Evidence-based practice and future development of enhanced recovery after surgery (ERAS) in urology: a multidimensional assessment based on the GRADE system.

Abstract

Enhanced recovery after surgery (ERAS) pathways in urology harness multidisciplinary, evidence-based interventions to attenuate surgical stress, expedite recovery, and reduce complications. In this PRISMA-guided review of 80 core publications (23 RCTs, 6 meta-analyses, 9 systematic reviews, 15 guidelines/consensus statements, 18 observational studies, 10 narrative reviews) from 1997 to 2025, we applied ROB 2.0 and GRADE methodology to classify 20 perioperative elements. Sixteen elements-such as preoperative education, carbohydrate loading, goal-directed fluid therapy, multimodal analgesia, early mobilisation, and early oral feeding-achieved high-quality evidence with strong recommendations (A1); three elements (preoperative medical optimisation, fasting regimen, sedative use) received moderate-quality, weak recommendations (B2); and one element (audit) was supported by low-quality, weak recommendation (C2). Implementation of A1 elements in radical prostatectomy, cystectomy, and nephrectomy shortened hospital stay by 1-3 days, cut complication rates by up to 30%, and reduced opioid consumption by approximately 30%. Key challenges include standardising fluid management for minimally invasive and outpatient procedures, improving protocol adherence, and integrating patient-reported outcomes. Future work should prioritise multicenter RCTs for moderate-evidence elements, cost-effectiveness analyses, and development of urology-specific ERAS guidelines incorporating digital monitoring and personalised risk stratification.