Nowadays, with the implementation of enhanced recovery after surgery (ERAS) protocols, preserving the physiological homeostasis and decreasing perioperative stress, the morbidity of postoperative and duration of urological cases hospital stay is reduced. The revolution of ERAS in high-income countries led to the improvement of surgical and anaesthesia complication rates and outcomes, as well as saving dollars due to fewer complications and decreased length of hospital stay. But ERAS is not only for high-income countries, and a modified approach to ERAS may improve all types of surgery outcomes in low- and lower-middle-income countries, too. Based on our knowledge, ERAS protocol is performed in pediatric AC, and in adults this method is done only in radical cystectomy surgery . In the current study, we aimed to investigate an adapted ERAS protocol in adult AC of consecutive cases referred to the tertiary teaching hospital between March 2016 and October 2020.

A total of 33 consecutive cases with a history of refractory idiopathic detrusor overactivity (IDO) or neurogenic bladder (NGB) referred to the urology department of our teaching hospital between March 2016 and October 2020 were enrolled in the current study. 
Patients fasted only 8 hours, and a high protein, low carbohydrate diet were started one day before surgery. We administered antibiotics (the combination of cephalosporin, aminoglycoside, plus metronidazole) just pre-procedure and continued one-day post-operation. We didn’t use narcotics as much as possible during anaesthesia, with continuous infusion of apotel post-operation. Early NGT removal was the other part of this protocol. An urology resident injected neostigmine postoperation to ileus prevention with a dose of o.5 mg/twice daily under cardiac monitoring and control of vital signs till the bowel function was returned. In addition, we injected 10 mg metoclopramide (Plasil, Lepetit) (i.v./ three times a day) for the prevention of postoperative nausea and vomiting. Early oral diet and mobilization were also other parts of this protocol. The regular diet was started one-day post-operation if the patients have bowel function (stool or repeated flatus). The duration of hospitalization in the new method was lower than the conventional technique, and the patients were discharged seven days post-operation. Discharge criteria were adequately control of postoperative pain with oral analgesics, mobilization (out of bed ≥6 hours daily), return of bowel function, and no complications in need of treatment in the hospital. All patients were re-visited after discharge by a urologist and interviewed by a trained nurse to evaluate any late-occurring complications. Postoperative morbidity and hospital stay duration were analyzed using SPSS version 21.

A total of 33 adults were operated. Twenty-two patients had IDO, and the remained cases were NGB, or had low bladder capacity or compliance. The mean (SD) age of patients in the IDO group was higher than that in NGB cases (P=0.020). Following the adapted ERAS protocol implementation, more than tw0-third of patients returned to a regular diet on the second-day post-operation in both groups. The mean (SD) hospital stay duration was 7.68 (1.50) days. Postoperative fasting time mean was 8.81 ± 3.67 hours, and bowel function was returned one-day post-operation in 82% of patients. Only 33.3% of adults need post-procedure apotel for two days, and in 11 cases it prescribed one day. All subjects except paraplegic patients had early mobilization one-day post-operation.

Our findings revealed adapted ERAS protocol could be safe, practical, and effective in adult augmentation cystoplasty in limited sources countries. It accompanied by few complications, reduced intestinal motility problems, and a short length of hospital stay.

ERAS protocol could be safe, practical, and effective in adult augmentation cystoplasty in limited sources countries.