Perioperative patient care issues in urogynecology
- Quinn Lippmann, MD, MPH
Quinn Lippmann, MD, MPH
- Attending Physician
- Virginia Urology
- Richmond, Virginia
- Emily S Lukacz, MD, MAS
Emily S Lukacz, MD, MAS
- Professor of Clinical Reproductive Medicine
- UC San Diego Heath System
Urogynecologic surgery is frequently performed to treat symptoms of incontinence and pelvic organ prolapse in women. As an example, in the United States, 20 percent of women are estimated to undergo some type of urogynecologic procedure in their lifetime . While certain elements of urogynecologic surgery are common to all operations, these procedures have unique components that must be addressed by the surgical team.
This topic will review pre-, intra-, and postoperative care issues specific to women undergoing urogynecologic procedures. Information on general planning for benign gynecologic surgery is reviewed separately. (See "Overview of preoperative evaluation and preparation for gynecologic surgery".)
Preparation for urogynecologic surgery includes counseling regarding the unique procedure-related risks, evaluation and testing as directed by the patient's history and symptoms, understanding patient preferences, and recognition of clinical scenarios that require additional action.
Counseling — Preoperatively, the surgeon has a detailed discussion of the risks, benefits, and alternatives to surgery with the patient and her support team, and clearly documents the conversation in the medical record. This conversation addresses potential complications common to all pelvic surgeries and identifies issues unique to each patient's surgical plan.
Universal urogynecologic surgical issues — Common potential complications related to urogynecologic surgery that are discussed and written in the surgical consent include:
- Wu JM, Matthews CA, Conover MM, et al. Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery. Obstet Gynecol 2014; 123:1201.
- FDA Safety Communication: Serious complications associated with transvaginal placement of surgical mesh for pelvic organ prolapse http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm262435.htm (Accessed on June 16, 2015).
- Committee on Gynecologic Practice. Committee Opinion no. 513: vaginal placement of synthetic mesh for pelvic organ prolapse. Obstet Gynecol 2011; 118:1459.
- Nager C, Tulikangas P, Miller D, et al. Position statement on mesh midurethral slings for stress urinary incontinence. Female Pelvic Med Reconstr Surg 2014; 20:123.
- FDA Safety Communication: Laparoscopic uterine power morcellation in hysterectomy and myomectomy http://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm424443.htm (Accessed on June 16, 2015).
- American Urogynecologic Society’s Guidelines Development Committee. Guidelines for providing privileges and credentials to physicians for transvaginal placement of surgical mesh for pelvic organ prolapse. Female Pelvic Med Reconstr Surg 2012; 18:194.
- Brown J. AAGL advancing minimally invasive gynecology worldwide: statement to the FDA on power morcellation. J Minim Invasive Gynecol 2014; 21:970.
- Kwon JS, McAlpine JN, Hanley GE, et al. Costs and benefits of opportunistic salpingectomy as an ovarian cancer prevention strategy. Obstet Gynecol 2015; 125:338.
- Walker JL, Powell CB, Chen LM, et al. Society of Gynecologic Oncology recommendations for the prevention of ovarian cancer. Cancer 2015; 121:2108.
- Parker WH, Broder MS, Liu Z, et al. Ovarian conservation at the time of hysterectomy for benign disease. Obstet Gynecol 2005; 106:219.
- Parker WH, Broder MS, Liu Z, et al. Ovarian conservation at the time of hysterectomy for benign disease. Clin Obstet Gynecol 2007; 50:354.
- Parker WH, Feskanich D, Broder MS, et al. Long-term mortality associated with oophorectomy compared with ovarian conservation in the nurses' health study. Obstet Gynecol 2013; 121:709.
- Robert M, Cenaiko D, Sepandj J, Iwanicki S. Success and Complications of Salpingectomy at the Time of Vaginal Hysterectomy. J Minim Invasive Gynecol 2015; 22:864.
