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Enhanced Recovery After Surgery (ERAS)

Enhanced Recovery After Surgery is a coordinated perioperative pathway that supports recovery through preparation, appropriate anesthesia and analgesia, nutrition, mobilization and complication prevention. General ERAS evidence supports shorter stays and fewer complications. In GU reconstruction, the pathway must also protect the urinary or bowel repair and preserve renal function.[1][2]

See also: Analgesia, Nerve Blocks, Antithrombotic Therapy, Constipation, Frailty.

Building a Procedure-Specific Pathway​

A pathway should state what is expected, who is responsible and when the plan needs reassessment. Standardize appropriate care while documenting contraindications and justified departures. A missed process step, a patient-specific exception and a new complication are different audit findings.

PhaseCore workAdaptation for reconstruction
Before surgeryExplain recovery, assess medical/nutritional/function risks, reconcile medication, agree fasting and prophylaxis plansDiscuss catheter, stent, drain or stoma care; assess ability to manage them and available support
During surgeryMultimodal analgesia, PONV prevention, normothermia, infection prevention, ventilation and hemodynamic managementProtect kidney and tissue perfusion; select blocks and positioning for the actual operation
After surgeryOral intake as tolerated, supported mobilization, opioid minimization, fluid review and complication surveillanceRetain necessary urinary drainage; distinguish ileus from obstruction or leak
After dischargeClear instructions, supplies, contact route and follow-upSpecify who removes each device, when review/imaging is needed and how to respond to blockage or deterioration

Preoperative Preparation​

  • Education and support: explain realistic recovery milestones, pain control and the expected devices. Arrange stoma teaching and marking when relevant.
  • Risk assessment: identify frailty, nutritional problems, anemia and unstable disease. Prehabilitation can be offered where appropriate, but its benefit and feasible duration vary; see Frailty.
  • Fasting and carbohydrate drinks: avoid unnecessarily prolonged fasting using the anesthesia team's protocol. Carbohydrate loading is a selected intervention, not an instruction for every patient with diabetes, impaired gastric emptying or aspiration risk. The 2022 AUGS-IUGA consensus rates as high-level evidence a fast of 6 hours for solids and clear fluids up to 2 hours before anesthesia.[14] For a healthy child having an elective reconstructive procedure, the ASA minimum fasting periods are 2 hours for clear liquids, 4 hours for breast milk, and 6 hours for infant formula, other nonhuman milk or a light meal. Meals containing fried or fatty foods or meat may require 8 or more hours; use the anesthesia team's pediatric protocol.[20]
  • Medication: agree diabetes, GLP-1, SGLT2, antithrombotic, steroid and chronic analgesic plans before admission. Use the Diabetes workflow and other relevant companion workflows rather than applying a generic ERAS medication-hold list.
  • Bowel preparation: EAU makes a strong recommendation against preoperative bowel preparation for radical cystectomy. Concomitant colorectal resection has a different pathway; coordinate its preparation and antibiotics with the colorectal team.[2][3][12]

Anesthesia and Analgesia​

Agree an opioid-sparing plan appropriate to the incision, renal function, bleeding risk and prior opioid exposure. Acetaminophen, suitable anti-inflammatory therapy, local infiltration and selected regional techniques can reduce opioid requirements. Epidural or spinal analgesia is not mandatory for every ERAS operation, and local-anesthetic combinations require dose and compatibility checks. Use Analgesia and Nerve Blocks for the actual choices and monitoring.[3][12]

Provide PONV prevention before symptoms occur, maintain temperature, use appropriate antimicrobial prophylaxis and redosing, and monitor ventilation and neuromuscular recovery. Manage glucose using the patient's perioperative diabetes pathway; avoid both hypoglycemia and uncontrolled hyperglycemia.

