Clinical application of 4N-enhanced recovery after surgery in retroperitoneal laparoscopic resection of adrenal tumors.

Background: Enhanced recovery after surgery (ERAS) has been widely applied in various surgical fields to improve postoperative recovery and reduce complications. However, its application in retroperitoneal laparoscopic resection of adrenal tumors remains limited. This study aimed to evaluate the effect and value of the 4N-ERAS protocol, which includes no Foley catheter, no drainage, no antibiotics, and "no pain" management for the postoperative recovery of patients undergoing retroperitoneal laparoscopic adrenal tumors resection.

Methods: We retrospectively analyzed data from 85 patients with adrenal tumors who were treated in the Urology Department of The University of Hong Kong-Shenzhen Hospital from January 2019 to December 2023. Of them, 42 patients were treated with the 4N-ERAS protocol (4N-ERAS group) and 43 patients received traditional treatment (control group). We compared clinical characteristics, such as sex, age, mean body mass index (BMI), preoperative diagnosis, tumor size, tumor location, and postoperative outcomes, including time to first flatus, time to first ambulation, time to Foley catheter removal, time to retroperitoneal drainage tube removal, postoperative pain score [Numeric Rating Scale (NRS)], length of hospital stay, total hospitalization costs, and postoperative complications between the two groups.

Results: There were no significant differences in terms of clinical characteristics between the two groups. Compared to the control group, the 4N-ERAS group exhibited shorter times for first flatus, first ambulation, Foley catheter removal, retroperitoneal drainage tube removal, lower postoperative pain scores (NRS), and shorter hospital stays (P<0.05). Furthermore, compared to the control group, the total hospitalization cost was significantly lower in the 4N-ERAS group (P<0.05). There were no significant differences in terms of postoperative complications between the two groups (P=0.19).

Conclusions: The 4N-ERAS protocol for retroperitoneal laparoscopic resection of adrenal tumors may expedite postoperative recovery, reduce pain, and lower overall hospital costs. This preliminary study demonstrated the safety and feasibility of the 4N-ERAS protocol for retroperitoneal laparoscopic resection of adrenal tumors, warranting future multicenter prospective, randomized, controlled trials in this field.