Enhanced Recovery Pathways Versus Standard Care After Cystectomy: A Meta-analysis of the Effect on Perioperative Outcomes

Abstract

Context Enhanced recovery after surgery (ERAS) protocols aim to improve surgical outcomes by reducing variation in perioperative best practices. However, among published studies, results show a striking variation in the effect of ERAS pathways on perioperative outcomes after cystectomy. Objective To perform a systematic review of the literature and a meta-analysis comparing the effectiveness of ERAS versus standard care on perioperative outcomes after cystectomy. Evidence acquisition We performed a literature search of PubMed, EMBASE, Web of Science, Google Scholar, the Cochrane Library, and the health-related grey literature in February 2016 according to the Preferred Reporting Items for Systematic Review and Meta-analysis and the Cochrane Handbook. Studies were reviewed according to criteria from the Oxford Centre for Evidence-Based Medicine. Thirteen studies (1493 total patients) met the inclusion criteria (ERAS: 801, standard care: 692). A pooled meta-analysis of all comparative studies was performed using inverse-weighted, fixed-effects models, and random-effects models. Publication bias was graphically assessed using contour-enhanced funnel plots and was formally tested using the Harbord modification of the Egger test. Evidence synthesis Pooled data showed a lower overall complication rate (risk ratio [RR]: 0.85, 95% confidence interval [CI]: 0.74–0.97, p = 0.017, I2 = 35.6%), a shorter length of stay (standardized mean difference: −0.87, 95% CI: −1.31 to −0.42, p = 0.001, I2 = 92.8%), and a faster return of bowel function (standardized mean difference: −1.02, 95% CI: −1.69 to −0.34, p = 0.003, I2 = 92.2%) in the ERAS group. No difference was noted for the overall readmission rates (RR: 0.74, 95% CI: 0.39–1.41, p = 0.36, I2 = 51.4%), although a stratified analysis showed a lower 30-d readmission rate in the ERAS group (RR: 0.39, 95% CI: 0.19–0.83, p = 0.015, I2 = 0%). Conclusions ERAS protocols reduce the length of stay, time-to-bowel function, and rate of complications after cystectomy. Patient summary Enhanced recovery after surgery pathways for cystectomy reduce complications and the amount of time patients spend in the hospital.

Enhanced recovery after urologic surgery—Current applications and future directions

“…28,35,44,45 A recent meta-analysis by Tyson and Chang found no significant difference in overall readmissions or 90-day mortality through ERAS implementation though a lower complication rate was noted (39.6% with ERAS vs 51.5% with standard care). 46 The same analysis also found a mean decrease in length of stay with ERAS of greater than 5 days along with a 1 day faster return of bowel function. 46 potential indicator of quality.…”

“…Additional groups have reported experiences with various ERAS protocols demonstrating consistently shorter time to regular diet, time to return of bowel function, and length of hospitalization . A recent meta‐analysis by Tyson and Chang found no significant difference in overall readmissions or 90‐day mortality through ERAS implementation though a lower complication rate was noted (39.6% with ERAS vs 51.5% with standard care) . The same analysis also found a mean decrease in length of stay with ERAS of greater than 5 days along with a 1 day faster return of bowel function .…”

“…A recent meta‐analysis by Tyson and Chang found no significant difference in overall readmissions or 90‐day mortality through ERAS implementation though a lower complication rate was noted (39.6% with ERAS vs 51.5% with standard care) . The same analysis also found a mean decrease in length of stay with ERAS of greater than 5 days along with a 1 day faster return of bowel function . In one of the few series to evaluate impact of ERAS on quality of life outcomes to date, Karl et al demonstrated significant early improvements in quality of life among patients in an early recovery protocol in comparison to standard care as measured by the European Organization for the Research and Treatment of Cancer (EORTC) Quality of Life questionnaire QLQ‐30 .…”

Is the open cystectomy era over? An update on the available evidence

“…Minimally invasive surgery has been added as one of the 22 elements of ERP thus, robotic surgeons try to apply ERP, but the fact remains that it is underutilized. ERP has shown that it decreases LOS, postoperative ileus, complications and risk for readmission at 30 days …”

“…ERP has shown that it decreases LOS, postoperative ileus, complications and risk for readmission at 30 days. 15 Having said this, we understand beforehand, that the absence of ERP and the intracorporeal approach might introduce bias and create problems in the interpretation of the results. If not all, many studies including all published RCTs, did not use the totally intracorporeal approach, did not describe thoroughly their clinical pathway or the use of ERP and in many cases, the diversion commonly used is the ileal conduit and not the neobladder.…”