Urogynecologic and Benign Pelvic Surgery​

For prolapse, incontinence and other benign vaginal or pelvic operations, the most directly relevant statements are the AUGS-IUGA joint clinical consensus statement (2022) and ACOG Committee Opinion 750 (2018). The AUGS-IUGA group rates the following as high-level evidence: limited fasting, euvolemia, normothermia, antibiotic and antithrombotic prophylaxis, strong antiemetic prophylaxis with dexamethasone, multimodal analgesia with restrictive opioid use, chewing gum to reduce ileus, catheter removal as soon as feasible, and avoiding routine drains or vaginal packing.[14] ACOG describes ERAS as a comprehensive program whose success depends on implementing multiple components together, and reports no increase in readmission, mortality or reoperation with ERAS in gynecologic surgery.[15] "As soon as feasible" still yields to the operation: a catheter after a fistula repair or urethral reconstruction follows the repair-specific plan below.

The 2025 AUGS white paper on improving surgical care and recovery adds urogynecology-specific catheter guidance for routine reconstructive pelvic surgery without lower urinary tract injury: remove urinary catheters within 24 hours for most patients (same-day removal is reasonable, with a possible increase in minor complications such as incomplete emptying and urinary tract infection); after an isolated midurethral sling, subjective assessment of urinary force of stream may be a safe and reliable option; and, for women discharged with an indwelling catheter or self-catheterization for postoperative retention, antibiotic prophylaxis is not recommended; those discharged with an indwelling catheter may remove it at home with subsequent assessment of voiding function as an alternative to an in-clinic voiding trial.[17] In a single-center randomized noninferiority trial of 128 women after prolapse or stress-incontinence surgery who failed a day-0 voiding trial, day-1 home removal met a prespecified 15% margin versus day 3–4 for continued retention (14.1% versus 10.9%; difference 3.2 percentage points, 95% CI −8.3 to 14.6).[23] The concomitant anti-incontinence-procedure subgroup was inconclusive, and patients needing prolonged drainage were excluded.[23]

A single-center before-and-after implementation study of a urogynecology-specific pathway (apical-suspension procedures: 58 transvaginal, 112 laparoscopic/robotic and 61 obliterative) illustrates the tradeoffs of an ERAS pathway in this population: mean duration of stay fell from 25.9 to 12.1 hours and same-day discharge rose from 25.9% to 91.7% (both P < .001), but 30-day readmission was higher after the pathway (8 of 121 versus 2 of 137 patients), and 30-day complications overall did not differ.[19] In this nonrandomized cohort, same-day discharge and readmission increased, as did discharge with a urethral catheter (57.9% versus 25.4%, P = .005).[19] In a seven-center Chinese randomized trial of women aged 60–80 undergoing transvaginal mesh prolapse repair (262 randomized; 257 analyzed), median postoperative stay was 3.92 days with ERAS versus 4.99 days with conventional care (HR for discharge 1.42, 95% CI 1.11–1.82); 30-day complications were 24/129 versus 29/128, with no readmissions in either arm.[24]

For radical cystectomy, the 2013 ERAS Society recommendations found cystectomy-specific studies for only seven of 22 items; the authors assessed whether evidence from colorectal and other pelvic surgery applied to the rest and used consensus where direct evidence was lacking.[16] A 2025 cystectomy-specific systematic review and surgeon e-Delphi consensus recommends avoiding bowel preparation, giving pharmacologic thromboprophylaxis and removing a routine nasogastric tube at surgery's end. Despite low-to-moderate evidence, the panel favored pelvic drain placement and ureteral stenting after radical cystectomy; it reached no consensus on epidural analgesia or selected urinary-catheter decisions.[22] The 2026 EAU guideline supplies graded cystectomy perioperative recommendations.[2]

Fluid and Hemodynamic Management​

Aim for adequate circulating volume and organ perfusion while avoiding overload. Do not impose a universal intraoperative net-fluid ceiling of 30 mL/kg, or discontinue IV support solely because 24 hours have elapsed. Evaluate blood loss, vasodilation, fluid responsiveness, cardiac or renal function and ongoing losses; reduce IV fluids as oral intake and clinical stability permit.[4][12]

The RELIEF trial randomized 3,000 higher-risk major-abdominal-surgery patients; 2,983 entered its modified intention-to-treat analysis. A restrictive regimen did not improve one-year disability-free survival and increased acute kidney injury (8.6% versus 5.0%). The study included urologic or renal operations but was not a reconstructive-specific trial.[4]

