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Enhanced Recovery After Surgery for an Uncommon Complex Urological Procedure: The Complete Primary Repair of Bladder
Andrea K Balthazar1, Julia B Finkelstein1, Vivian Williams1
1Department of Urology, Boston Children's Hospital, Boston, Massachusetts.
Insights
Implementing enhanced recovery after surgery (ERAS) protocols for bladder exstrophy repair significantly reduced hospital stays and intensive care unit admissions. This study shows ERAS is effective even for less common pediatric urological surgeries.
Area of Science:
- Pediatric Urology
- Surgical Outcomes
- Healthcare Management
Background:
- Complete primary repair of bladder exstrophy traditionally involves prolonged intensive care unit (ICU) stays and extended hospitalization.
- Enhanced Recovery After Surgery (ERAS) protocols aim to optimize perioperative care and accelerate patient recovery.
- The application of ERAS to complex pediatric urological procedures like bladder exstrophy repair has not been extensively studied.
Purpose of the Study:
- To evaluate the impact of implementing an ERAS pathway on the length of stay and patient outcomes for children undergoing complete primary repair of bladder exstrophy.
- To determine the feasibility and effectiveness of ERAS principles in a less common, high-complexity urological surgery.
- To reduce variations in care and improve resource utilization for bladder exstrophy repair.
Main Methods:
- Development and implementation of a multidisciplinary ERAS pathway for complete primary repair of bladder exstrophy, including a staged surgical approach over two days.
- Comparison of patient outcomes (length of stay, ICU utilization, feeding tolerance, need for escalated care) between a historical cohort (pre-ERAS) and patients managed under the ERAS pathway.
- Continuous refinement of the ERAS pathway following its initial launch.
Main Results:
- Patients managed with the ERAS pathway demonstrated immediate extubation and significantly earlier feeding initiation compared to the historical cohort.
- Median intensive care unit length of stay decreased from 2.5 to 1 day, and overall length of stay reduced from 14.5 to 7.5 days.
- Post-ERAS implementation, there was no ICU utilization in a subset of patients, no escalation of care required, and no difference in emergency department visits or readmissions.
Conclusions:
- Implementing ERAS principles for complete primary repair of bladder exstrophy significantly decreases length of stay and improves patient outcomes.
- The ERAS pathway led to decreased variations in care and more effective resource utilization.
- This study demonstrates the adaptability and feasibility of ERAS pathways for less common pediatric urological surgeries.
Purpose:
ERAS (enhanced recovery after surgery) protocols are designed to optimize perioperative care and expedite recovery. Historically, complete primary repair of bladder exstrophy has included postoperative recovery in the intensive care unit and extended length of stay. We hypothesized that instituting ERAS principles would benefit children undergoing complete primary repair of bladder exstrophy, decreasing length of stay. We describe implementation of a complete primary repair of bladder exstrophy-ERAS pathway at a single, freestanding children's hospital.
Materials And Methods:
A multidisciplinary team developed an ERAS pathway for complete primary repair of bladder exstrophy, which launched in June 2020 and included a new surgical approach that divided the lengthy procedure into 2 consecutive operative days. The complete primary repair of bladder exstrophy-ERAS pathway was continuously refined, and the final pathway went into effect in May 2021. Post-ERAS patient outcomes were compared with a pre-ERAS historical cohort (2013-2020).
Results:
A total of 30 historical and 10 post-ERAS patients were included. All post-ERAS patients had immediate extubation (P = .04) and 90% received early feeding (P < .001). The median intensive care unit and overall length of stay decreased from 2.5 to 1 days (P = .005) and from 14.5 to 7.5 days (P < .001), respectively. After final pathway implementation, there was no intensive care unit use (n=4). Postoperatively, no ERAS patient required escalation of care, and there was no difference in emergency department visits or readmissions.
Conclusions:
Applying ERAS principles to complete primary repair of bladder exstrophy was associated with decreased variations in care, improved patient outcomes, and effective resource utilization. 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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