Feasibility of Enhanced Recovery After Surgery (ERAS) implementation in Pediatric Urology: Pilot-phase outcomes of a prospective, multi-center study.

INTRODUCTION/BACKGROUND: Enhanced Recovery After Surgery (ERAS) is a fundamental shift in perioperative care that has consistently demonstrated an improved outcome for a wide variety of surgeries in adults but has only limited evidence in the pediatric population. OBJECTIVE: We aimed to assess the success with and barriers to implementation of ERAS in a prospective, multi-center study on patients undergoing complex lower urinary tract reconstruction. STUDY DESIGN: Centers were directed to implement an ERAS protocol using a multidisciplinary team and quality improvement methodologies. Providers completed pre- and post-pilot surveys. An audit committee met after enrolling the first 5 patients at each center. Pilot-phase outcomes included enrollment of ≥2 patients in the first 6 months of enrollment, completion of 90 days of follow-up, identification of barriers to implementation, and protocol adherence. RESULTS: A total of 40 patients were enrolled across 8 centers. The median age at surgery was 10.3 years (IQR 6.4-12.5). Sixty five percent had a diagnosis of myelomeningocele, and 33 % had a ventriculoperitoneal shunt. A bladder augmentation was performed in 70 %, Mitrofanoff appendicovesicostomy in 52 %, Monti ileovesicostomy in 15 %, and antegrade continence enema channel in 38 %. The most commonly perceived barriers to implementation on the pre-pilot survey were "difficulty initiating and maintaining compliance with care pathway" in 51 % followed by a "lack of time, money, or clinical resources" in 36 %. The pre-pilot study experience, implementation, and pilot-phase outcomes are provided in the Table. All primary and secondary outcomes were achieved. DISCUSSION: The findings of the present study were similar to several small comparative studies with regard to the importance of a multidisciplinary team, strong leadership, and continuous audit for successful implementation of ERAS. Similar barriers were also encountered to other studies, which primarily related to a lack of administrative support, leadership, and buy-in from other services. The limitations of the present study included a relatively small heterogeneous cohort and absence of a comparative group, which will be addressed in the larger exploratory phase of the trial. The findings may also not be generaziable due to the need for sustainable processes that were unique to each center as well as an absence of adequate volume or resources at smaller centers. CONCLUSIONS: ERAS was successfully implemented for complex lower urinary tract reconstruction across 8 centers through a multidisciplinary team, structured approach based on the local context, and focus on a continuous audit.

A Systematic Scoping Review of Comparative Effectiveness Studies in Kidney Stone Disease.

OBJECTIVE: To review the status of comparative effectiveness studies for kidney stone disease with focus on study outcome, type, population, time trends, and patient-centered approaches. METHODS: A systematic scoping review was performed for articles published between January 1, 2005, and March 30, 2021, using keywords relevant to kidney stone disease. Studies published in English that compared two or more alternative methods for prevention, diagnosis, treatment, monitoring, or care delivery were included. Two reviewers independently reviewed abstracts and an arbitrator resolved discrepancies. Nine reviewers abstracted information from full-length studies. Descriptive statistics were summarized, and linear regression was performed to evaluate temporal trends of study characteristics. RESULTS: We reviewed 1773 abstracts and 707 full-length manuscripts focused on surgical intervention (440); medical expulsive therapy (MET) (152); analgesic control (80); and homeopathic, diagnostics, and/or prophylaxis (84). Randomized controlled trials were common across all outcome categories, including surgery (41.6%), MET (60.2%), analgesic control (81.3%), homeopathic (41.2%), diagnostic (47.6%), and prophylaxis (49.1%). Patient-reported outcomes were utilized in 71.7% and 95% of MET and analgesic control studies, respectively, but in the minority of all other study themes. Over time, meta-analyses and multicenter studies increased [P < .001]. CONCLUSION: Surgical and MET themes dominate published comparative literature in kidney stone disease. There is substantial variation in use of patient-reported outcomes across surgical themes. Multicentered studies and those generating higher level evidence have increased over time but opportunities exist to improve collaborative, high-quality, and patient-centered research in kidney stone disease.

Experience with glycerin for antegrade continence enema in patients with neurogenic bowel.

PURPOSE: Malone antegrade continence enemas are used in the management of neurogenic bowel to attain fecal continence. Several different irrigation solutions have been described but glycerin, an osmotic laxative that promotes peristalsis, has rarely been mentioned or studied. We assessed clinical outcomes in our patients with a Malone antegrade continence enema using glycerin based irrigation. MATERIALS AND METHODS: We retrospectively reviewed patients with neurogenic bowel who underwent a Malone antegrade continence enema procedure between 1997 and 2011. Glycerin diluted with tap water followed by a tap water flush is our preferred irrigation protocol. Bowel regimen outcomes examined included fecal continence, emptying time, leakage from stoma, enema volume, frequency and independence. RESULTS: Of the 23 patients with followup greater than 6 months 19 used glycerin based irrigation. Average age at surgery was 8.8 years. Patients using glycerin instilled a median of 30 ml (mean 29) glycerin and 50 ml (131) tap water. Fecal continence rate was 95% and stoma leakage rate was 16%, and only 16% of patients required daily irrigation. CONCLUSIONS: Glycerin is a viable and effective alternative irrigant for antegrade enemas of neurogenic bowel, with an excellent fecal continence rate. The volume of irrigant needed is typically less than 90 ml, which is much less than in published reports using tap water alone.