- Siedhoff MT, Clark LH, Hobbs KA, et al. Mechanical bowel preparation before laparoscopic hysterectomy: a randomized controlled trial. Obstet Gynecol 2014; 123:562.
- Ballard AC, Parker-Autry CY, Markland AD, et al. Bowel preparation before vaginal prolapse surgery: a randomized controlled trial. Obstet Gynecol 2014; 123:232.
- Arnold A, Aitchison LP, Abbott J. Preoperative Mechanical Bowel Preparation for Abdominal, Laparoscopic, and Vaginal Surgery: A Systematic Review. J Minim Invasive Gynecol 2015; 22:737.
- ACOG Committee on Practice Bulletins--Gynecology. ACOG practice bulletin No. 104: antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2009; 113:1180.
- Fok CS, McKinley K, Mueller ER, et al. Day of surgery urine cultures identify urogynecologic patients at increased risk for postoperative urinary tract infection. J Urol 2013; 189:1721.
- Nager CW, Brubaker L, Litman HJ, et al. A randomized trial of urodynamic testing before stress-incontinence surgery. N Engl J Med 2012; 366:1987.
- AUGS. Urodynamic testing before stress incontinence surgery: An AUGS position statement. 2012. www.augs.org/p/cm/ld/fid=218 (Accessed on May 24, 2015).
- Committee Opinion No. 603: Evaluation of uncomplicated stress urinary incontinence in women before surgical treatment. Obstet Gynecol 2014; 123:1403.
- American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 426: The role of transvaginal ultrasonography in the evaluation of postmenopausal bleeding. Obstet Gynecol 2009; 113:462.
- Kandadai P, Flynn M, Zweizig S, Patterson D. Cost-utility of routine endometrial evaluation before le fort colpocleisis. Female Pelvic Med Reconstr Surg 2014; 20:168.
- Shayya RF, Weinstein MM, Lukacz ES. Pyometra after Le Fort colpocleisis resolved with interventional radiology drainage. Obstet Gynecol 2009; 113:566.
- Practice Bulletin No. 149: Endometrial cancer. Obstet Gynecol 2015; 125:1006.
- Alnaif B, Drutz HP. Bacterial vaginosis increases in pessary users. Int Urogynecol J Pelvic Floor Dysfunct 2000; 11:219.
- Larsson PG, Carlsson B. Does pre- and postoperative metronidazole treatment lower vaginal cuff infection rate after abdominal hysterectomy among women with bacterial vaginosis? Infect Dis Obstet Gynecol 2002; 10:133.
- Yılmaz VT, Avcı AB, Şahin AF, et al. Acute renal failure due to uterine prolapse: a case report. Ren Fail 2013; 35:879.
- Moslemi MK, Abedinzadeh M, Nazari A. Obstructive uropathy due to prolapsed lower ureters and bladder in patients with severe procidentia: A report of two cases. Int J Surg Case Rep 2013; 4:348.
- Dancz CE, Walker D, Thomas D, Özel B. Prevalence of Hydronephrosis in Women With Advanced Pelvic Organ Prolapse. Urology 2015; 86:250.
- Rahn DD, Good MM, Roshanravan SM, et al. Effects of preoperative local estrogen in postmenopausal women with prolapse: a randomized trial. J Clin Endocrinol Metab 2014; 99:3728.
- The universal protocol for preventing wrong site, wrong procedure, and wrong person surgery. http://www.jointcommission.org/assets/1/18/UP_Poster1.PDF (Accessed on May 24, 2015).
- American College of Obstetricians and Gynecologists Women's Health Care Physicians, Committee on Gynecologic Practice. Committee Opinion No. 571: Solutions for surgical preparation of the vagina. Obstet Gynecol 2013; 122:718.
- Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999; 20:250.
- American College of Obstetricians and Gynecologists. ACOG Committee Opinion. Number 372. July 2007. The Role of cystourethroscopy in the generalist obstetrician-gynecologist practice. Obstet Gynecol 2007; 110:221.
