Enhanced recovery after surgery (ERAS) represents a fundamental shift in perioperative care with the goal of achieving an earlier and improved recovery after major surgery. Its basic principles include a multidisciplinary team, a multimodal approach to all aspects of perioperative care, an incorporation of evidence-based practices, and a continuous audit with the use of quality improvement methodology. The individual elements of ERAS vary by the specific protocol but are all designed to modulate the pathophysiologic response to surgical stress. Since its first description for colonic resection in 1998, ERAS has been widely adopted in adults, with studies consistently demonstrating a decreased length of stay (LOS), decreased complication rates, reduced cost of care, and improved satisfaction and quality of life.¹

Its success has led to a growing interest in the adoption of ERAS in the pediatric population.² However, the current evidence is still limited, with a recent scoping review identifying only 8 studies in pediatric urology.³ A majority of pediatric urologists are also not familiar with or currently using ERAS. In a recent survey of 113 members of the Societies for Pediatric Urology, 61% were somewhat or not familiar with ERAS, and only 20% were currently using a standardized protocol.⁴

Lower urinary tract reconstruction is an ideal candidate for the implementation of ERAS due to the wide variability in perioperative care as well as the high complication and readmission rates.^5,6 The traditional model typically involves a prolonged preoperative fast, mechanical bowel preparation, open surgery with a large incision, postoperative fasting with nasogastric decompression until a return of bowel function, aggressive fluid resuscitation, and avoidance of regional blocks and NSAIDs. These practices may have a detrimental impact on recovery and are specifically addressed by ERAS.

Rove et al were the first to describe an ERAS protocol for lower urinary tract reconstruction in a pilot study of 13 patients and 26 matched historical controls. Adherence improved from a median of 8 (IQR 4-9) to 12 (IQR 11-12) elements with the implementation of ERAS. Although it was underpowered to observe a significant difference, the LOS decreased from a median of 6 (IQR 5-7) to 5 (IQR 3-6) days with no significant difference in the emergency department visits, readmissions, or reoperations. The complications decreased from 2.1 to 1.3 per patient (odds ratio [OR] 0.71, 95% CI 0.51-0.97) as well.⁷ In a subsequent study on the same cohort, Han et al reported an improvement in the anesthetic outcomes with a significantly decreased proportion of patients who did not receive any intraoperative or postoperative narcotics (0% vs 15%, P = .046), decreased maximum pain scores in the post-anesthesia care unit (3 vs 0, P < .001) despite a decreased narcotic use and decreased postoperative use of supplemental oxygen (85% vs 38%, P = .013).⁸ Haid et al also assessed the implementation of a similar 17-item protocol in a consecutive series of 15 patients undergoing an augmentation cystoplasty or urinary diversion and compared them to the last 15 patients prior to implementation. Adherence improved from a mean of 7.9 (range 5-10) to 15.9 (range 15-16) elements with the implementation of ERAS. The LOS significantly decreased from 19.9 to 11.9 days (P < .001). Although not statistically significant, the total number of complications decreased from 5 to 1, all of which were Clavien-Dindo grades 1 and 2 bowel-related complications.⁹ Chan et al more recently described a quality improvement initiative with the implementation of an expanded 24-item protocol in a consecutive series of 20 patients undergoing the creation of a continent catheterizable channel, augmentation cystoplasty, or bladder neck reconstruction and compared them to the last 20 patients prior to implementation. A median of 16 (range 12-19) elements were successfully implemented. Consistent with the prior studies, the LOS significantly decreased from a median of 9 (range 2-31) to 4 (range 3-29) days with no significant difference in the unplanned returns to the operating room or readmissions (P < .05). However, the complication rate did not change with the implementation of ERAS.¹⁰

Despite these promising results, a larger prospective study is needed. Our groups collaborated with other centers across the United States to establish the Pediatric Urology Recovery After Surgery Endeavor (PURSUE) with the objectives to develop and implement an ERAS protocol for lower urinary tract reconstruction in a prospective case-control study of patients between 4 and 25 years of age undergoing the creation of a continent catheterizable channel, augmentation cystoplasty, or urinary diversion (ClinicalTrials.gov NCT03245242).¹¹ A 20-item protocol was developed as a guide to standardize but not dictate the perioperative care (Table). A pilot phase was recently completed for the first 5 patients at each center (a total of 40 patients across 8 centers) to determine the feasibility of implementation and adherence prior to undertaking the exploratory study. The median duration of implementation was 64 days (range 15-306), while the median duration of the pilot phase was 150 days (22-952). One center experienced a prolonged implementation and pilot phase due to a lack of buy-in from a comanaging colorectal surgical service. The most commonly perceived barriers to implementation were “difficulty initiating and maintaining compliance with care pathway” in 51%, followed by a “lack of time, money, or clinical resources” in 36% on the prepilot survey. A median of 16 (of 20) elements was achieved (range 15-18), with 7 of 8 centers reaching the goal of ≥ 70% adherence.¹² The PURSUE study group recently completed the enrollment for the exploratory study with the plan to compare to a propensity-matched cohort from the 5 years prior to implementation.

Table. Enhanced Recovery After Surgery Protocol for Lower Urinary Tract Reconstruction

The implementation and sustainability of ERAS are challenging due to the need for the incorporation of many new practices throughout the perioperative space.² A multidisciplinary team is critical with the engagement of all relevant stakeholders, regular communication, and designated champions within each discipline. The PURSUE study group and others have identified a variety of reasons for an inconsistent buy-in, including a resistance to change; lack of time, support, and resources; perceived impact on efficiency in the operating room; and lack of high-quality supporting evidence.^2,4,10,12 A continuous audit is also integral to the successful implementation and sustainability of ERAS. The PURSUE study group has been able to monitor the adherence at each center, provide feedback from experiences at other centers, and improve their processes with a continuous audit. These processes need to be sustainable and unique to each center, as those at one center may not be successful at others.¹²

The current evidence is promising but still limited on ERAS for lower urinary tract reconstruction in the pediatric population. Higher-quality studies are needed to corroborate the findings of earlier studies and to allow for the refinement of pediatric-specific best practices and the development of pediatric guidelines in the future.