ERAS 2025: Ambulatory ERAS®

(UroToday.com) Dr. Packiam discussed ambulatory ERAS in the context of non-muscle invasive bladder cancer. ERAS has transformed perioperative care for major oncologic operations, but its role in non-muscle-invasive bladder cancer (NMIBC) remains largely undefined. Yet NMIBC patients often undergo repeated interventions—transurethral resections (TURBT), intravesical therapies, stent placements, office cystoscopies—that impose a chronic treatment burden on bladder function and quality of life. As therapies become more effective and bladder-sparing increasingly feasible, recovery and tolerability must receive greater focus.

Several areas highlight the need for structured recovery pathways. Preoperatively, tools such as blue-light cystoscopy improve detection in heavily pretreated patients, but also increase procedure intensity. Intraoperatively, key questions remain unanswered: should smaller instruments or reduced resection be favored to minimize morbidity? Is it necessary to fully resect all visible CIS, or can biopsy and ablation suffice? What is the optimal strategy for stenting and catheter duration after TURBT? Postoperatively, trials have demonstrated high symptom burdens—hematuria, dysuria, constipation, and unplanned ER visits—suggesting that TURBT recovery is more morbid than traditionally appreciated. Simple ERAS-inspired measures such as multimodal analgesia, standardized bowel regimens, and defined catheter protocols could meaningfully improve patient experience.

Intravesical therapy likewise requires attention. With expanding options and improved response rates, treatment selection should also consider tolerability. Current toxicity reporting, often based on CTCAE grading, lacks the nuance to capture real-world patient distress. More granular outcomes and standardized supportive measures—such as consistent urine cultures before certain instillations, prophylactic use of anticholinergics or phenazopyridine, and structured follow-up—could help optimize adherence and quality of life.

In sum, while NMIBC management has historically prioritized efficacy, there is a compelling rationale to develop ERAS-style pathways for this population. By systematically addressing perioperative and peritreatment recovery, urologists can improve patient comfort, reduce complications, and enhance long-term outcomes for the growing population of bladder-preserving patients.

Presented by: Vignesh Packiam, MD, Director of Clinical and Translational Research in Urologic Oncology, Associate Professor of Surgery, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, RWJ Barnabas Health, New Brunswick, NJ

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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