A 2026 post hoc RELIEF follow-up found no significant difference in new or progressive stage ≥3 CKD between restrictive and liberal groups (56.0% versus 53.4%; adjusted OR 1.13, 95% CI 0.91–1.41). Follow-up was available for 1,670 of the original 2,983 participants, with 1,520 in the primary kidney analysis.[13]

In OPTIMISE II, 2,498 eligible older gastrointestinal-surgery patients were studied after four age-ineligible enrolments were excluded. Cardiac-output-guided fluids plus fixed low-dose inotrope infusion, chiefly dobutamine, did not reduce 30-day infection (23.2% versus 22.7%) and increased acute cardiac events within 24 hours (3.0% versus 1.7%), mainly arrhythmias.[5]

Postoperative Recovery​

Nutrition and Mobilization​

Offer early oral intake and supported mobilization when clinically appropriate. Colorectal and gynecologic guidance support a regular diet within 24 hours in uncomplicated recovery, including suitable bowel-resection patients. Adjust for vomiting, obstruction, aspiration risk, hemodynamic instability or another complication. Review nutrition support when intake remains inadequate; use Nutrition.[3][12]

Mobilization requires adequate analgesia, hemodynamic tolerance and practical assistance. Set achievable goals with nursing and therapy staff; investigate an unexpected decline rather than recording it only as poor compliance. Older adults may need delirium prevention, sensory aids and additional discharge support.

Catheters, Drains and Nasogastric Tubes​

Avoid devices without an indication and remove them when their purpose has ended. A catheter protecting a urethral anastomosis, bladder repair, fistula repair or new reservoir is not an unnecessary routine catheter. Specify drainage and imaging plans by the reconstruction. Similarly, an indicated drain or therapeutic nasogastric tube should not be removed merely to satisfy a generic early-removal target.[2][3][12]

The 2026 gynecologic guideline distinguishes routine early bladder-catheter removal from injury and complex reconstruction. Use the dedicated operative or trauma guidance for the latter, particularly after radiation; there is no single catheter-removal day for all GU repairs.[3]

Bowel Recovery and Alvimopan​

Prevent avoidable opioid exposure, dehydration and electrolyte disturbances. New distension or vomiting requires assessment for ileus, obstruction, leak or infection rather than automatic escalation of laxatives. See Constipation.

Alvimopan's US indication is gastrointestinal recovery after partial bowel resection with primary anastomosis, not “open radical cystectomy” as a stand-alone labeled indication. Treatment begins 30 minutes to 5 hours before surgery and is limited to inpatient short-term use (maximum 7 days and 15 doses) under its REMS, because of a myocardial infarction signal with long-term use. Therapeutic opioid use for more than seven consecutive days immediately beforehand is a contraindication.[7]

The cystectomy trial randomized 280 patients, with 277 in the primary modified intention-to-treat analysis; it improved bowel recovery and hospital stay in a setting largely involving open surgery and postoperative IV opioids. Its incremental benefit in a modern low-opioid minimally invasive pathway may differ. Doses and label limits remain in the pharmacology companion.[8]

VTE Prevention​

Combine procedure-specific thrombosis risk with patient factors, bleeding risk and neuraxial constraints. EAU makes a strong recommendation to offer pharmacologic prophylaxis after radical cystectomy, starting the first postoperative day and continuing for at least four weeks.[2] European urology guidance distinguishes ambulatory surgery, prostate surgery or lymph-node dissection and cystectomy. Use Antithrombotic Therapy for selection, timing and duration.[2][6]

Discharge Readiness​

Discharge depends on a stable clinical course, an achievable oral treatment plan, suitable intake and mobility, safe device care, help where needed and a clear route back to care.

