Design and development of the Pediatric Urology Recovery After Surgery Endeavor (PURSUE) multicentre pilot and exploratory study

Abstract

IntroductionLower urinary tract reconstruction in paediatric urology represents a physiologically stressful event that is associated with high complication rates, including readmissions and emergency room visits. Enhanced recovery after surgery (ERAS) protocol is a set of multidisciplinary, perioperative strategies designed to expedite surgical recovery without adversely impacting readmission or reoperation rates. Early paediatric urology data demonstrated ERAS reduced complications in this population.Methods and analysisIn 2016, a working group of paediatric urologists and anaesthesiologists convened to develop an ERAS protocol suitable for patients undergoing lower urinary tract reconstruction and define study process measures, patient-reported outcomes and clinically relevant outcomes in paediatric and adolescent/young adult patients. A multicentre, prospective, propensity-matched, case–control study design was chosen. Each centre will enrol five pilot patients to verify implementation. Subsequent enrolled patients will be propensity matched to historical controls. Eligible patients must be aged 4–25 years and undergoing planned operations (bladder augmentation, continent ileovesicostomy or appendicovesicostomy, or urinary diversion). 64 ERAS patients and 128 controls will be needed to detect a decrease in mean length of stay by 2 days. Pilot phase outcomes include attainment of ≥70% mean protocol adherence per patient and reasons for protocol deviations. Exploratory phase primary outcome is ERAS protocol adherence, with secondary outcomes including length of stay, readmissions, reoperations, emergency room visits, 90-day complications, pain scores, opioid usage and differences in Quality of Recovery 9 scores.Ethics and disseminationThis study has been registered with authors’ respective institution review boards and will be published in peer-reviewed journals. It will provide robust insight into the feasibility of ERAS in paediatric urology, determine patient outcomes and allow for iteration of ERAS implementations as new best practices and evidence for paediatric surgical care arise. We anticipate this study will take 4 years to fully accrue with completed follow-up.Trial registration numberNCT03245242.

Caudal block vs. transversus abdominis plane block for pediatric surgery: a systematic review and meta-analysis

“…Trends toward improved pain scores, reduced number of rescue doses, and PONV are suggestive of key areas for study. This information could be impactful for the design, implementation, and success of enhanced recovery after surgery (ERAS) pathways ( 15 , 16 , 40 ). The impact of prolonged duration of anesthesia on the progression to persistent pain is another key question for exploration.…”

“…While both techniques can be safely and successfully applied, there is limited data specifically related to the impact on the quality of postoperative analgesia, recovery, and efficiency of care when TAP block or caudal block are part of multimodal analgesia for lower abdominal surgeries in children. Such information is vitally important in an era increasingly focused on cost-effective patient-centered care that can resonate beyond the operating suite, such as enhanced recovery efforts ( 15 , 16 ). This meta-analysis can help address this gap in the literature.…”

Development of an enhanced recovery after surgery program for pediatric solid tumors

“…Adult and existing pediatric ERAS protocols were reviewed. The Pediatric Urology Recovery After Surgery Endeavor (PURSUE) trial formed the basis of the protocol, given its success ( 13 ) and similarities in surgical complexity to the pediatric oncology patient population ( 14 ). The study team determined protocol inclusion criteria based on literature review, observed issues in pediatric patients undergoing solid tumor resections, and group consensus.…”

The role of enhanced recovery after surgery (ERAS) in promoting quality improvement and patient safety in pediatric urology

“…Meanwhile, evidence in pediatrics suggests that a clear liquid carbohydrate drink may promote a more stable perioperative metabolic state, particularly for longer operations (29). Based on existing data, a group of pediatric urologists and anesthesiologists have incorporated a preoperative clear liquid complex carbohydrate load into their revised ERAS protocols for lower urinary tract reconstructions (30).…”

“…This particular example illustrates the consideration in outcomes among different patient populations when evaluating whether intended effects of ERAS elements are equally distributed. Overall, foregoing this step has been a welcome addition to ERAS protocols for many institutions due to improved perioperative experiences for patients and reductions in costs associated with decreased LOS (9,30,31).…”