title: Are we doing "better"? The discrepancy between perception and practice of enhanced recovery after cystectomy principles among urologic oncologists.
abstract: OBJECTIVE
  The concept of enhanced recovery after surgery has been around since the 1990s when it was first introduced as a means to improve postoperative recovery of general surgical patients. In the field of urology, the uptake of enhanced recovery pathways has been slow for unclear reasons. Recently, interest in enhanced recovery after cystectomy (ERAC) has been increasing, but the current urologic oncology practice patterns remain unclear. In this study, we investigate modern perioperative patterns of care and rates of application of ERAC principles by cystectomy surgeons.
  
  
  METHODS
  ERAC principles were identified by reviewing urology and general surgery literature. An adapted version of The Royal College of Surgeons of England fast-track surgical principles survey was used. Preoperative education, bowel preparation avoidance, nasogastric tubes avoidance, normothermia, opioid avoidance, early ambulation, and early feeding were all practices queried with the survey. Surveys were distributed electronically to faculty of Society of Urologic Oncology fellowships with bladder cancer as a special area of interest. Additional participants were identified by recent publications on cystectomies for bladder cancer. In total, 128 surveys were e-mailed to the previously identified experts. Of these, 61 (48%) completed the survey. Responses were classified as congruent with commonly accepted ERAC principles (ERAC group) or noncongruent (non-ERAC group). Chi-square test was used for categorical variables and Wilcoxon-Mann-Whitney for ordinal variables.
  
  
  RESULTS
  Of the urologists who classified themselves in the ERAC group (64%), the average length of stay was reported to be 6.1 days and 7.2 days in the non-ERAC group (P = 0.02). Only 20% were practicing all interventions. Among the ERAC surgeons 1, 2 or 3 of the interventions were omitted by 13%, 25%, and 23% of the respondents, respectively. Significant differences were found between the self-reported ERAC adopters and nonadopters in the use of bowel preparation (P = 0.01), nasogastric tubes (P = 0.007), alvimopan (P<0.001), and the average day of advancement to clear liquids (P<0.001). There were no differences in postoperative ambulation and opiate or nonsteroidal anti-inflammatory drug use. Lack of convincing evidence was cited as the main reason for the non-ERAC group not yet implementing an ERAC pathway followed by lack of resource availability.
  
  
  CONCLUSIONS
  Urologists who consider themselves as practicing ERAC do not universally practice all of the pathway tenets. A significant gap exists between self-perception and practice of enhanced recovery. ERAC implementation is challenging but represents a significant opportunity to improve the quality of care for cystectomy patients.
authors.affiliation: Department of Urology, University of Rochester Medical Center, Rochester, NY. Electronic address: Janet_kukreja@urmc.rochester.edu.
authors.forename: Janet E
authors.initials: JE
authors.lastname: Baack Kukreja
authors.affiliation: Department of Urology, University of Rochester Medical Center, Rochester, NY.
authors.forename: Edward M
authors.initials: EM
authors.lastname: Messing
authors.affiliation: Department of Urology, M.D. Anderson Cancer Center, Houston, TX.
authors.forename: Jay B
authors.initials: JB
authors.lastname: Shah
mesh_terms: D015653:Cystectomy; D006801:Humans; D007902:Length of Stay; D010465:Perception; D010818:Practice Patterns, Physicians'; D011379:Prognosis; D020127:Recovery of Function; D013997:Time Factors; D001749:Urinary Bladder Neoplasms / Q000601:surgery*; D014547:Urinary Diversion
keywords: Cystectomy; Enhanced recovery after surgery; Fast track; Quality improvement; Survey