What Outcomes Are Supported?​

EvidenceMain findingInterpretation
Sauro 2024 meta-analysis: 74 RCTsHospital stay shorter by 1.88 days in 44 trials; overall complications RR 0.71 in 14 trials; 30-day complications RR 0.73 in nine trialsSubstantial heterogeneity; only two included trials were urologic[1]
Same meta-analysis: 30-day readmission and mortalityReadmission RR 1.04 (95% CI 0.81–1.35); mortality RR 0.95 (0.48–1.88), each from 19 trialsNo demonstrated reduction[1]
Cochrane 2022 gynecologic cancer review: seven RCTs, 747 participantsHospital stay MD −1.71 days (six trials, 638 participants); 30-day readmission RR 0.45 (95% CI 0.22–0.90; three trials, 385 participants); overall complications RR 0.71 (0.48–1.05; five trials, 537 participants)Low-certainty estimates; mortality estimate very uncertain (one trial, 99 participants)[11]
POWER colorectal cohort: 2,084 patientsHigher adherence associated with fewer complicationsObservational association; postoperative illness can itself prevent adherence

Pooled effects depend on the operation, baseline care, bundle and study quality. Avoid giving a universal promise of a 30–50% reduction in stay, a fixed dollar saving or preserved long-term oncologic outcomes from an ERAS bundle.[1][9][11]

For augmentation, complex urethroplasty, benign diversion and fistula repair, borrow suitable recovery principles while auditing the relevant endpoints: renal complications, bowel dysfunction, leak, infection, readmission, device management, functional recovery and patient experience.

Implementation and Audit​

  1. Agree a written operation-specific pathway with surgery, anesthesia, nursing, nutrition and therapy teams.
  2. Name a coordinator and assign responsibility for each phase, including post-discharge problems.
  3. Integrate recovery discussions into safety checks. The 2023 Delphi ERAS surgical checklist provides prompts before induction, incision and leaving the operating room.[10] This is a distinct, later tool from the WHO Surgical Safety Checklist: in an earlier eight-hospital implementation study spanning a range of economic settings, in-hospital mortality observed through discharge or day 30 was 1.5% before and 0.8% after implementation (P = .003), while inpatient complications fell from 11.0% to 7.0% (P < .001) after its introduction.[18] For a lower-tract endourologic procedure with a side to confirm, mark the laterality where the operative team can see it during time-out — for example on a wristband — rather than at the urethral meatus, and repeat the time-out when the surgeon changes or the team moves to a distinct, separate procedure.[21]
  4. Record each applicable element, including reasons it was not used.[3] The 2026 gynecologic guideline proposes ≥80% overall compliance.[3]
  5. Audit both process and outcomes. Review pain, nausea, oral intake, mobilization, kidney injury, bowel recovery, infection, thrombosis, readmission and patient-reported recovery. Separate improvement over time from changes in case mix or discharge resources.

References​

1. Sauro KM, Smith C, Ibadin S, et al. Enhanced Recovery After Surgery Guidelines and Hospital Length of Stay, Readmission, Complications, and Mortality: A Meta-Analysis of Randomized Clinical Trials. JAMA Netw Open. 2024;7:e2417310. doi:10.1001/jamanetworkopen.2024.17310. Figure correction.

2. European Association of Urology. Muscle-invasive and Metastatic Bladder Cancer guideline: perioperative care and radical cystectomy recommendations. 2026. Official guideline.

3. Nelson G, Altman AD, Metcalfe A, et al. Enhanced Recovery After Surgery (ERAS®) Society Guidelines for Gynecologic Oncology: 2026 Update. Gynecol Oncol. 2026;210:153–173. doi:10.1016/j.ygyno.2026.05.022.

4. Myles PS, Bellomo R, Corcoran T, et al. Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery. N Engl J Med. 2018;378:2263–2274. doi:10.1056/NEJMoa1801601.

5. OPTIMISE II Trial Group. Cardiac Output-guided Haemodynamic Therapy for Patients Undergoing Major Gastrointestinal Surgery: OPTIMISE II Randomised Clinical Trial. BMJ. 2024;387:e080439. doi:10.1136/bmj-2024-080439.

6. Tikkinen KAO, et al. European Guidelines on Peri-operative Venous Thromboembolism Prophylaxis: First Update. Chapter 12: Urology. Eur J Anaesthesiol. 2024. Full text.

7. Alvimopan. US prescribing information, label effective February 2024. DailyMed.

8. Lee CT, Chang SS, Kamat AM, et al. Alvimopan Accelerates Gastrointestinal Recovery After Radical Cystectomy: A Multicenter Randomized Placebo-controlled Trial. Eur Urol. 2014;66:265–272. doi:10.1016/j.eururo.2014.02.036.

