ENHANCED RECOVERY AFTER SURGERY GUIDELINES’ IMPACT ON VULVAR SURGICAL OUTCOMES: A retrospective cohort study

ENHANCED RECOVERY AFTER SURGERY GUIDELINES’ IMPACT ON VULVAR SURGICAL OUTCOMES: A retrospective cohort study | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 24 June 2025 V1 Latest version Share on ENHANCED RECOVERY AFTER SURGERY GUIDELINES’ IMPACT ON VULVAR SURGICAL OUTCOMES: A retrospective cohort study Authors : Audrey Feng-Emond , Elise de Castro Hillmann 0000-0001-7676-4005 , and Vanessa Samouëlian [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.175073604.43011819/v1 192 views 118 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objective The main objective is to analyze ERAS’s impact on vulvar oncology surgery. Design Retrospective observational cohort study Setting A single center, an academic reference center, and main referral for gynecology oncological patients in Quebec province, Canada. Population or Sample All patients who underwent surgery for vulvar cancer (or suspicious lesions) from the pre-ERAS (2015) and ERAS (2019-2021) periods were included. Methods The length of stay, postoperative complications, readmissions, reoperation and mortality rate were compared between pre-ERAS and ERAS cohorts. CHUM’s practices were compared to ERAS guidelines recommendations and ERAS Interactive Audit System (EIAS®). Proportions were used to analyze compliance with available guidelines. Main Outcome Measures The primary outcome of this study is ERAS’ impact on vulvar oncology surgery outcomes. Other outcomes include the analysis of CHUM’s compliance to ERAS guidelines and EIAS® ability to evaluate compliance for vulvar surgeries. Results 154 patients were included. Compliance increased from 28.5% % to 85.7%. We observed a reduction in length of stay (p=0.002), hospitalization complications(p=0.033) [respiratory (p=0.009), psychiatric (p=0.012) and pain (0.047)], hospitalization serious complications (p=0.011), postdischarge wound infections (p<0.001) with similar postdischarge complication rates (p=0.598). EIAS compliance algorithm only correctly interpreted 21.4% of recommendations. Conclusions ERAS implementation is beneficial regarding vulvar cancer surgery outcomes. All applicable guidelines should be grouped into a single checklist. EIAS compliance algorithm should be adapted to vulvar surgery. Funding This study received one scholarship grant from the PRogramme d’Excellence en Médecine pour l’Initiation En Recherche . Keywords ERAS, guideline, vulvar cancer, surgery, EIAS ENHANCED RECOVERY AFTER SURGERY GUIDELINES’ IMPACT ON VULVAR SURGICAL OUTCOMES: A retrospective cohort study Audrey Feng-Emond 1 , Elise de Castro Hillmann 2 , Vanessa Samouëlian 1,2 1 Faculty of Medecine, Université de Montréal 2 Gynecological oncology, Centre de Recherche - Centre Hospitalier de l’Université de Montréal (CR-CHUM) Corresponding author: Vanessa Samouëlian [email protected] 1000 rue Saint-Denis - Porte B06.8099 Montréal, QC, H2X 0C1 Tél: +1-514-890-8000 #24672 Fax: +1-514-412-7605 math_shortcuts Shortened running title ERAS GUIDELINES’ IMPACT ON VULVAR SURGICAL OUTCOMES Objective The main objective is to analyze ERAS’s impact on vulvar oncology surgery. Design Retrospective observational cohort study 11pt, fleqn, a4paper, ]LegrandOrangeBook Setting A single center, an academic reference center, and main referral for gynecology oncological patients in Quebec province, Canada. math_shortcuts Population or Sample All patients who underwent surgery for vulvar cancer (or suspicious lesions) from the pre-ERAS (2015) and ERAS (2019-2021) periods were included. Methods The length of stay, postoperative complications, readmissions, reoperation and mortality rate were compared between pre-ERAS and ERAS cohorts. CHUM’s practices were compared to ERAS guidelines recommendations and ERAS Interactive Audit System (EIAS®). Proportions were used to analyze compliance with available guidelines. Main Outcome Measures The primary outcome of this study is ERAS’ impact on vulvar oncology surgery outcomes. Other outcomes include the analysis of CHUM’s compliance to ERAS guidelines and EIAS® ability to evaluate compliance for vulvar surgeries. Results 154 patients were included. Compliance increased from 28.5% % to 85.7%. We observed a reduction in length of stay (p=0.002), hospitalization complications(p=0.033) [respiratory (p=0.009), psychiatric (p=0.012) and pain (0.047)], hospitalization