The article by Schmit et al. [1] evaluating the role of mechanical bowel preparation (MBP) before nephrectomy in the minimally invasive surgery (MIS) era is a well-structured important contribution to the field. I appreciate the authors’ rigorous analysis and the important contribution this study makes to the evolving dialogue on perioperative practices in urology. The findings align with broader trends in surgery where the routine use of MBP has been challenged, yet there are aspects of the study that could benefit from further discussion.

The study concludes that MBP is not associated with a reduction in complications such as postoperative ileus, reoperation, or surgical site infections across both open and MIS nephrectomy. A noteworthy finding is within the MIS group, where the authors report a paradoxical finding: MBP is linked to a lower rate of postoperative ileus but a higher incidence of pneumonia and pulmonary embolism. The authors suggest this may reflect selection bias or incomplete adherence to Enhanced Recovery After Surgery (ERAS) protocols, but it is worth considering additional perioperative factors that may contribute to these outcomes, which the study does not fully address.

One such factor is the potential impact of MBP on patient hydration and electrolyte balance. In general surgery, MBP has been shown to exacerbate dehydration and electrolyte imbalances, particularly in elderly or frail patients, which can predispose them to complications such as postoperative ileus, acute kidney injury, and, notably, pulmonary complications [2,3]. This physiologic stress may counteract the benefits of early ambulation and respiratory exercises promoted by ERAS, particularly in patients undergoing lengthy MIS procedures involving pneumoperitoneum, which can further compromise respiratory mechanics and venous return.

The findings that MBP was associated with a reduced rate of 30-day readmission in the MIS group post-matching, yet concurrently increased risks of pneumonia and pulmonary embolism, underscore the need to consider patient-specific factors beyond those captured by standard covariates like age or American Society of Anesthesiologists classification. Factors such as preoperative functional status, the extent of surgical manipulation required, and the role of bowel mobilization in the context of nephrectomy could provide additional insights. For example, bowel mobilization, even in MIS, can influence postoperative outcomes by impacting the risk of ileus and other gastrointestinal complications, which are not typically accounted for in large database studies [4].

In conclusion, this study provides compelling evidence supporting the limited utility of MBP in nephrectomy and effectively highlights the challenges of translating perioperative practices across different surgical specialties. The authors have conducted a thorough analysis, shedding light on important nuances that impact patient outcomes. Their work offers a high level of analysis and valuable insights for clinical practice. Further exploration of perioperative management strategies and procedural nuances in future research will continue to refine and improve best practices in nephrectomy and other surgical fields.

Conflict of interest

The author has no conflicts of interest to declare.

Funding/support

None.

Data availability

The data presented in this study are available on request from the corresponding author.