Enhanced Recovery After Surgery and Radical Cystectomy: A Systematic Review and Meta-Analysis

Figures & data

Figure 1 The risk of bias summary of included studies.

Table 1 Characteristics of Each Study

First Author, Year	Country	Study Type	ERAS/Non-ERAS	Variable Outcomes	Level of Evidence
Bansal et al,^Citation9 2020	India	Prospective	27/27	[1,2,3,4,6,7,9,10]	3b
Choi et al,^Citation14 2010	South Korea	Prospective	30/30	[1,2,3,4,6,7,8,9,10]	2b
Adamakis et al,^Citation8 2010	Greece	Prospective	22/21	[1,2,3,5,8,9,10]	2b
Collins et al,^Citation15 2016	Sweden	Prospective	135/86	[1,2,3,4,5,6,8]	3b
Declercq et al,^Citation16 2015	Belgium	Prospective	46/48	[1,2,3,6,7,8,9,10]	3b
Deibert et al,^Citation17 2016	USA	Prospective	50/52	[2,4,6,7,8,9,10]	3b
Ercolino et al,^Citation18 2019	Italy	Prospective	75/116	[1,2,3,6,7,8,9]	3b
Frees et al,^Citation29 2017	Canada	Prospective	10/13	[1,2,3,4,7,8,9,10]	2b
Jensen et al,^Citation19 2014	Denmark	Prospective	50/57	[1,2,3,4,6,7,8,9]	3b
Lee et al,^Citation20 2014	USA	Prospective	143/137	[1,2,3,6,7,8,9,10]	3b
Lin et al,^Citation21 2017	China	Prospective	144/145	[1,2,3,6,7,8,9,10]	3b
Maffezzini et al,^Citation10 2007	Italy	Retrospective	71/40	[1,2,4,6,8,9]	3b
Mukhtar et al,^Citation11 2013	England	Prospective	51/26	[1,2,3,4,5,6,7,8,9]	3b
Moeen et al,^Citation12 2019	Egypt	Prospective	54/57	[1,2,3,4,6,7,8,9,10]	3b
Vlad et al,^Citation13 2020	Romania	Prospective	45/45	[1,2,3,4,6,7,8,9,10]	3b

Notes: Includes the number of patients in ERAS group against the number of patients in the Non-ERAS group. 1) age, 2) gender, 3) body mass index (BMI), 4) American Society of Anesthesiology (ASA) Score, 5) history of previous surgery, 6) clinical stage, 7) operation type, 8) diversion type, 9) operation time, 10) estimated blood loss.

Abbreviation: ERAS, enhanced recovery after surgery.

Table

First Author, Year	Adamakis et al, 2010	Bansal et al, 2020	Choi et al, 2010	Collins et al, 2016	Declercq et al, 2015	Deibert et al,2016	Ercolino et al, 2019	Frees et al, 2017	Jensen et al, 2014	Lee et al, 2014	Lin et al, 2017	Maffezzini et al, 2007	Mukhtar et al, 2013	Moeen et al, 2019	Vlad et al, 2020
Patient counseling and education	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	X	✓	✓	✓
MBP omission	✓	✓	X	✓	✓	✓	✓	✓	✓	X	✓	✓	✓	✓	✓
Limited preoperative fasting	✓	✓	X	✓	✓	✓	✓	✓	✓	X	✓	X	✓	✓	✓
Carbohydrate loading	✓	✓	X	✓	✓	✓	✓	✓	✓	X	✓	✓	✓	✓	✓
Antibiotics prophylaxis	X	✓	X	X	✓	✓	X	✓	✓	X	✓	✓	X	✓	✓
Venous thrombosis prevention	✓	✓	X	✓	X	✓	✓	✓	✓	X	✓	X	✓	✓	✓
EDA	✓	✓	X	✓	✓	✓	X	✓	✓	X	X	✓	✓	✓	✓
Minimal invasive approach	X	X	✓	✓	✓	✓	X	X	✓	✓	✓	X	✓	X	✓
GDFT	X	X	X	✓	✓	X	X	✓	✓	X	✓	X	✓	✓	✓
Prevention of hypothermia	✓	X	X	✓	✓	X	✓	✓	✓	X	✓	✓	✓	X	X
Early removal of NG tube	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓
Pain management	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓
Early mobilization	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓
Early oral intake	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓
Early removal of UC	X	✓	X	✓	✓	X	✓	X	✓	✓	✓	X	✓	✓	✓
POI prevention	✓	✓	✓	✓	✓	X	✓	✓	✓	✓	✓	X	X	X	✓
Total ERAS elements	12	13	7	15	15	12	12	14	16	8	15	9	14	13	14

Abbreviations: MBP, mechanical bowel preparation; EDA, epidural anesthesia; GDFT, goal-directed fluid therapy; NG, nasogastric; UC, urinary catheter; ✓, Included; X, Not included.

Figure 2 Flowchart of literature selection process.

Figure 3 Forest plot displaying a random-effects meta-analysis of the effect of enhanced recovery after surgery (ERAS) on length of stay after cystectomy. Weights are from random-effects analysis.

Abbreviations: CI, confidence interval; SMD, standardized mean difference.

Figure 4 Forest plot displaying a fixed-effects meta-analysis of the effect of enhanced recovery after surgery (ERAS) on complication rates after cystectomy.

Abbreviations: CI, confidence interval; RR, risk ratio.

Figure 5 Forest plot displaying a random-effects meta-analysis of the effect of enhanced recovery after surgery (ERAS) on time to bowel function recovery after cystectomy. Weights are from random-effects analysis.

Abbreviations: CI, confidence interval; SMD, standardized mean difference.