serious complications (p=0.011), postdischarge wound infections (p<0.001) with similar postdischarge complication rates (p=0.598). EIAS compliance algorithm only correctly interpreted 21.4% of recommendations. Conclusions ERAS implementation is beneficial regarding vulvar cancer surgery outcomes. All applicable guidelines should be grouped into a single checklist. EIAS compliance algorithm should be adapted to vulvar surgery. math_shortcuts Funding This study received one scholarship grant from the PRogramme d’Excellence en Médecine pour l’Initiation En Recherche . Keywords ERAS, guideline, vulvar cancer, surgery, EIAS MAIN BODY Funding This study received one scholarship grant from the PRogramme d’Excellence en Médecine pour l’Initiation En Recherche . The funder played no role in conducting research or the writing of the paper. INTRODUCTION Primary vulvar cancers are uncommon as they constitute 4% of all gynecological cancers(1). In 2020, vulvar cancer represented 0.2% of all cancers(2). Enhanced Recovery After Surgery (ERAS) protocols are composed of recommendations aiming at a faster and safer recovery after surgery by optimizing patient trajectory. By reducing physiologic stress, patients benefit from a speedier recovery and sooner return to their daily activities: the average length of stay (LOS) is shorter and complication rates are reduced(3). The ERAS gynecology/oncology guideline was recently developed(3-5) and the ERAS guideline for vulvar and vaginal surgeries was only published in 2020(6). However, the vulvar and vaginal surgery ERAS guideline is not exclusive to oncology patients and is partially based on other specialties’ data due to the lack of literature on vulvar and vaginal malignancies. Surgery is the treatment of choice for vulvar noninvasive lesions and cancers (7). Vulvar oncology surgeries have unique postoperative challenges due to their higher complication rates (76%) compared with other gynecological procedures, such as lymphocyst formation (40%), postoperative wound infection (39%), lymphedema (28%), and wound dehiscence (17%)(8). Literature on vulvar surgical management is restricted and sample sizes are limited because of the rarity of these malignancies. Additionally, no publication analyzing ERAS’s impact on vulvar oncology surgical outcomes is currently available. The Centre hospitalier de l’Université de Montréal (CHUM) has gradually and fully implemented ERAS in all gynecology services ERAS in 2017 and 2019. This academic center treats a high rate of vulvar cancer and therefore has a high volume of vulvar cancer patients. Does the implementation of an ERAS protocol benefit vulvar oncology patients? Although guidelines and compliance algorithms were developed, following all available recommendations is a complex task. Do guidelines differ from each other? Does this center follow all recommendations applicable for vulvar oncology surgeries? Is the ERAS Interactive Audit System (EIAS®) algorithm adapted to evaluate this center’s compliance for vulvar surgeries? EIAS® was the only system commercially available at the time of this study. A coherence analysis between available ERAS guidelines applicable for vulvar and vaginal surgeries, the EIAS compliance algorithm variables and this center’s practices should also be conducted. The primary outcome of this study evaluates ERAS’s impact on patients’ length of stay, complication rates, reoperation rates, readmission rates, pre-post implementation. Other outcomes include the analysis of this center’s compliance to gynecologic/oncologic, vulvar and vaginal surgeries ERAS guidelines and EIAS® ability to evaluate compliance for vulvar surgeries. METHODOLOGY Design and patient selection A single center retrospective observational cohort study comparing 2015 (pre-ERAS) and 2019-2021 (ERAS) vulvar cancer patients’ surgical outcomes and compliance to gynecologic/oncologic, vulvar and vaginal ERAS guidelines recommendations was conducted. All data from 2015 to 2019 was retrospectively collected and data from 2020 to 2021 was retrospectively collected except for postdischarge complications for which an ERAS nurse called patients at postoperative day 30. The gynecology oncology service at the CHUM is an academic reference center and main referral for gynecology oncological patients in Quebec province, Canada. Patients undergoing primary vulvar oncologic surgery (invasive diseases or suspicious lesions) were operated on by the oncology gynecology surgeons at the CHUM. Eight gynecology oncology surgeons within the gynecology oncology division at this academic reference center were involved in patient surgery. All vulvar malignancy patients undergoing a non-elective surgery from January 1 rst 2015 to December 31 rst 2015 were reviewed in the pre-ERAS group and patients operated from January 1 rst 2019 to December 31 rst 2021 were reviewed in the ERAS group. The four-year gap was chosen to avoid the possible progressive change of practice contamination between the study years pre and post implementation. 