- Thiagamoorthy G, Khalil A, Cardozo L, et al. The value of vaginal packing in pelvic floor surgery: a randomised double-blind study. Int Urogynecol J 2014; 25:585.
- Westermann L. To pack or not to pack? A randomized trial of vaginal packing after vaginal reconstructive surgery. Female Pelvic Med Reconstr Surg 2016; 11:111.
- Murphy AM, Tunitsky-Bitton E, Krlin RM, et al. Utility of postoperative laboratory studies after female pelvic reconstructive surgery. Am J Obstet Gynecol 2013; 209:363.e1.
- Watkins PB, Kaplowitz N, Slattery JT, et al. Aminotransferase elevations in healthy adults receiving 4 grams of acetaminophen daily: a randomized controlled trial. JAMA 2006; 296:87.
- US Department of Health and Human Services. Organ-specific warnings; internal analgesic, antipyretic, and antirheumatic drug products for over-the-counter human use; final monograph. Final rule. Fed Regist 2009; 74:19385.
- American Urological Association white paper on catheter associated urinary tract infections: Definitions and significance in the urologic patient. https://www.auanet.org/common/pdf/education/clinical-guidance/Catheter-Associated-Urinary-Tract-Infections-WhitePaper.pdf (Accessed on June 17, 2015).
- Jackson D, Higgins E, Bracken J, et al. Antibiotic prophylaxis for urinary tract infection after midurethral sling: a randomized controlled trial. Female Pelvic Med Reconstr Surg 2013; 19:137.
- Shepherd JP, Jones KA, Harmanli O. Is antibiotic prophylaxis necessary before midurethral sling procedures for female stress incontinence? A decision analysis. Int Urogynecol J 2014; 25:227.
- Marschall J, Carpenter CR, Fowler S, et al. Antibiotic prophylaxis for urinary tract infections after removal of urinary catheter: meta-analysis. BMJ 2013; 346:f3147.
- Juthani-Mehta M. Should antibiotic prophylaxis after urinary catheter removal be standard practice? BMJ 2013; 346:f3938.
- Lusardi G, Lipp A, Shaw C. Antibiotic prophylaxis for short-term catheter bladder drainage in adults. Cochrane Database Syst Rev 2013; :CD005428.
- Edenfield AL, Siddiqui NY, Wu JM, et al. Polyethylene Glycol 3350 and Docusate Sodium Compared With Docusate Sodium Alone After Urogynecologic Surgery: A Randomized Controlled Trial. Obstet Gynecol 2016; 128:543.
- Nygaard IE, Hamad NM, Shaw JM. Activity restrictions after gynecologic surgery: is there evidence? Int Urogynecol J 2013; 24:719.
- Yamasato KS, Oyama IA, Kaneshiro B. Intraabdominal pressure with pelvic floor dysfunction: do postoperative restrictions make sense? J Reprod Med 2014; 59:409.
- Gerten KA, Richter HE, Wheeler TL 2nd, et al. Intraabdominal pressure changes associated with lifting: implications for postoperative activity restrictions. Am J Obstet Gynecol 2008; 198:306.e1.
- Barber MD, Brubaker L, Burgio KL, et al. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA 2014; 311:1023.
- - Universal urogynecologic surgical issues
- - Procedure-specific issues
- - Timing with regards to childbearing
- - General
- - Procedure-specific
- - Testing
- - Urodynamic studies
- Management of specific patient groups
- - Abnormal uterine bleeding
- - Bladder symptoms
- - Obliterative procedures
- - Pessary removal
- - Prolapse
- - Vaginal atrophy
- - Smokers
- Surgical preparation of skin and vagina
- Bladder catheter
- Retractor use in surgery
- Intraoperative cystourethroscopy
- Vaginal packing
- Pain management
- Catheter removal and voiding trial
- Postoperative antibiotics
- Bowel function
- Resumption of estrogen therapy
- Activity restrictions
- FOLLOW-UP CARE
- SPECIAL POPULATIONS
- SUMMARY AND RECOMMENDATIONS