Clinical efficacy and safety of enhanced recovery after surgery for patients treated with radical cystectomy and ileal urinary diversion: a systematic review and meta-analysis of randomized controlled trials

The aim of this study was to evaluate the effect of enhanced recovery after surgery (ERAS) on perioperative outcomes in patients undergoing radical cystectomy (RC) and ileal urinary diversion (IUD). We performed a literature search of PubMed, Web of Science, EMBASE, the Cochrane Library and three main Chinese databases (WANFANG, CNKI and VIP) in December 2019 without language restrictions. Two reviewers independently selected studies, evaluated methodological quality and extracted data using Cochrane Collaboration's tools. Efficacy was assessed by the time to first flatus, first bowel movement, and hospitalization time. Safety was assessed by 30-day readmission and complications after surgery. Our searches identified 6 studies, including 628 patients. A total of 323 (51%) patients took ERAS. We observed that ERAS reduced the time to first flatus [standard mean difference (SMD): -1.65, 95% CI: -2.63 to -0.68, P=0.0009], first bowel movement (SMD: -1.14, 95% CI: -1.78 to -0.50, P=0.0005), and hospitalization time (MD: -4.09, 95% CI: -6.34 to -1.85, P=0.0004). We did not detect significant difference in terms of 30-day readmission [relative risk (RR): 1.33, 95% CI: 0.61-2.88, P=0.48] and postoperative complications (RR: 0.91, 95% CI: 0.65-1.26, P=0.56) between ERAS and conventional recovery after surgery (CRAS). Our findings indicated that ERAS protocols throughout the perioperative period of RC with IUD might reduce hospitalization expenses and contribute to higher turnover ward, more efficient utilization of medical resources and lower risk of nosocomial infection as a result of shorter length of stay. Besides, early rehabilitation of gastrointestinal function might not only facilitate wound healing and early mobilization, thereby reducing the incidence of basic complications such as cardiopulmonary disease, but also improve patients' psychological trauma and stress response, increase self-confidence and motivation in treatments, and then lead to unexpected benefits. Further large volume, multicenter randomized controlled studies are warranted before making the final clinical guidelines.