Enhanced Recovery Pathways Versus Standard Care After Cystectomy: A Meta-analysis of the Effect on Perioperative Outcomes

Context: Enhanced recovery after surgery (ERAS) protocols aim to improve surgical outcomes by reducing variation in perioperative best practices. However, among published studies, results show a striking variation in the effect of ERAS pathways on perioperative outcomes after cystectomy. Objective: To perform a systematic review of the literature and a meta-analysis comparing the effectiveness of ERAS versus standard care on perioperative outcomes after cystectomy. Evidence acquisition: We performed a literature search of PubMed, EMBASE, Web of Science, Google Scholar, the Cochrane Library, and the health-related grey literature in February 2016 according to the Preferred Reporting Items for Systematic Review and Meta-analysis and the Cochrane Handbook. Studies were reviewed according to criteria from the Oxford Centre for Evidence-Based Medicine. Thirteen studies (1493 total patients) met the inclusion criteria (ERAS: 801, standard care: 692). A pooled meta-analysis of all comparative studies was performed using inverse-weighted, fixed-effects models, and random-effects models. Publication bias was graphically assessed using contour-enhanced funnel plots and was formally tested using the Harbord modification of the Egger test. Evidence synthesis: Pooled data showed a lower overall complication rate (risk ratio [RR]: 0.85, 95% confidence interval [CI]: 0.74-0.97, p = 0.017, I-2 = 35.6%), a shorter length of stay (standardized mean difference: -0.87, 95% CI: -1.31 to -0.42, p = 0.001, I-2 = 92.8%), and a faster return of bowel function (standardized mean difference: -1.02, 95% CI: -1.69 to -0.34, p = 0.003, I-2 = 92.2%) in the ERAS group. No difference was noted for the overall readmission rates (RR: 0.74, 95% CI: 0.39-1.41, p = 0.36, I-2 = 51.4%), although a stratified analysis showed a lower 30-d readmission rate in the ERAS group (RR: 0.39, 95% CI: 0.19-0.83, p = 0.015, I-2 = 0%). Conclusions: ERAS protocols reduce the length of stay, time-to-bowel function, and rate of complications after cystectomy. Patient summary: Enhanced recovery after surgery pathways for cystectomy reduce complications and the amount of time patients spend in the hospital. (C) 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.