163 patients with vulvar malignancy (high risk noninvasive and invasive diseases) were included for review. Figure 1 describes patient selection process. 9 patients were excluded from analyses: patients with low grade intraepithelial lesion, with other concomitant cancer, with irresectable cancer and with no malignancy. All patients’ medical records were revised. ERAS surgical outcomes A database describing patients’ characteristics, disease histology, staging and treatment as well as surgery indication was developed. Patients’ preoperative, intraoperative, and postoperative trajectories were documented using EIAS. Pre-ERAS and ERAS cohorts’ length of stay, postoperative complications, readmissions and mortality outcomes were used to evaluate ERAS’s impact. Postoperative complications were separated into two periods: during hospitalization and after discharge. Postoperative complications were graded according to the Clavien-Dindo classification and were documented until the 30 th postoperative day. ERAS guidelines comparison and compliance To evaluate this center’s compliance with the available ERAS guidelines, the gynecologic/oncology surgery ERAS guideline was compared to the vulvar and vaginal surgery ERAS guideline. All recommendations present in both guidelines were grouped together in a database. The recommendations were then identified as additional and/or missing from each guideline ( Table 1 ). The center’s practices were compared to all recommendations to determine which were followed and which were missing in patient trajectory. Two methods were considered for compliance calculations. First, EIAS compliance algorithm variables were evaluated to assess if they were properly adapted for vulvar and vaginal cancer surgery. All recommendations identified in the gynecologic/oncology surgery ERAS guideline and the vulvar and vaginal surgery ERAS guideline were compared to EIAS compliance algorithm variables. The recommendation items that were missing or misinterpreted by EIAS were identified in the database ( Table 1 ). Due to the lack of consistency in both recommendation presence and interpretation (further explanations in the discussion), compliance was calculated using the proportion of recommendations incorporated in this center’s practice for gynecology oncology surgeries, analyzed for each pre-ERAS and ERAS periods. 11pt, fleqn, a4paper, ]LegrandOrangeBook Statistical analysis Descriptive analyses were calculated using means and standard deviation, medians, ranges as well as percentages. Numeric means were compared using Student T-test. Categorical variables were compared using Chi-square test. Proportions between the two groups were compared using Chi-square test. The statistical significance was 0.05. Ethics This study was approved by the Institutional Review Board (IRB) under the number 16.240 at the Centre hospitalier de l’Université de Montréal. RESULTS math_shortcuts Patient description All 2015 (pre-ERAS) and 2019 to 2021 (ERAS) suspicious vulvar malignancy patients undergoing a non-elective surgery were reviewed (n=163). 154 patients were included in this study. Descriptive data regarding patient characteristics, disease characteristics, surgery characteristics, pathological findings as well as neoadjuvant and adjuvant treatments are available in Table 2 . Mean age and other patients characteristics were similar in both pre-ERAS and ERAS cohorts, except smoking rates which were higher in the pre-ERAS cohort (37.3%) compared to the ERAS cohort (21.4%). In both cohorts, squamous cell carcinomas were predominant, 72.5% and 68.9%, respectively. Followed by melanomas and adenocarcinomas. Other cancers were identified. Most patients had a FIGO stage I cancer (49.0% pre-ERAS group and 46.6% ERAS), FIGO stage III cancers were the second most frequent and were higher in the ERAS cohort (26.2%) than