Bladder cancer is the sixth most common malignancy in the US and is most prevalent among older patients with significant co-existing comorbidities, causing approximately 18,000 deaths annually [1]. Radical cystectomy (RC) serves as the standard treatment for patients with muscle-invasive bladder cancer, certain high-risk non-muscle invasive diseases, non-muscle invasive disease refractory to intravesical therapy, and after failure of trimodal therapy [2,3]. Despite RC's efficacy, it remains one of the most complex urologic procedures with a significant risk, presenting a 30-day and 90-day mortality rate of 2.7% and 7.2%, respectively [4].

In order to optimize perioperative care and reduce postoperative complications, enhanced recovery after surgery (ERAS) protocols have been proposed [5]. ERAS is an evidence-based, multi-disciplinary approach to patient care, including preoperative counseling, avoidance of bowel preparation and nasogastric tube insertion, early feeding, standardized pain management, and early mobilization [[6], [7], [8]]. ERAS significantly improves perioperative care and patients’ quality of life. Implementation of ERAS protocol in RC significantly reduces the length of hospital stay (LOS) without increasing the complication rate, diminishes the need for fluid therapy and blood product transfusion, and improves patient quality of life during early phases of recovery [7,[9], [10], [11], [12], [13], [14]].

While there have been numerous studies examining the impact of ERAS protocols on perioperative outcomes following RC, there remains a paucity of data regarding their influence on long-term oncological outcomes [12,15]. Theoretically, surgical manipulation is known to lead to systematic release of tumor cells [16,17]. Whether these cells cause metastasis largely depends on how aggressive the tumor cells are against the patient's immunity. Surgery triggers a stress response that can weaken host defenses and encourage tumor growth. The hypothesis is that ERAS can reduce the inflammatory response perioperatively, decrease patient's stress level, and hasten faster postoperative recovery, all of which may have implications for better oncologic outcomes [18]. This study aims to compare the oncological outcomes of patients who underwent RC with and without ERAS protocols in a large clinical cohort.