Marcella Zanzarini Sanson and G. Willy Davila Urogynaecological procedures are particularly well served as ambulatory procedures because most can be done via the vaginal approach, the anaesthetic time and surgical duration are rather brief, and post‐operative pain does not often limit discharge. In the United States, the Centers for Medicare and Medicaid Services (CMS – the national insurance plan for retirees) has classified most urogynecological procedures including vaginal hysterectomy and mid‐urethral slings as day‐surgery procedures. Most private insurance companies have followed suit and as a consequence, the standard of care in the United States is that most pelvic reconstructive procedures performed vaginally are performed as day‐care procedures. We have reported on our experience with a model of all vaginal procedures being performed as ambulatory same‐day surgeries. Overall, clinical outcomes are not negatively impacted, although, patient acceptance and satisfaction are greatly dependent on pre‐operative education. Outside of the United States, institutions have followed this pattern of shifting pelvic floor surgeries to the outpatient setting. Similar positive results in terms of clinical outcomes and patient satisfaction have been reported. This chapter will review the many steps pelvic reconstructive surgeons have taken, to safely and efficiently perform pelvic reconstructive surgeries as ambulatory day‐surgery cases. In ambulatory surgical procedures, general peri‐operative considerations have to be followed. These include avoidance of medications with anti‐coagulant properties, avoidance of pre‐operative constipation, and the implementation of enhanced recovery after surgery protocols (ERAS). Addressing specific aspects in the urogynaecological procedures and adopting ERAS protocols can make prolapse surgeries amenable to ambulatory care. The patient and her family should be involved in the decision to perform a procedure in the ambulatory setting. ERAS protocols utilise multidisciplinary teams to optimise patient outcomes with improved patient satisfaction and decreased hospital costs. ERAS protocols have been applied to urogynecologic surgery as well, with a positive impact being noted. Overall, when compared to traditional management, no significant differences were noted, except that ERAS patients were more likely to be discharged with a urinary catheter and had a slightly higher readmission rate but patient satisfaction was high. The essentials of ERAS protocols are based on four stages, all aiming to reduce surgical stress, maintain normal physiological function perioperatively, and expedite post‐operative recovery (see Table 8.1). The pre‐operative phase is an opportunity to educate patients, set expectations of what will occur before, during, and after the surgery. This includes a discussion regarding postoperative pain and a management strategy (see Table 8.2). At the time, the patient is advised to reduce alcohol consumption and quit smoking. Smoking cessation four weeks before surgery has been associated with fewer peri‐ and post‐operative complications. All medications, medical conditions, and nutritional status should be optimised before surgery. Precise ambulatory surgery protocols largely rely on the participation of the patient, her family, and the entire clinical team in order to achieve a successful and complication‐free ambulatory procedure. Preoperative discharge planning is key to a successful ambulatory vaginal surgery programme. Supportive family or friends will make recovery much more pleasant for the patient and this should be explored in the pre‐admission discussion. Frequently, family members include elderly spouses who may not be comfortable caring for a patient during the first few days after surgery. Education regarding pain‐medication dosing, assistance with ambulation, presence of vaginal bleeding, among other details specific to the procedure should be discussed during the informed‐consent process prior to surgery. A significant proportion of patients following a urogynaecological surgery may go home with a urinary catheter, and the possibility of post‐operative catheterization should be discussed. Up to 60% of patients undergoing pelvic floor surgery will need catheter drainage beyond the first day, so all should be made aware of the possibility of going home with a catheter. A frank discussion pre‐operatively regarding this is the key to managing expectations and to avoid a disappointed or unhappy patient. Table 8.1 Enhanced recovery after surgery (ERAS) protocol stages. Preoperative fasting increases catabolism that may affect peri‐operative outcomes. Reducing fasting to six hours for solid food and two hours for clear liquids improves surgical outcomes with no increased risk of aspiration. Pre‐operative bowel preparation should be avoided for patients undergoing benign gynecologic procedures. Even though patients can experience a high level of anxiety before surgery, long‐acting anxiolytics should be avoided. To minimise opioid exposure and control pain, multimodal non‐opioid analgesia can be administered immediately before entering the operating room: Acetaminophen (paracetamol, 1000 mg PO), Gabapentin (600–1200 mg PO) or Pregabalin (100–300 mg PO) and Celecoxib (200–400 mg PO) are examples of pre‐emptive pain therapy. Table 8.2 Peri‐operative pain‐management options.
8
Pelvic Organ Prolapse Surgery as an Ambulatory Procedure
General Requirements
Enhanced Recovery Protocols
The First Stage for ERAS is Pre‐admission
Stage of ERAS
Area of Focus
Intervention/Meds
Pre‐admission
Patient education
Medical optimization
Reduce alcohol consumption and stop smoking
Nutritional and physical condition
Explore home support
Pre‐operative
Reduce fasting time
Avoid mechanical bowel preparation
Analgesia
Intra‐operative
Minimally invasive surgery
Non‐opioid analgesia
Euvolemia
Normothermia
PONV prophylaxis
Post‐operative
Mobilisation
Euvolemia
Early dispositive removal
Early oral intake
Multimodal analgesia
The Second Stage of ERAS is Pre‐operative
Stage of ERAS
Medication options
Pre‐operative treatment
Celecoxib 400 mg PO
Gabapentin 600 mg PO
PONV prophylaxis
Dexamethasone 4–8 mg IV at incision
Ondansetron 4 mg before incision closure
Intra‐operative analgesia
Per anaesthesia routine
IV acetaminophen (paracetamol)
IV Toradol
Local lidocaine
Local bupivacaine liposome
Immediate post‐operative pain
Related posts:
Role of Nurse Practitioners in Ambulatory Urogynaecological Care
Ambulatory Management of Renal Stone Disease
Urethral Catheters and Ambulatory Management of Urinary Retention
An Ambulatory Approach to Benign Prostatic Obstruction
Magnetic Resonance Imaging in Urology
Common Urethral and Vaginal Lesions in Ambulatory Urogynaecology
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