BACKGROUND AND OBJECTIVES: Enhanced Recovery After Surgery (ERAS) guidelines for Radical Cystectomy (RC) were published over ten years ago. Aim of this systematic review is to update ERAS recommendations for patients undergoing RC and to give an expert opinion on the relevance of each single ERAS item. METHODS: A systematic review was performed to identify the impact of each single ERAS item on RC outcomes. Embase and Medline (through Pubmed) were searched systematically. Relevant articles were selected and graded. For each ERAS item, a level of evidence was determined. An e-Delphi consensus was then performed amongst an international panel with renowned experience in RC to provide recommendations based on expert opinion. KEY FINDINGS AND LIMITATIONS: Preoperative medical optimization and avoiding bowel preparation are highly recommended. Robotic-assisted RC with intracorporeal urinary diversion is moderately recommended and can help in applying other ERAS items, such as early mobilization. Medical thromboprophylaxis should be administered and nasogastric tube should be removed at the end of surgery. Perioperative fluid restriction as well as opioid-sparing anesthesia protocols should be implemented. Generally, consensus was reached on most ERAS items, with the exception of epidural anesthesia (no consensus), resection site drainage (consensus against), and type of urinary drainage. Limitations include the lack of a multidisciplinary approach to the present consensus, giving however a highly specialized surgical opinion on ERAS. CONCLUSIONS: and clinical implications: The current study updates ERAS recommendations for patients undergoing RC and suggests application of ERAS by a panel of experts in the field.

Academic Urology Unit University of Sheffield Sheffield UK; Sheffield Teaching Hospitals NHS Foundation Trust Sheffield UK

Alta Uro AG Basel Switzerland; University of Basel Basel Switzerland

Department of Urology and Division of Experimental Oncology URI Urological Research Institute IRCCS San Raffaele Scientific Institute 20132 Milan Italy

Department of Urology AZ Maria Middelares Hospital Ghent Belgium Belgium

Department of Urology Claude Huriez Hospital CHU Lille Lille 59037 France

Department of Urology Comprehensive Cancer Center Medical University of Vienna Vienna Austria; Department of Urology 2nd Faculty of Medicine Charles University Prague Czech Republic; Department of Special Surgery Division of Urology The University of Jordan Amman Jordan; Department of Urology University of Texas Southwestern Medical Center Dallas TX USA; Departments of Urology Weill Cornell Medical College New York NY USA; Departement of Urology Karl Landsteiner Institute of Urology and Andrology Vienna Austria; Department of Urology Research Center for Evidence Medicine Tabriz University of Medical Sciences Tabriz Iran

Department of Urology Fundació Puigvert Autonoma University of Barcelona Barcelona Spain

Department of Urology Hopital La Croix du Sud Toulouse France

Department of Urology Hopital Universitaire de Bruxelles Universite' Libre de Bruxelles Bruxelles Belgium

Department of Urology Icahn School of Medicine at Mount Sinai New York NY USA

Department of Urology Kantonsspital Luzern Lucerne Switzerland

Department of Urology Netherlands Cancer Institute Amsterdam the Netherlands

Department of Urology Onze Lieve Vrouwziekenhuis Aalst Belgium

Department of Urology Pitié Salpêtrière Hospital AP HP GRC 5 Predictive Onco Urology Sorbonne University Paris France

Department of Urology Policlinico Umberto 1 Sapienza University Rome Italy

Department of Urology Rijnstate Hospital 6815 AD Arnhem the Netherlands

Department of Urology UT MD Anderson Cancer Center Houston TX USA

Division of Urology Department of Surgical Sciences University of Turin and Città Della Salute e Della Scienza Turin Italy

Faculty of Medicine Hôtel Dieu de France Saint Joseph University Beirut Lebanon

Oncologic Minimally Invasive Urology and Andrology Unit Department of Experimental and Clinical Medicine Careggi Hospital University of Florence Florence Italy

Urology Service Department of Surgery Memorial Sloan Kettering Cancer Center New York NY USA

Urology Unit Department of Surgical Sciences Tor Vergata University Hospital University of Rome Tor Vergata Rome Italy

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