Early experience with implementing enhanced recovery after surgery protocol during robot-assisted radical prostatectomy

Background: Enhanced recovery after surgery (ERAS) is a multidisciplinary perioperative care protocol that aims to reduce postoperative complications and the length of hospital stay. ERAS has been mainly implemented in gastrointestinal surgeries, and its adaptation in urological surgery remains uncommon. This study aimed to introduce ERAS in the perioperative management of robot-assisted radical prostatectomy (RARP) at the NTT Medical Center Tokyo. Methods: One hundred and five patients with prostate cancer who underwent RARP with the perioperative ERAS program between June 2021 and August 2022 at our institution were included in this observational study. ERAS was performed by a multidisciplinary team of urologists, anesthesiologists, physical therapists, registered dietitians, nurses, pharmacists, diabetologists, and critical pathway committee members. Among the 22 ERAS items, preoperative items (counseling, carbohydrate-loading), perioperative items (minimally invasive surgery under general anesthesia, transversus abdominis plane blocking, limited intravenous fluid infusion, omission of the surgical site drainage tube, removal of the nasogastric tube immediately after surgery), and postoperative items (pain control, early food intake, early mobilization) were introduced. Patients were administered 250 mL of carbohydrate fluid (Arginaid Water®: 100 kcal, 22.5 g carbohydrate with 2.5 g arginine per 125 mL) at 2 and 12 h preoperatively. Patients walked 20 meters 3 h after surgery and started an oral diet 4 h after surgery, respectively. The success rate of early mobilization was assessed to verify the safety and feasibility of the ERAS protocol for RARP. Results: Three patients were excluded from the study because of intraoperative complications. Among the 102 patients enrolled in the program, 99 (97%) were successfully mobilized from their beds and walked 20 m 3 h after surgery. Two patients with orthostatic hypotension and nausea, and one with tachycardia secondary to paroxysmal atrial fibrillation failed to mobilize. The hospital stay of 17 patients was extended owing to postoperative complications. Conclusions: The implementation of ERAS during RARP is safe and feasible, with a 97% success rate for early mobilization.