Feasibility of Implementing Enhanced Recovery After Surgery in Pediatric Urology

Research study background 

Enhanced recovery after surgery (ERAS) protocols have been widely adopted in adult healthcare, with published guidelines demonstrating strong evidence of improved outcomes. However, this promising multi-modal approach to perioperative care hasn’t yet gained as much traction in pediatrics.

In 2018, Kyle Rove, MD, a pediatric urologist at Children’s Hospital Colorado, and his research team reported the first ERAS protocol for children undergoing complex lower urinary tract reconstruction in a small prospective study that reported decreases in length of stay and complications. That work expanded to additional research, including the multicenter Pediatric Urology Recovery after Surgery Endeavor (PURSUE) study. PURSUE includes this pilot led by Dr. Rove that explores the feasibility of and adherence to implementing the protocol at eight centers across the U.S.

Study authors hypothesized ERAS would be implemented at ≥70% adherence in ≥75% of centers. High-level measures were based on Children’s Colorado’s pilot protocol. Outcomes included enrollment of two patients in the first six months, completion of a 90-day follow-up, identification of barriers to implementation and protocol adherence.

Between 2014 and 2016, the pilot enrolled a total of 40 patients planning to undergo surgery for bladder augmentation or creation of a continent catheterizable channel. Centers reported on multidisciplinary collaboration, their approach based on local context as well as internal audits and survey.

The pilot was successful, with all but one center reporting ≥70% protocol adherence per patient and all secondary outcomes met, though it wasn't without some difficulty. It took centers an average of seven meetings over two months to implement the protocol, and all struggled, to some degree, with adhering to the use of a minimally invasive approach, maintenance of intraoperative normothermia and early discontinuation of intravenous fluids.

The most reported barriers to implementation were “difficulty initiating and maintaining compliance with care pathway,” and “lack of time, money, or clinical resources.”

Clinical implications

Although this pilot had a multicenter design, the findings may not be generalizable. What may be sustainable for one center may not be for another, such as smaller centers with low volumes of complex lower urinary tract reconstruction. Study authors emphasized the key components for successful ERAS implementation include a multidisciplinary team, stakeholder buy-in, regular communication and adjusting to local context, given internal structures and processes differ by center.

Results of the full PURSUE study, which compares patient outcomes for the ERAS protocol to the standard of care, are expected to be published in late 2024.