the pre-ERAS cohort (23.5%). Noninvasive diseases (11.8% pre-ERAS and 20.4% ERAS) were found among our patients, and were kept in the study since those patients followed the same surgical protocol as the rest of the group and their results were only confirmed by pathology around 4 weeks after surgery. VIN III was the most prevalent noninvasive disease (8.4%), followed by Paget’s disease (7.1%). Most patients had primary vulvar cancer surgery (71.4%). Some patients (28.6%) had surgeries for recurrence. Only 2 (1.3%) of patients’ surgery was a lymphadenectomy alone without vulvar surgery. Two (1.3%) patients received a neoadjuvant treatment (radiotherapy or immunotherapy). 29 patients (18.8%) patients had adjuvant treatment (radiotherapy, chemotherapy, radiochemotherapy, or immunotherapy). ERAS surgical outcomes Surgical outcomes are described in Table 3. Estimated blood loss is statistically significantly lower (p<0.001) in the ERAS cohort (78.1 cc) than to pre-ERAS cohort (136.6 cc) but is not clinically meaningful. Operation time did not differ significantly in the ERAS cohort (98.2 minutes) compared to the pre-ERAS cohort (91.8 minutes) (p=0.598). Reoperation rate, readmission rate, post discharge complications of all grades, including severe complications (≥ grade IIIa), did not significantly differ. The length of stay significantly decreased (p=0.002) from 7.0 days pre-ERAS to 3.1 days post-ERAS. No mortality rates (until the 30 th postoperative day) were observed in neither cohort. Descriptive analyses of surgical complications Postoperative complications rate during hospitalization significantly decreased from 25.5% (pre-ERAS cohort) to 11.9% (ERAS cohort), regardless of complication grade (p=0.033). Severe complications (≥ grade IIIa) during hospitalization also significantly diminished from 11.8% to 2.0% for respectively the pre-ERAS and ERAS cohorts (p=0.011). Postoperative complications are described in Table 4 . Patients’ worst grade complication during hospitalization was a grade IIIa severity complication (11.8% pre-ERAS; 2.0% ERAS), which decreased pre-post ERAS implementation (p=0.011). Other complication grade severities were not statistically different. Regarding complication types during hospitalization, we had a significant decrease from pre-ERAS to after ERAS implementation of: respiratory complications with drop of 5 patients to 1(p=0.009); psychiatric complications, from 7 down to 3 (p=0.012) and pain from 2 to none (p=0.047). The wound infection rate significantly decreased from 19patients pre-ERAS to 6 patients post ERAS implementation (29.8% pre-ERAS:6.2% ERAS) (p<0.001). No significant differences were present between cohorts regarding complication grade. Guidelines, EIAS and practices comparison 11pt, fleqn, a4paper, ]LegrandOrangeBook When combining the gynecology/oncology surgery ERAS guidelines and from the vulvar and vaginal surgery ERAS guideline, 42 recommendation items are suggested for vulvar surgery. 14 recommendations (33.3%) were common to both guidelines, 25 recommendations (59.5%) were only present in the gynecology/oncology surgery ERAS guidelines. Three recommendations (7.1%) were only present in the vulvar and vaginal surgery ERAS guideline: the maintenance of inguinofemoral drains until there is less than 30-50 cc per day of drainage, saphenous vein preservation in inguinofemoral lymph node dissections, and the use of occlusive dressings in vulvar laser surgery. math_shortcuts 20 recommendations (47.6%) were not assessed in the EIAS compliance algorithm. The EIAS compliance algorithm evaluated and correctly interpreted 9 recommendations (21.4%). 10 recommendations (23.8%) were evaluated in the EIAS compliance algorithm but were not interpreted as recommended in the guidelines. Additionally, 3 recommendations (7.1%) were assessed by EIAS (information is obtained by the system) and were not evaluated by the EIAS compliance algorithm. Although EIAS is the only commercially available tool at the time of this study and auditing practices are essential to ERAS compliance, this audit system is not adapted to audit vulvar surgery compliance for ERAS protocol. Enhanced audit practices should be implemented to truthfully monitor ERAS compliance in vulvar surgery. Our institution practice was also evaluated for ERAS compliance in vulvar surgery. 