Enhanced Recovery Pathways Versus Standard Care After Cystectomy: A Meta-analysis of the Effect on Perioperative Outcomes
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1Department of Urology, Mayo Clinic Hospital, Phoenix, AZ, USA; Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
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.