An intra-operative checklist for low-impact robotic urologic surgery: a three-round J-ERUS/YAU Delphi consensus

Enhanced recovery pathways emphasise peri-operative pharmacology, whereas many modifiable intra-operative practices remain under-standardised and supported by heterogeneous evidence. Standardising these practices is central to low-impact robotic surgery, aiming to minimise avoidable procedural and physiological stress, and may improve early recovery, including post-operative pain. A three-round, online modified Delphi was conducted within the J-ERUS/YAU network, inviting 21 experts (19 urologists, 2 anaesthetists). Round-1 presented 21 items (5-point Likert). A priori thresholds-blinded to panellists-were: Include = median ≥ 4 with interquartile range (IQR) ≤ 1; Exclude = median < 3; otherwise = revote. Rounds-2/-3 re-rated non-consensus items and validated new items proposed from R1 free-text; at each revote, the prior round's median and IQR were shown. Late submissions were excluded in Rounds 1 and 2. R1 analysed 20 valid responses: 5 Include, 2 Exclude, 14 to revote. R2 analysed 19 responses and re-rated 14 carried plus 9 new items from R1 suggestions: 16 reached Include, 7 to revote. R3 analysed 16 responses: 2 reached Include, 5 without consensus. In total, 23 items met Include (5 R1 + 16 R2 + 2 R3). The checklist integrates pharmacologic/anaesthetic measures (multimodal analgesia; regional techniques as appropriate; structured anti-PONV prophylaxis) with non-pharmacologic practices across surgical (pressure-point padding; low pneumoperitoneum/valveless insufflation) and environmental (active temperature management) domains. This Delphi produced a 23-item consensus checklist that standardises modifiable intra-operative practices underpinning low-impact robotic urologic surgery. Prospective implementation should evaluate effects on recovery outcomes, including post-operative pain, opioid use and PONV.