AUGS-IUGA Joint Clinical Consensus Statement on Enhanced Recovery After Urogynecologic Surgery

ABSTRACT The field of urogynecology and female pelvic medicine and reconstructive surgery (FPMRS) is dedicated entirely to the goal of improving the lives of women who suffer from pelvic floor disorders, while both minimizing risks and maximizing efficacious treatments. Differences between local, regional, national, and even international surgical settings can have impacts on the well-documented catabolic state caused by patient stress surrounding surgical procedures. Although this state can include relative tissue hypoxia, increased insulin resistance, increased cardiac demand, and altered pulmonary and gastrointestinal function, the postsurgical paradigm shift through the cost-effective strategy Enhanced Recovery After Surgery (ERAS) is intended to promote rapid recovery, shorten hospital stay length, and decrease both the cost of particular surgical interventions and rates of complications. Multiple caretakers are involved in implementing an ERAS program. Anesthetists, surgeons, nursing staff from units caring for the patient, and an ERAS coordinator (typically a nurse or physician assistant) are all involved in counseling preoperatively, using primarily minimally invasive surgery routes, managing nutrition, avoiding opioid use and standardizing analgesia, and minimizing fluid and electrolyte imbalance. An adoption of ERAS protocols in urogynecology could potentially benefit patients by reducing pain and hastening recovery. Therefore, the primary objective of this report is an evaluation of existing evidence in gynecology and urogynecology (as well as additional fields such as colorectal or general surgery) to develop recommendations for the implementation and practice of an ERAS pathway. For this analysis, a collaboration between the review team and a research librarian allowed for the creation of a search in PubMed, which was also translated into various databases: Web of Science (Clarivate), CINAHL (EBSCO), Scopus (Elsevier), and Cochrane Central Register of Controlled Trials (Wiley). English language publications dated between January 1, 2001, and March 22, 2021, were included, with the application of 2 exclusion filters: an age filter to adapt to adult populations and a publication filter to eliminate editorials, case reports, and commentaries. Reference lists of acquired studies were cross-checked for additional relevant studies. Finally, the evidence base of each item was reviewed by 2 authors. Reviews of each study assessed the conclusions and strength of evidence for each article using the Grading of Recommendations, Assessment, Development, and Evaluation system. Following are various recommendations from the writing group on the application of ERAS in various circumstances: (1) ERAS specifically for the older population Standard ERAS protocol is both feasible and safe for patients undergoing colorectal resection, providing advantages such as shorter hospital stays and lower rates of postoperative morbidity. Although consensus is lacking for definitions of the terms “elderly” or “older,” consensus does exist for a strong recommendation in favor of ERAS for improving the care of this group. (2) Preadmission information, education, and counseling Clear communication between patient and physician about ERAS is critical to its success. Preoperative-visit discussions of ERAS can both reduce anxiety and increase patient satisfaction. It can also reduce pain and nausea, along with improve well-being. The recommendation is to give the patient information both in written and oral format. (3) Prehabilitation This aspect encompasses 4 principles: (1) resistance and aerobic exercises, (2) targeted functional exercises, (3) dietary interventions, and (4) psychological stress-reducing interventions that support behavior change for the benefit of overall well-being. The primary recommendation of prehabilitation is a multimodal approach encompassing dietary interventions, exercise, and psychological interventions for improving overall well-being. (4) Preoperative fasting and carbohydrate treatment and perioperative nutritional care Current evidence-based guidelines recommend a decrease in preoperative fasting time, allowing for the consumption of clear liquids and carbohydrate-rich beverages up to 2 hours before surgery. This recommendation has been associated with improved well-being, insulin resistance, and decreased nausea. The overall recommendation is to encourage patients to consume a light meal up to 6 hours preoperatively and clear fluids up to 2 hours before surgery. (5) Preoperative bowel preparation Evidence reports very little benefit to mechanical bowel preparation or rectal enema across surgery specialties. The recommendation is to avoid routine preoperative bowel preparation before urogynecologic surgery. (6) Standardized anesthetic protocol These protocols are a cornerstone of ERAS pathways and should be designed with the facilitation of rapid recovery in mind. Administration of sedatives for anxiety reduction purposes should be avoided. Local anesthesia plus sedation, regional anesthesia, and general anesthesia have all been used successfully for urogynecologic surgery. The recommendation is to use short-acting anesthetics and monitoring of neuromuscular block depth (and complete reversal). Protective strategies should be used with ventilation. Every use of anesthetic should facilitate a rapid recovery. (7) Perioperative management of intravenous fluids The overall goal of intraoperative fluid administration should be euvolemia, and the use of balanced salt solutions takes precedence over saline. Once a patient has resumed and tolerated oral hydration, intravenous fluid use should cease. (8) Antithrombotic prophylaxis Thorough evaluation of individual and surgical risk factors for VTE should take place as part of the preoperative assessment. Intermittent pneumatic compression is recommended for outpatient urogynecologic procedures. (9) Surgical site infection prophylaxis Gynecological procedures involving breach of the vaginal epithelium are considered clean-contaminated, which means genital or urinary tracts are entered “under controlled” conditions. Vaginal flora may instigate surgical site infection. Risk factors such as smoking, hyperglycemia, and obesity may all contribute to surgical site infection. (10) Minimally invasive surgical access When feasible, vaginal surgery, conventional laparoscopy, and robotic-assisted laparoscopy should all be considered over abdominal approaches to urogynecologic surgery. (11) Preoperative multimodal medications Postoperative pain is improved by perioperative acetaminophen and nonsteroidal anti-inflammatory drugs, whereas gabapentinoid administration may only have a modest effect on postoperative pain, but with adverse effect of respiratory and central nervous system depression. (12) Intraoperative analgesia There are no systemic adverse effects to appropriate use of incisional infiltration of local anesthetics and transversus abdominis plane block. As such these interventions should be considered routinely. (13) Postoperative multimodal medications Decreasing postoperative opioid use can be decreased via utilization of preoperative multimodal medications and postoperative oral acetaminophen and anti-inflammatory drugs. (14) Adjunctive techniques Significant limitation of postoperative inpatient narcotic use (and elimination of outpatient opioid use) can be attained using perineal ice packs. (15) Postoperative nausea, vomiting, and gut dysfunction Preoperative assessment of risk factors for postoperative nausea and vomiting should occur, and patient-specific risks should be the basis of prophylaxis administration. Drinking coffee, chewing gum, euvolemia, opioid-sparing analgesia, and early feeding are all safe, effective, and inexpensive ways to decrease the time it takes for bowel function to return. (16) Vaginal packing Routine vaginal drains and packing following vaginal surgery have no evidence of benefit and are therefore not recommended. (17) Trial without catheter/urinary drainage Length of hospital stay is shortened by the removal of the urinary catheter within 3 to 8 hours. Removing it as soon as is feasible with subsequent monitoring is ideal. (18) Same-day discharge Same-day discharge as part of ERAS pathways of urogynecologic surgery is both feasible and safe. It should be considered for properly selected patients. (19) Tracking of protocol adherence ERAS implementation takes a coordinated effort which ought to be led by individuals familiar with institutional protocols. Compliance with the various components of ERAS principles should be tracked, since compliance is correlated with clinical outcomes.