2 recommendations (4.8%) were variably incorporated into patient trajectory, due to lack of consistency in application of these recommendations, they were considered as not incorporated for the analysis. Although we cannot truthfully audit those practices due to the lack of an adapted audit system, the use of declared practices was considered. Finally, CHUM’s practice compliance pre-ERAS implementation was 28.5% and 85.7% post-ERAS implementation. DISCUSSION Main Findings This study analyzed the impact of ERAS on patients’ surgical outcomes as well as CHUM’s compliance with gynecologic/oncologic, vulvar and vaginal surgeries ERAS guidelines. The length of stay was significantly reduced after ERAS implementation. The study also presented a significant decline in postoperative complications rate of all grades, including serious complication grade severity (≥ grade IIIa), respiratory complications, psychiatric complications, and pain during hospitalization. Although no significant difference in post discharge complications rate was found, except for a significant decrease in wound infections and an increase in patient declared pain after discharge in the ERAS cohort, which may be due to bias in data collection (introduction of 30 days post-op nurse follow-up phone calls), this is a positive results, since no increase in complication rates are shown after an earlier discharge. There is a difference in data collection as postoperative complications after discharge in the ERAS cohort was partially prospectively collected at postoperative day 30 by an ERAS nurse phone call, allowing a better data collection than in the pre-ERAS cohort, but also maybe rising the number of declared post-discharge symptoms. Length of stay and postoperative complications during hospitalization In this study, the length of stay significantly reduced from 7.0 days in the pre-ERAS cohort to 3.1 days in the ERAS cohort. In Gitas and al .’s(9) study on vulvar cancer surgery complications, the average length of stay was 9.2 days. Narducci and al .’s(10) patients undergoing a vulvectomy with or without vacuum-assisted closure were respectively hospitalized in average for 17.8 days and 18.4 days. Additionally, Jones and al .(11) presented a median length of stay varying from 4.5 days to 10.7 days when performing an inguinofemoral lymph node dissection in vulvar cancer patients, depending on skin incision type. Although these are the only available LOS data, they were not evaluated under an ERAS protocol, which is a determining factor for earlier discharge in our study. As suggested by Jones and al .’s as well as Narducci and al .’s results, many factors could influence this reduction, such as wound care and surgery technique. Nevertheless, other ERAS trajectory components may play a key role in improving patients’ outcomes. This reduction in length of stay was accomplished without compromising patient care quality as post-discharge complications, reoperation rates, readmission rates, and mortality did not significantly differ pre-post ERAS. Furthermore, complications during hospitalization also decreased. However, there is currently no literature available data to compare results as most studies make no distinction between postoperative periods. Postoperative complications postdischarge description Post discharge complications following vulvar cancer surgery was documented up to postoperative day 30, similarly to current literature. Up to 76% of patients developed at least one postoperative complication following a vulvectomy(8). Due to treatment advancements, these results may not apply to today’s patient trajectory. More recently, Wills and al . found that up to 58% of patients undergoing a vulvectomy suffer from postoperative complications(12). These rates of complications surpass our complication rates in both pre-ERAS (48.9%) and ERAS (53.6%) groups (not statistically different). Another study presented complication rates as low as 28.7% following vulvar surgery indicated for premalignant lesions(13). Considering the lower radicality of these lesions’ surgical procedures these low rates are not comparable to the complication rates of our cohort. We had a significant decline in postoperative complications rate of all grades during hospitalization (including severe complication grades (>IIIa)) . As Gitas and al. proposed(9), patients with advanced disease (FIGO staging III-IV) were more likely to develop postoperative complications than patients with local disease (FIGO staging I-II). Our cohorts’ disease stages (FIGO I-II vs FIGO