ERAS 2025: The Importance of Surgical Technique in Optimizing Outcomes After Radical Cystectomy

Both Drs. Ghodoussipour and Preston presented their review of radical cystectomy and the impact of ERAS on perioperative outcomes. Radical cystectomy remains a cornerstone in the curative treatment of muscle-invasive and select high-risk bladder cancers. Despite advances in bladder-sparing strategies, there remains a significant cohort of patients for whom cystectomy is essential. While the operation itself is not new, perioperative care and surgical technique continue to evolve, with ERAS protocols reshaping outcomes by challenging long-standing dogma. Traditional practices such as prolonged nasogastric decompression, delayed feeding, and extended hospitalization have been replaced by early mobilization, early nutrition, and multimodal care pathways. These improvements, supported by randomized trials, highlight that recovery is influenced less by surgical approach and more by perioperative care.

The debate between open and robotic cystectomy persists. Although robotic surgery has demonstrated feasibility, randomized data suggest that length of stay and complication rates are similar when ERAS principles are applied. Institutions vary in adoption; many still perform the majority of cystectomies open, with robotics reserved for select cases. Ultimately, institutional expertise and adherence to oncologic principles outweigh the choice of approach.

One such principle is the extent of pelvic lymph node dissection (PLND). Historically, retrospective studies suggested a therapeutic benefit from higher lymph node yields, but randomized evidence has challenged this. European and SWOG phase III trials comparing limited, standard, and extended PLND failed to show significant survival advantages with extended dissection. Instead, extended PLND was associated with higher complication rates, including lymphoceles requiring intervention. Importantly, these trials were conducted before widespread ERAS adoption, leaving questions as to whether modern perioperative care could mitigate morbidity.

In practice, most high-volume centers now perform standard template PLND, balancing diagnostic value with safety. The focus moving forward is on integrating evidence-based perioperative care with technical precision to ensure patients undergoing cystectomy receive both oncologic efficacy and optimized recovery. ERAS is a critical element to improved outcomes for this complex surgery.

Presented by: Saum Ghodoussipour, MD, MPH, Rutgers University, New Brunswick, New Jersey; Mark Preston, Brigham and Women’s Hospital, Boston, MA

Written by: Stephen B. Williams, MD, MBA, MS, FACS, FACHE @SWilliams_MD on Twitter during the 11th Enhanced Recovery After Surgery (ERAS®) World Congress, September 17-19, 2025, Turin, Italy

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