Enhanced Recovery After Surgery in Pediatric Urology Patients Undergoing Complex Lower Urinary Tract Reconstruction

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Importance: Enhanced recovery after surgery (ERAS) is a multidisciplinary framework to standardize perioperative care. Pediatric Urology Recovery After Surgery Endeavor (PURSUE) is a multicenter study of ERAS in children undergoing complex lower urinary tract reconstruction. Use of ERAS in children is still relatively uncommon and outcomes are not well understood. Objective: To attempt to achieve 70% or more ERAS adherence while reducing length of stay and opioid use without an increase in complications or other balancing measures. Design, Setting, and Participants: This study prospectively enrolled patients who were propensity matched to recent historical controls prior to ERAS implementation and outcomes were compared. From 2017 through 2022, 8 pediatric hospitals implemented ERAS for pediatric patients undergoing catheterizable channel creation, bladder augmentation, and/or bladder neck procedures. Patients aged 4 to 24 years undergoing these operations were prospectively enrolled in the study. Patients with unmanaged neurogenic bowel were excluded. Patients who underwent these operations in the 5 years prior to protocol implementation at each center were used as a comparator group. These data were analyzed from July 2022 to April 2025. Intervention: ERAS protocol encompassing 20 evidence-based preoperative, intraoperative, and postoperative elements was designed and implemented as standard of care. Patients were followed up postoperatively for a minimum of 1 year. Main Outcomes and Measures: The primary outcome was compliance with the ERAS protocol. Secondary outcomes included length of stay, opioid usage, pain scores, 90-day complications, and 90-day balancing measures of return to hospital. Results: A total of 153 ERAS patients and 153 historical controls were matched with a median (IQR) age of 10.2 (7.6-13.7) and 10.4 (8.0-14.6) years, respectively (P = .47). Median protocol adherence increased from 8 to 16 measures between historical and ERAS cohorts (P < .001). Median length of stay decreased from 8.0 to 5.3 days (P < .001). Postoperative opioid use decreased 74% without an increase in maximum pain scores. Complication rates decreased from 72.5% to 60.1% (P = .01) with no differences in 90-day emergency department visits, readmissions, or reoperations. Conclusions and Relevance: In this study, ERAS was highly effective at standardizing perioperative care in pediatric urology patients undergoing complex lower urinary tract reconstruction. ERAS was associated with better outcomes of reduced length of stay, lower postoperative opioid use, and lower complication rates.

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