title: Enhanced Recovery after Urological Surgery: A Contemporary Systematic Review of Outcomes, Key Elements, and Research Needs.
abstract: Enhanced Recovery after Surgery (ERAS) programs are multimodal care pathways that aim to decrease intra-operative blood loss, decrease postoperative complications, and reduce recovery times.
  
  
  
  To overview the use and key elements of ERAS pathways, and define needs for future clinical trials.
  
  
  
  A comprehensive systematic MEDLINE search was performed for English language reports published before May 2015 using the terms "postoperative period," "postoperative care," "enhanced recovery after surgery," "enhanced recovery," "accelerated recovery," "fast track recovery," "recovery program," "recovery pathway", "ERAS," and "urology" or "cystectomy" or "urologic surgery."
  
  
  
  We identified 18 eligible articles. Patient counseling, physical conditioning, avoiding excessive alcohol and smoking, and good nutrition appeared to protect against postoperative complications. Fasting from solid food for only 6h and perioperative liquid-carbohydrate loading up to 2h prior to surgery appeared to be safe and reduced recovery times. Restricted, balanced, and goal-directed fluid replacement is effective when individualized, depending on patient morbidity and surgical procedure. Decreased intraoperative blood loss may be achieved by several measures. Deep vein thrombosis prophylaxis, antibiotic prophylaxis, and thermoregulation were found to help reduce postsurgical complications, as was a multimodal approach to postoperative nausea, vomiting, and analgesia. Chewing gum, prokinetic agents, oral laxatives, and an early resumption to normal diet appear to aid faster return to normal bowel function. Further studies should compare anesthetic protocols, refine analgesia, and evaluate the importance of robot-assisted surgery and the need/timing for drains and catheters.
  
  
  
  ERAS regimens are multidisciplinary, multimodal pathways that optimize postoperative recovery.
  
  
  
  This review provides an overview of the use and key elements of Enhanced Recovery after Surgery programs, which are multimodal, multidisciplinary care pathways that aim to optimize postoperative recovery. Additional conclusions include identifying effective procedures within Enhanced Recovery after Surgery programs and defining needs for future clinical trials.
authors.affiliation: Urology Department, King Abdulaziz University, Jeddah, Saudi Arabia; USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. Electronic address: raazhar@kau.edu.sa.
authors.forename: Raed A
authors.initials: RA
authors.lastname: Azhar
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY, USA.
authors.forename: Bernard
authors.initials: B
authors.lastname: Bochner
authors.affiliation: Academic Units of Urology and Molecular Oncology, University of Sheffield, Sheffield, South Yorkshire, UK.
authors.forename: James
authors.initials: J
authors.lastname: Catto
authors.affiliation: Department of Urology, Houston Methodist Hospital, Houston, TX, USA.
authors.forename: Alvin C
authors.initials: AC
authors.lastname: Goh
authors.affiliation: Division of Surgery and Interventional Science, UCL Medical School, University College London, London, UK.
authors.forename: John
authors.initials: J
authors.lastname: Kelly
authors.affiliation: James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
authors.forename: Hiten D
authors.initials: HD
authors.lastname: Patel
authors.affiliation: Division of Urologic Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: Raj S
authors.initials: RS
authors.lastname: Pruthi
authors.affiliation: Department of Urology, University Hospital Inselspital, Bern, Switzerland.
authors.forename: George N
authors.initials: GN
authors.lastname: Thalmann
authors.affiliation: USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
authors.forename: Mihir
authors.initials: M
authors.lastname: Desai
mesh_terms: D004032:Diet; D004434:Early Ambulation; D019990:Perioperative Care / Q000379:methods*; D011183:Postoperative Complications / Q000517:prevention & control; D020127:Recovery of Function; D016540:Smoking Cessation; D013997:Time Factors; D013520:Urologic Surgical Procedures
keywords: ERAS; Enhanced recovery after surgery; Perioperative care