1843 EVIDENCE-BASED PERIOPERATIVE MANAGEMENT OF WOMEN UNDERGOING PELVIC RECONSTRUCTIVE SURGERY

Abstract

INTRODUCTION AND OBJECTIVES: Pelvic organ prolapse and female stress urinary incontinence are prevalent, costly, and significantly impact quality of life. The perioperative management of these conditions becomes increasingly important for optimizing outcomes and minimizing complications; however, perioperative regimens differ widely and may not be supported by evidence–based studies. The aim of this pilot study is to evaluate available literature regarding the perioperative management for female patients undergoing pelvic floor reconstructive surgery (PFRS) and to identify evidence gaps to guide development of evidence–based pathways. METHODS: After IRB approval, a PubMed review of the English–language literature using MeSH subheadings was conducted regarding multiple perioperative variables: bowel preparation, antibiotics, antiseptic skin preparation and hair removal, patient positioning, DVT prophylaxis, routes of anesthesia, postoperative analgesia, activity level, diet, and bowel regimen. Five representative operations were selected by approach: (1) sling only; (2) sling with prolapse repair, any route; (3) prolapse repair, vaginal; (4) prolapse repair, abdominal; and, (5) prolapse repair, robotic. Studies were graded using the Oxford Guidelines (Level 1–4), with Level 1 studies representing the highest level of evidence. Grades of recommendation (A–D) were assigned, with Grade A being the highest. RESULTS: Initial search yielded over 4000 potential manuscripts. Out of these, fewer than 150 usable manuscripts could be isolated regarding the chosen perioperative variables. AUA Best Practice Statements exist for prophylactic antibiotic use and DVT prophylaxis (Grade A). There is also Level 1 evidence supporting specific methods of antiseptic skin preparation and pubic/abdominal hair removal (Grade A). The quality of evidence regarding the remaining perioperative variables tends to be low (Grades C and D). The bulk of the information was found in the gynecological and general surgery literature, rather than in the urologic literature. CONCLUSIONS: At present, high–quality, evidence–based support for the way women undergoing PFRS are managed is lacking in several categories. Furthermore, the urologic literature is overall deficient in its content regarding perioperative management strategies. Based on the available literature, we present an evidence–based perioperative protocol for women undergoing PFRS with the future goal of prospective implementation. The ultimate goal is to optimize surgical satisfaction and minimize adverse events.