Surgical Decision-making and Patient Preparation for the Operating RoomChapter 1

Surgical decision-making for pelvic floor disorders in women is an art form. The surgeon needs to consider a number of different factors, including their own surgical expertise, patient characteristics, and unique procedure-related factors (Table 1.1). As a condition that affects a patient's quality of life, pelvic floor disorders can have a grave impact on a patient's activity level, mood, and fall-fracture risks. With this in mind, a female pelvic surgeon must constantly consider what outcomes will result in minimal risks, maximum benefits, and the best results (Fig. 1.1).

Patients undergoing urogynecologic surgical procedures require broad-spectrum antibiotics, usually with a first generation cephalosporin (i.e. Cefazolin 1g or 2g) in nonallergic patients. A combination of clindamycin (600 mg IV) and gentamicin (1.5 mg/kg IV) can be used in all others.² As in all gynecologic procedures, patients need a second dose of antibiotics when procedures take more than 4 hours, or blood loss is more than 1500 cc. In addition, some authors recommend use of prophylactic antibiotics during reconstructive and incontinence procedures for indwelling catheter use postoperatively, although evidence is sparse.³

Recent data suggests that in many surgical cases, including female pelvic medicine and reconstructive surgery (FPMRS), patients benefit from a standardized approach to pre-, intra- and postoperative management. Simple steps like managing pain with mutimodal analgesia and anesthesia (preoperative acetaminophen, gabapentin and celecoxib), intraoperative fluid management and postoperative care may result in enhanced recovery for patients. Postoperative regimens focus on pain management, bowel regimens, early mobilization, and early feeding. Many hospitals have incorporated their own protocols and have resulted in increased same-day discharges for minimally invasive procedures.⁴

Shaving prior to the operating room is generally not recommended and can be performed safely by surgeons in the operating room. Care should be taken to avoid close shaving, and hair clipping is preferred.⁵

There is currently no evidence that the use of bowel preparation enhances surgical outcomes, or improves visualization of the surgical field in open, vaginal, or laparoscopic procedures.^6,7

Patients undergoing surgery less than 30 minutes long and under the age of 40 with no additional risk factors, need only immediate postoperative mobilization. However, most patients undergoing pelvic floor surgery do not fall into this category. New guidelines from the ACOG Practice bulletin suggest that patients over the age of 60, may not benefit from intermittent pneumatic compression devices alone. In elderly patients undergoing procedures such as prolapse surgery, surgeons should consider adding low molecular weight heparin or unfractionated heparin for DVT prophylaxis.⁸

Elderly patients undergoing urogynecologic procedures generally have good outcomes, however assessing a patient's frailty may assist in surgical decision-making. Frailty, and not age, has been identified as a risk factor for poor outcomes in this population. Frailty assessment indexes, such as National Surgical Quality Improvement Program—Frailty Index (NSQIP-FI) may be useful in preoperative assessments. Also, physicians should consider geriatric depression screening.^9,10 An advanced directive, screening for substance abuse, assessments such as the Mini-Cog should be considered prior to surgery.¹¹

The surgical consent process in vaginal reconstructive surgeries can be time-consuming and complex. Careful consideration should be placed in understanding a patient's level of health literacy as well as ensuring appropriate translators are available when needed. Consenting may take up to one hour in complex situations, and ample time should be allowed to ensure understanding. Techniques such as “read-back” may be utilized to ensure patient understanding. Often counseling needs to include risks and benefits of multiple procedures in one patient: anterior, posterior repair, uterine morcellation, mid-urethral sling mesh, Fallopian tubes, and ovaries. We find that a handouts with images are useful in summarizing the large amount of information being transferred during the informed consent process. The website AUGS.org has many useful resources for patient counseling.