Figure 6 Forest plot displaying a fixed-effects meta-analysis of the effect of enhanced recovery after surgery (ERAS) readmission rates within 30 d after cystectomy.

Abbreviations: CI, confidence interval; RR, risk ratio.

Table 3 Eggers’ Test

Outcomes	P-Intercept	95% CI	t value	P value
LO.S	−2.143	[−6.43 to 2.14]	−0.981	0.347
Bowel movement	−5.88	[−11.28 to −0.48]	−2.135	0.065
Overall complications	0.57	[−1.34 to 2.54]	0.602	0.560
30d-readmission	−0.37	[−1.65 to 0.92]	−0.564	0.593

Abbreviations: LOS, length of stay, CI, confidence interval.

Figure 7 Contour-enhanced funnel plots for (A). Length of stay (B). bowel function (C). rate of complications (D). 30d readmission.

Bansal D, Nayak B, Singh P, et al. Randomized controlled trial to compare outcomes with and without the enhanced recovery after surgery protocol in patients undergoing radical cystectomy. Indian J Urol. 2020;36(2):95–100. doi:10.4103/iju.IJU_11_20

 Web of Science ®Google Scholar

Ercolino A, Bianchi FM, Chessa F, et al. Perioperative outcomes of fast track protocol applied to patients treated with radical cystectomy and intestinal urinary diversion: a comparison with standard management in a high-volume center. Eur Urol Suppl. 2019;18(9):e3280–e3281. doi:10.1016/s1569-9056(19)33686-3

 Google Scholar

Adamakis I, Tyritzis SI, Koutalellis G, et al. Early removal of nasogastric tube is beneficial for patients undergoing radical cystectomy with urinary diversion. Int Braz J Urol. 2011;37(1):42–48. doi:10.1590/S1677-55382011000100006

 Web of Science ®Google Scholar

Jensen BT, Petersen AK, Jensen JB, Laustsen S, Borre M. Efficacy of a multiprofessional rehabilitation programme in radical cystectomy pathways: a prospective randomized controlled trial. Scand J Urol. 2015;49(2):133–141. doi:10.3109/21681805.2014.967810

 Web of Science ®Google Scholar

Lee CT, Chang SS, Kamat AM, et al. Alvimopan accelerates gastrointestinal recovery after radical cystectomy: a multicenter randomized placebo-controlled trial. Eur Urol. 2014;66(2):265–272. doi:10.1016/j.eururo.2014.02.036

 PubMed Web of Science ®Google Scholar

Lin T, Li K, Liu H, et al. Enhanced recovery after surgery for radical cystectomy with ileal urinary diversion: a multi-institutional, randomized, controlled trial from the Chinese bladder cancer consortium. World J Urol. 2018;36(1):41–50. doi:10.1007/s00345-017-2108-3

 Web of Science ®Google Scholar

Maffezzini M, Gerbi G, Campodonico F, Parodi D. Multimodal perioperative plan for radical cystectomy and intestinal urinary diversion. I. Effect on recovery of intestinal function and occurrence of complications. Urology. 2007;69(6):1107–1111. doi:10.1016/j.urology.2007.02.062

 Web of Science ®Google Scholar

Frees SK, Aning J, Black P, et al. A prospective randomized pilot study evaluating an ERAS protocol versus a standard protocol for patients treated with radical cystectomy and urinary diversion for bladder cancer. World J Urol. 2018;36(2):215–220. doi:10.1007/s00345-017-2109-2

 Web of Science ®Google Scholar

Mukhtar S, Ayres BE, Issa R, Swinn MJ, Perry MJA. Challenging boundaries: an enhanced recovery programme for radical cystectomy. Ann R Coll Surg Engl. 2013;95(3):200–206. doi:10.1308/003588413X13511609957579

 Web of Science ®Google Scholar

Moeen SM, Moeen AM. Usage of intravenous lidocaine infusion with enhanced recovery pathway in patients scheduled for open radical cystectomy: a randomized trial. Pain Physician. 2019;22(2):E71–E80. doi:10.36076/ppj/2019.22.e71

 Web of Science ®Google Scholar

Vlad O, Catalin B, Mihai H, et al. Enhanced recovery after surgery (ERAS) protocols in patients undergoing radical cystectomy with ileal urinary diversions: a randomized controlled trial. Medicine. 2020;99(27):e20902. doi:10.1097/MD.0000000000020902

 Web of Science ®Google Scholar

Choi H, Kang SH, Yoon DK, et al. Chewing gum has a stimulatory effect on bowel motility in patients after open or robotic radical cystectomy for bladder cancer: a prospective randomized comparative study. Urology. 2011;77(4):884–890. doi:10.1016/j.urology.2010.06.042

 Web of Science ®Google Scholar

Collins JW, Adding C, Hosseini A, et al. Introducing an enhanced recovery programme to an established totally intracorporeal robot-assisted radical cystectomy service. Scand J Urol. 2016;50(1):39–46. doi:10.3109/21681805.2015.1076514

 PubMed Web of Science ®Google Scholar

Declercq P, De Win G, Van der Aa F, et al. Reduced length of stay in radical cystectomy patients with oral versus parenteral post-operative nutrition protocol. Int J Clin Pharm. 2015;37(2):379–386. doi:10.1007/s11096-015-0072-9

 Web of Science ®Google Scholar

Deibert CM, Silva MV, RoyChoudhury A, et al. A prospective randomized trial of the effects of early enteral feeding after radical cystectomy. Urology. 2016;96:69–73. doi:10.1016/j.urology.2016.06.045

 Web of Science ®Google Scholar