Enhanced recovery after surgery (ERAS) protocols: Time to change practice?

Radical cystectomy with pelvic lymph node dissection remainsthe standard treatment for patients with muscle invasive bladdercancer. Despite improvements in surgical technique, anesthesiaand perioperative care, radical cystectomy is still associatedwith greater morbidity and prolonged in-patient stay after surgerythan other urological procedures. Enhanced recovery after surgery(ERAS) protocols are multimodal perioperative care pathwaysdesigned to achieve early recovery after surgical procedures bymaintaining preoperative organ function and reducing the profoundstress response following surgery. The key elements of ERASprotocols include preoperative counselling, optimization of nutrition,standardized analgesic and anesthetic regimens and earlymobilization. Despite the significant body of evidence indicatingthat ERAS protocols lead to improved outcomes, they challengetraditional surgical doctrine, and as a result their implementationhas been slow.The present article discusses particular aspects of ERAS protocolswhich represent fundamental shifts in surgical practice, includingperioperative nutrition, management of postoperative ileus andthe use of mechanical bowel preparation.