Effectiveness of Enhanced Recovery After Surgery Protocols for Robot Assisted Radical Prostatectomy: A Systematic Review and Meta-Analysis

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols aim to improve perioperative outcomes through evidence-based, multimodal care pathways. While ERAS is well established in radical cystectomy, its role in robotic-assisted radical prostatectomy (RARP) remains less clearly defined. This systematic review and meta-analysis evaluates the safety and efficacy of ERAS protocols in patients undergoing RARP. METHODS: A systematic search of PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies comparing ERAS or modified ERAS protocols with standard care in patients undergoing RARP were included. Outcomes assessed included length of stay (LOS), return of bowel function, operative time, estimated blood loss, and postoperative complications. A random-effects meta-analysis was performed using Stata 18, with results reported as Hedges' g standardized mean differences and 95% confidence intervals (CI). RESULTS: Seven studies comprising 1314 patients (615 ERAS, 699 standard care) met inclusion criteria. ERAS protocols were associated with a statistically significant reduction in LOS (mean 5.98 versus 7.45 days, Hedges' g -0.68; 95% CI: -1.21 to -0.15). ERAS also showed an earlier return of gastrointestinal function: time to flatus (mean 1.66 versus 2.03 days, Hedges' g -0.60; 95% CI: -0.91 to -0.30) and time to defecation (mean 2.68 versus 3.13 days, Hedges' g -0.43; 95% CI: -0.61 to -0.24). No significant differences were observed in complication rates, operative time, or blood loss. CONCLUSIONS: ERAS protocols in RARP are associated with improved short-term postoperative recovery, particularly gastrointestinal function. However, the clinical impact on LOS may be modest in contemporary practice, where early discharge is increasingly routine, particularly with the adoption of single-port surgery. Future studies should focus on identifying high-yield ERAS components and evaluating their role in higher-risk patient populations who may derive greater benefit from structured perioperative optimization.