9. Ripollés-Melchor J, Ramírez-Rodríguez JM, Casans-Francés R, et al. Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Colorectal Surgery: The POWER Study. JAMA Surg. 2019;154:725–736. doi:10.1001/jamasurg.2019.0995.

10. Pilkington M, Nelson G, Cauley C, et al. Development of an Enhanced Recovery After Surgery Surgical Safety Checklist Through a Modified Delphi Process. JAMA Netw Open. 2023;6:e2248460. doi:10.1001/jamanetworkopen.2022.48460.

11. Chau JPC, Liu X, Lo SHS, et al. Perioperative Enhanced Recovery Programmes for Women With Gynaecological Cancers. Cochrane Database Syst Rev. 2022;3:CD008239. doi:10.1002/14651858.CD008239.pub5.

12. Irani JL, Hedrick TL, Miller TE, et al. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From ASCRS and SAGES. Dis Colon Rectum. 2023;66:15–40. doi:10.1097/DCR.0000000000002650.

13. McIlroy DR, Wallace SK, Forbes A, et al. Perioperative Intravenous Fluid and Chronic Kidney Disease: Long-Term Follow-Up of the Restrictive Versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) Randomised Trial. Br J Anaesth. 2026;137:479–489. doi:10.1016/j.bja.2026.05.010.

14. Developed by the Joint Writing Group of the International Urogynecological Association and the American Urogynecologic Society. AUGS-IUGA Joint clinical consensus statement on enhanced recovery after urogynecologic surgery. Int Urogynecol J. 2022;33(11):2921-2940. doi:10.1007/s00192-022-05223-4

15. ACOG Committee Opinion No. 750: Perioperative Pathways: Enhanced Recovery After Surgery. Obstet Gynecol. 2018;132(3):e120-e130. doi:10.1097/AOG.0000000000002818

16. Cerantola Y, Valerio M, Persson B, et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS) society recommendations. Clin Nutr. 2013;32(6):879-887. doi:10.1016/j.clnu.2013.09.014

17. Reagan K, Hardart A. White Paper: Guidance for Improving Surgical Care and Recovery in Urogynecologic Surgery. Urogynecology (Phila). 2025;31(11):1001-1004. doi:10.1097/SPV.0000000000001755

18. Haynes AB, Weiser TG, Berry WR, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. N Engl J Med. 2009;360(5):491-499. doi:10.1056/NEJMsa0810119

19. Carter-Brooks CM, Du AL, Ruppert KM, Romanova AL, Zyczynski HM. Implementation of a urogynecology-specific enhanced recovery after surgery (ERAS) pathway. Am J Obstet Gynecol. 2018;219(5):495.e1-495.e10. doi:10.1016/j.ajog.2018.06.009

20. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology. 2017;126(3):376-393. doi:10.1097/ALN.0000000000001452

21. Chen T. Fundamentals of Intraoperative Patient Safety. In: Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, eds. Campbell-Walsh-Wein Urology. 13th ed. Elsevier; 2025:167-174.

22. Albisinni S, Orecchia L, Mjaess G, et al. "Enhanced recovery after surgery for patients undergoing radical cystectomy: Surgeons' perspectives and recommendations ten years after its implementation." Eur J Surg Oncol. 2025;51(3):109543. doi:10.1016/j.ejso.2024.109543

23. Tholemeier L, Vanukuru T, Geng B, et al. "Early patient removal of urinary catheters after urogynecologic surgery, a randomized trial." Am J Obstet Gynecol. Published online July 6, 2026. doi:10.1016/j.ajog.2026.07.001

24. Yan Y, Zhang Y, Wang L, et al. "Effects of an enhanced recovery after surgery (ERAS) program in elder patients undergoing transvaginal reconstructive surgery for pelvic organ prolapse (POP): a multicenter randomized parallel open-label controlled trial." Arch Gynecol Obstet. 2025;312(6):2221–2231. doi:10.1007/s00404-025-08212-2