title: Enhanced Recovery After Surgery protocols for radical cystectomy surgery: review of current evidence and local protocols.
abstract: BACKGROUND
  Radical cystectomy (RC) remains a morbid procedure. The use of Enhanced Recovery After Surgery (ERAS) pathways has proven to reduce care time and post-operative complications after colorectal surgery. There is a high potential for reducing morbidity associated with RC by utilizing ERAS in this setting. The purpose of this review is to examine the current evidence for ERAS in preoperative, intra-operative and post-operative setting of care for RC patients and to propose ERAS evidence-based protocol for patients undergoing RC in the Australian and New Zealand environment.
  Patient's medical optimization, avoidance of oral mechanical bowel preparation and emphasis on preoperative administration of high-energy carbohydrate drinks from colorectal literature has led to inclusion of these strategies in the preoperative considerations of ERAS in RC.
  Epidural analgesia has an integral role in reducing surgical stress response, improving analgesia and expediting functional recovery and should be included in ERAS RC protocols. Of relevance is 72 h maximum length of its duration. With regard to minimally invasive approach to RC, despite encouraging results from high-volume centres, high-level evidence in this field are lacking (ongoing clinical trials). Standardized anaesthetic protocols with particular emphasis on perioperative fluid management are essential components of ERAS protocols.
  Avoidance of routine nasogastric tube placement, early mobilization and multifaceted approach to optimization of gut function and elimination of post-operative ileus are the cornerstones of post-operative care in the setting of ERAS in RC patients.
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.|Urology Department, Miller School of Medicine, University of Miami, Florida, USA.
authors.forename: Maria C
authors.initials: MC
authors.lastname: Mir
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.
authors.forename: Homayoun
authors.identifier: http://orcid.org/0000-0001-8424-1087
authors.initials: H
authors.lastname: Zargar
authors.affiliation: Austin Health, The University of Melbourne, Melbourne, Victoria, Australia.
authors.forename: Damien M
authors.initials: DM
authors.lastname: Bolton
authors.affiliation: Peter MacCallum Cancer Center, The University of Melbourne, Melbourne, Victoria, Australia.
authors.forename: Declan G
authors.initials: DG
authors.lastname: Murphy
authors.affiliation: Austin Health, The University of Melbourne, Melbourne, Victoria, Australia.|Peter MacCallum Cancer Center, The University of Melbourne, Melbourne, Victoria, Australia.|Olivia Newton-John Cancer Research Institute, Austin Health, The University of Melbourne, Melbourne, Victoria, Australia.
authors.forename: Nathan
authors.initials: N
authors.lastname: Lawrentschuk
mesh_terms: D001315:Australia; D015653:Cystectomy / Q000379:methods*; D004434:Early Ambulation; D006801:Humans; D009520:New Zealand; D019990:Perioperative Care / Q000379:methods*; D011183:Postoperative Complications / Q000517:prevention & control*; D017410:Practice Guidelines as Topic; D020127:Recovery of Function
keywords: convalescence; cystectomy; recovery of function; rehabilitation; urinary bladder neoplasm; urological surgical procedure