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Bladder cancer (BCa) is the second most common genitourinary malignancy with 81,190 estimated new diagnoses for 2018 in the United States alone (1). Radical cystectomy (RC) with bilateral pelvic lymph node dissection (PLND) and perioperative chemotherapy is the standard treatment recurrent high risk non-muscle invasive and for muscle invasive BCa (2). However, RC as well as perioperative chemotherapy represent a complex procedure associated with high perioperative morbidity and mortality as a consequence also of the characteristics of the population which is generally affected by multiple comorbidities when compared to other surgical procedures (3, 4). One of the strategies proposed to reduce the perioperative morbidity and mortality consist in the application of an Enhanced recovery after surgery (ERAS) program (5). It consists in a multidisciplinary, multi-element care pathway that aim to standardize and improve perioperative management. ERAS program was firstly introduced in colorectal surgery, where ERAS or fast track surgery pathways have been developed to accelerate recovery by attenuating the stress response. Thereafter, a metanalyses have provided level 1 evidence reporting a reduction of complications, and hospital stay for colorectal surgery patients where ERAS was applied (6, 7). ERAS protocol has been also proposed in the field of RC, however at the time only limited evidences exist (8, 9). It is an approach comprehensive of preoperative, perioperative and postoperative interventions. During the consensus (5) 34 points were individuated. A preoperative counselling and education with verbal and written information regarding surgery, urinary diversion and planned early recovery is necessary to involve the patient in the therapeutic management. In this period several assessments have to be proposed: a preoperative medical optimization, nutritional assessment, visit by a stoma nurse with advice on stoma and neobladder care, cardiopulmonary exercise testing if indicated, advice and support for cessation of smoking and social issue addressed and discharge planning. Smoke cessation in this setting has been demonstrated to be highly effective in increasing survival and perioperative outcomes after RC (10). These elements required a multidisciplinary team composed by urologists, nurses, nutritionists and social workers. The day before RC, a carbohydrate loading is required, while no bowel preparation is recommended. The day of RC, solids up to 6 hours and clear fluids up to 2 hours preoperative including carbohydrate loading are permitted. From the Vol. 45 (4): 655-657, July August, 2019

Enhanced recovery after surgery (ERAS) in radical cystectomy patients: from consensus to evidences