III-IV) were not different pre-post ERAS (p=0.954). Therefore, our rates of complications aren’t influenced by FIGO staging. Current literature describes wound infection in the groin region as the most prevalent vulvar cancer surgery postoperative complication (14). Wound infection rates and cellulitis rates respectively vary from 21%-39% and 21%-57%(12). Gaarenstromm and al . described a 39% rate of wound infection in the groin region(8). These rates are similar to our pre-ERAS group (29.8%) and much higher than our ERAS group (6.2%). Wound infection was previously associated with an increase in LOS(15). Our reduction in wound infections could also be explained by the decreased LOS and the systematic antimicrobial prophylaxis recommended by ERAS (3-5) . Although wound infection is considered as the most prevalent vulvar postoperative complication, our groups presented higher rates of wound dehiscence, which were not significantly different (46.8% pre-ERAS:43.2% ERAS). These rates are higher than the 17-39%(12) rates of wound dehiscence described in current literature. Mullen and al . found an increase in wound complications in vulvar surgery in their smokers’ sample(13). ERAS has the potential to positively affect wound scarring. For instance, ERAS’ recommendation to stop smoking 4 weeks prior to surgery (3-5), could decrease tissue inflammation and optimize healing(16). We found no difference in wound dehiscence, which could be because ERAS’ smoking cessation recommendation is still not fully incorporated at CHUM. Other surgical complications such as lymphocysts and lymphedema are also common following vulvar cancer surgery with rates of 14%-48.8%(14) and 5.5%-40% (8, 14), respectively. In both of our cohorts, no lymphedema was reported. This is most probably an impact of the large development of sentinel node technique for vulvar cancer surgery at our center. Indeed, Van der Zee and al. reported a reduction in lymphedema from 25.2% with lymphadenectomy to 1.9% with a sentinel node dissection (17). Finally, ERAS measures allowed to reduce LOS, notably by adopting systematic comorbidities management and active patient engagement in self-recovery, which allowed an earlier return to daily activities. Additionally, multimodal pain management contributes to better pain control and prevents disorientation related to systemic opioids use. Both early return to familiar routine and multimodal pain control may have contributed to our reduction of psychiatric complications during hospitalization. An early mobilization, drain avoidance as well as an earlier discharge may have also favorized the decrease in wound infection. math_shortcuts Compliance Our institution declared compliance significantly increased from 28.5% to 85.7%. As expected from previous ERAS literature, we observed significant benefits for our patients such as reduced length of stay, reduced hospitalization complications, similar post discharge complication rates and reduced post discharge wound infections. Our cohort is the first to evaluate ERAS’ impact on vulvar cancer surgery. In fact, ERAS surgical guidelines were only recently adapted to vulvar surgery and the EIAS is not adapted to audit the new components of this guideline. Consequently, we report our compliance to guidelines without being able to compare them to other centers. Current literature describes reduced complications rates when EIAS compliance surpasses 70%(18) to 80%(19) in gynecologic procedures, although these rates aren’t specific to vulvar cancer surgery. Guideline compliance assessment Only 33.3% of vulvar surgery recommendations are common to the gynecology/oncology ERAS guideline and the ERAS vulvar/vaginal guideline. Unfortunately, the recommendations applicable to vulvar cancer surgery are dispersed among various guidelines which leads to an uncertainty as to application. math_shortcuts Unique vulvar surgery guideline or joint to ERAS gynecological guidelines? An ERAS vulvar surgery guideline presents a unique list of items that should be considered for vulvar and vaginal surgery, but should they be considered in addition or not to the current gynecology/oncology ERAS guideline? Since 59.5% of recommendations were only present in the gynecology/oncology ERAS guideline, we considered the vulvar ERAS guideline should be applied as an additional list of items to the gynecology/oncology guideline for a more comprehensive approach. A new guideline grouping