: 25 Oct 2023
*Co-first authors.
Balthazar AK, Finkelstein JB, Williams V, et al. Enhanced recovery after surgery for an uncommon complex urological procedure: the complete primary repair of bladder exstrophy. J Urol. 2023;210(4):696-703.
Study Need and Importance
Enhanced recovery after surgery (ERAS) protocols are designed to optimize perioperative care and expedite recovery. Historically, complete primary repair of bladder exstrophy (CPRE) has included postoperative recovery in the intensive care unit and extended length of stay. There are no guidelines or published studies that discuss ERAS principles in the bladder exstrophy population.
What We Found
The outcomes of 10 post-ERAS patients were compared with a historical cohort of 30 CPRE patients (2013-2020). The median overall length of stay significantly decreased from 14.5 to 9 days to 6.5 days (P = .0001, see Table). Refinement of the CPRE-ERAS pathway required an iterative learning process to maximally adapt enhanced recovery interventions to the needs of our specific patient population, which ultimately resulted in the elimination of intensive care unit use after final pathway implementation (n=4). Postoperatively, no ERAS patient required escalation of care, and there was no difference in emergency department visits or readmissions.
Table. A Comparison of the Primary Study Outcome: Length of Stay
| Pre-ERAS (N=30) | Post-ERASa Phase 1 (N=6) | Post-ERASa Phase 2 (N=4) | P value | |
|---|---|---|---|---|
| ICU LOS, median (IQR), d | 2.5 (2-4) | 1.5 (1-2) | 0 (0-0) | .003 |
| Overall LOS, median (IQR), d | 14.5 (13-19.8) | 9.0 (8.3-12) | 6.5 (6-7) | .001 |
| Abbreviations: ERAS, enhanced recovery after surgery; ICU, intensive care unit; IQR, interquartile range; LOS, length of stay. Bolded values indicate statistical significance. aThe post-ERAS cohort is grouped as those patients who underwent complete primary repair of bladder exstrophy (CPRE) during Phase 1 (initial CPRE-ERAS pathway, June 2020-April 2021) and Phase 2 (final CPRE-ERAS pathway, May 2021-December 2021). |
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Limitations
We describe implementation of a CPRE-ERAS pathway at a single, freestanding children’s hospital. The small, unmatched cohort lends itself to the introduction of biases. The observed significant results only imply an association between ERAS implementation and the outcomes. Additionally, given the comprehensive nature of the CPRE-ERAS protocol, we are unable to decipher which elements had the most critical impact on intraoperative metrics and postoperative outcomes.
Interpretation for Patient Care
Applying ERAS principles to CPRE was associated with improved patient outcomes and effective resource utilization. We believe that agreement and collaboration toward a common goal, engaging key stakeholders, and educational efforts were crucial to improving the care of bladder exstrophy patients. Although ERAS has typically been utilized for high-volume procedures, our study highlights that an enhanced recovery pathway is both feasible and adaptable to less common urological surgeries.
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