Urology Division Upgrades Approach to Recovery After Surgery

Postoperative recovery is getting easier for pediatric patients undergoing bladder surgery. By studying a protocol already widely used with adults, researchers in Cincinnati Children’s Division of Urology are striving to improve the quality of care and long-term outcomes for these children.

The approach is a care pathway known as ERAS—Enhanced Recovery After Surgery. Evidence already exists to show this protocol shortens the hospital stay and accelerates an adult patient’s return to normal functioning. Now, says Andrew Strine, MD, pediatric urologist and lead site investigator, researchers are working to determine whether it can be safely and effectively implemented with children.

So far, the results are promising.

“These patients definitely have a better experience and better quality of life with this newer protocol compared to the older one,” he says.

Rather than requiring patients to fast prior to surgery or using narcotics to control their pain, ERAS flips the script on these traditional practices of caring for patients before and after surgery. Both long-standing practices, as well as several others, can negatively impact patients.

“Prolonged fasting before surgery is harmful to the patient. It shifts them to a catabolic state, it disturbs their electrolyte balance and it potentially causes insulin resistance,” Strine says. “Narcotic use also impairs recovery after surgery. It paralyzes the bowel—that can only lead to delayed return of bowel function and impaired postoperative healing.”

ERAS can eliminate those problems, he says. To show the difference, Cincinnati Children’s has sought to expand the body of evidence around using this care pathway with children. Partnering with eight other centers, Cincinnati Children’s is examining how changes to 20 elements of surgical care, including fasting elimination, pain control with catheters and blocks, earlier post-surgical mobilization and feeding, and judicious use of IV fluids, can improve pediatric outcomes. To date, approximately 160 children—44 from Cincinnati—have participated.

The study’s goal, he says, is to shorten the length of hospital stay, reduce complications, decrease readmissions, control pain medication use and limit the number of additional operations.

So far, results show implementing ERAS is effective. It has already begun to shorten the hospital stay. Analysis of its impact on visits to the emergency department, readmissions, reoperations, complications, pain control and quality of life is ongoing.

As of December 2021, every participating institution has successfully implemented a median of 16 of the 20 elements, he says, demonstrating it is possible to employ this updated protocol with children. These findings are encouraging, he says, but more research is needed to determine the best way to widely implement these changes.

The key to shifting this enhanced recovery protocol, he says, is multidisciplinary coordination. Surgeons, anesthesiologists, nurses and all other providers must actively collaborate in the peri-op care of the child.

“There are a lot of different parts to the perioperative space that need to be on board and involved in this process. There are so many different areas in the hospital, so many different providers who care for these patients on a daily basis,” he says. “It’s really important to engage all the relevant stakeholders preoperatively, intraoperatively and postoperatively.”

Ultimately, the hope is that using ERAS with more pediatric patients will make surgery easier and less stressful for children. In addition, he says, it could pave the way for more kids to be discharged from the hospital sooner, potentially leading to a better recovery at home.

“The main benefit is that these patients have earlier discharge after surgery without an increased risk of being readmitted,” Strine says. “There are good data on adults to suggest they have a low risk of complications, and we’re hopeful we’re going to see something similar in children.”