all recommendations applicable to vulvar surgery could facilitate recommendations application in medical centers. Additionally, when we evaluated the EIAS algorithm, it only considered and correctly interpreted 9 recommendations (21.4%). Therefore, 78.6% of the recommendations applicable to vulvar cancer surgery aren’t properly assessed. For instance, the EIAS algorithm doesn’t evaluate saphenous vein preservation, which is a risk factor to developing postoperative complications such as lymphedema(20). It also doesn’t evaluate preoperative diabetes screening which could limit patient recovery as diabetes slows wound healing(12). Various variables are differently considered in the EIAS and the ERAS recommendations. Therefore, in this study, we couldn’t only use the EIAS compliance algorithm to measure compliance. Instead, we used proportions. The EIAS algorithm needs to be revised to follow actual recommendations applicable for vulvar cancer surgery. Strengths and limitations Although our sample size is small, it is considerably large considering the rarity of vulvar malignancies. Additionally, documented patients were operated on during the same timeframe (within 6 years). Few surgeons were implicated and therefore physicians’ treatment management preferences were less susceptible to influence results. We addressed the EIAS limitations by developing our own compliance proportion. However, it doesn’t evaluate individual compliance. Control over data availability and missing documents was limited due to being a retrospective study. Next steps Although many benefits resulted from ERAS implementation, our center’s practices could benefit from being further adapted to current vulvar cancer surgery recommendations. LOS was considerably reduced. Our experience could encourage other centers to adopt new vulvar cancer surgery ERAS measures. However, a revision of ERAS vulvar surgery guideline grouping all applicable recommendations could facilitate implementation. Additionally, the EIAS compliance algorithm for vulvar cancer surgery needs to be revised. A prospective study could help determining which key components in patients’ trajectory are responsible for improving surgical outcomes and patients’ satisfaction. CONCLUSION Vulvar ERAS guidelines’ implementation in our center induced major benefits for our patients. Our center could further adapt its vulvar cancer patient trajectory to ERAS guidelines. Due to the complexity of all available guidelines for vulvar cancer surgery, a single reference checklist would facilitate ERAS implementation. Furthermore, ERAS guidelines should include recommendations on compliance calculations to ensure adequate comparison among centers. ERAS audit systems should be further adapted to specific guidelines (i.e., vulvar guideline). Further studies are needed to better understand the impact of each ERAS recommendation on vulvar cancer surgical trajectory. REFERENCES 1. Olawaiye AB, Cotler J, Cuello MA, Bhatla N, Okamoto A, Wilailak S, et al. FIGO staging for carcinoma of the vulva: 2021 revision. Int J Gynaecol Obstet. 2021;155(1):43-7.2. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F. 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Gynecol Oncol. 2007;105(3):722-6. Supplementary Material File (all tables article vulve 20-06-2025.xlsx) Download 100.68 KB File (figure 1- eligibility and methods of selection for vulvar cancer surgery patients.pptx) Download 32.06 KB Information & Authors Information Version history V1 Version 1 24 June 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords audit: hospital carcinoma of the vulva: surgery clinical guidelines gynaecological oncology gynaecological surgery: gynaecological cancer Authors Affiliations Audrey Feng-Emond Universite de Montreal Faculte de Medecine View all articles by this author Elise de Castro Hillmann 0000-0001-7676-4005 Centre de Recherche du Centre Hospitalier de l'Universite de Montreal View all articles by this author Vanessa Samouëlian [email protected] Universite de Montreal Faculte de Medecine View all articles by this author Metrics & Citations Metrics Article Usage 192 views 118 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Audrey Feng-Emond, Elise de Castro Hillmann, Vanessa Samouëlian. ENHANCED RECOVERY AFTER SURGERY GUIDELINES’ IMPACT ON VULVAR SURGICAL OUTCOMES: A retrospective cohort study. Authorea . 24 June 2025. 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