A perioperative inter-disciplinary and inter-professional approach for major open urological surgeries is crucial to optimize patient-specific outcomes

Abstract

We wish to commend the authors on their statements concerning enhanced recovery after surgery (ERAS) and holistic approach in urological surgery [1]. However, their comments need some analysis and clarification. The authors highlight that being able to follow the surgeon’s steps is of great importance to the anesthesiologist. We totally agree with this appraisal. As such, urologic surgeries are an optimal example. In the last few decades, with technological advances, such as robot-assisted interventions and refinement of transurethral procedures, all persons involved including the operating room nurses and anesthetists can follow the procedure with ease as multiple screens are available displaying all surgical steps. This enables ongoing communication between surgeons and anesthetists to anticipate the surgical and anesthesiological course of action required with particular focus on proactive blood loss and fluid management. Minimally invasive procedures, which are performed with increasing frequency in urology, considerably facilitate intraoperative patient management and are maybe lacking to the same extent in other major surgical specialties. Furthermore, we wish to somewhat disagree concerning the implementation of ERAS. Enhanced recovery after surgery (ERAS) is a complex process, which aims to reduce complications and ease recovery after major surgery. Implementation of ERAS requires time and personnel and in an era of increasing financial awareness, benefit and cost need to be taken into account. There is no doubt, that patients significantly benefit from ERAS principles following complex surgery, such as cystectomy and urinary diversion. On the other hand, robot-assisted interventions and transurethral procedures are surgical procedures with a low complication rate and hence the benefits of ERAS principles in this setting maybe confounded. In comparison to an open surgical approach, not only robotic radical prostatectomies but robotic kidney procedures can be performed as day surgery [2–5]. Is an ERAS approach really a one-size-fits-all approach or would a decision based on an inter-disciplinary and inter-professional evaluation be more appropriate? We completely agree with the authors about the need for a highly specialized inter-disciplinary and inter-professional team to manage patients before, during and after their hospital stay, as stated in Engel et al. conclusion [6]. The urological department at the University Hospital of Bern, a tertiary referral center with a high caseload of complex surgery, has this privilege and implemented this concept a long time ago. All patients are managed periand post-operatively by an experienced dedicated senior surgeon, a specialized nurse for long-term patient management and an anesthetist completely dedicated to urology. In addition, the clinic has its own operating rooms with dedicated operating room nurses, an intermediate care unit run inter-disciplinarily by the same team present in the operating room and by nurses specialized in the perioperative management of complex urological cases. In particular, the responsible team (surgeons, anesthesiologist and nurses) is also familiar with the complex management of complications following major oncological and functional urological surgery. This comment refers to the article available online at https:// doi. org/ 10. 1007/ s0034502103677-7.