Evidence-Based GYN Surgery

Check out: https://www.ajog.org/article/S0002-9378(18)30583-0/fulltext

Remember the evidence-based C-section? Turns out, there is also good evidence for gyn surgery practices!

Preoperative - Includes things that are part of the ERAS protocol

1. Patient Education 

   • Two randomized control trials 

   • There was some potential association between preoperative patient education and improved outcomes (low level evidence) —> perhaps some decrease in length of stay and pain.

2. Bowel Prep

   • Minimally invasive gyn surgery:

     • Strong evidence that oral mechanical bowel prep should not be used.

   • In those with high risk of colorectal resection:

     • Based on colorectal surgery evidence, oral mechanical bowel prep alone is not effective 

     • Use of one of the following regimens can be considered: (moderate level evidence) 

       • Oral bowel prep AND oral antibiotic 

       • Oral antibiotic alone

3. Surgical site infection bundles - high level of evidence

   • High level of evidence - use of surgical site infection bundles should be considered! 

     • Listen back to our episode on “Infection Prevention and Gynecologic Surgery”: https://creogsovercoffee.com/notes/2019/10/13/infection-prevention-and-gynecologic-surgery

     • Sometimes, it’s not always just a single thing, but the whole bundle!

4. Glucose management 

   • Goal of <180 mg/dL (high level of evidence) 

5. Diet

   • Reduce fasting - may ingest solids until 6 hours prior to anesthesia induction and clear liquids until 2 hours prior to induction 

     • High level of evidence 

   • Carbohydrate loading - routine carbohydrate loading is recommended (moderate level of evidence) 

     • May ingest 2-3 hours up to induction of anesthesia - can include things like apple juice, ensure clear, etc. 

6. Pre-anesthesia medication 

   • Pain:

     • Combination of acetaminophen, COX-2 inhibitor (celecoxib, for example), and/or gabapentin - level of evidence is high!

   • Nausea:

     • Scopolamine, midazolam, or gabapentin (high level of evidence) 

7. VTE prophylaxis - moderate evidence 

   • Overall low rates of VTE in general, but preoperative intermittent pneumatic compression alone for patients undergoing MIS or laparotomy for benign disease

   • Weak evidence from observational studies supports adding preoperative pharmacologic prophylaxis for patients undergoing laparotomy for gynecologic malignancies  

Intra-operative 

1. Drains 

   • Routine NG tube - associated with patient discomfort and no known benefit (high level of evidence) - from the ERAS Society 

   • Routine peritoneal drains - not recommended routinely in gyn or onc surgery including cases with lymphadenectomy or bowel surgery

     • 2017 Cochrane Database showed drainage was not associated with reduced rates of lymphocyst formation. However, use of surgical drains increased rates of symptomatic lymphocyst formation when the pelvic peritoneum was left open 

     • Overall, moderate evidence  

2. Antibiotic prophylaxis

   • Given within 1 hour prior to incision per CDC and ACOG; redose prophylactic antibiotics for long procedures (ie. Ancef 3-4 hours after incision)

     • Level of evidence is high

3. Skin prep

   1. Ideally use 2% chlorhexidine and 70% isopropyl alcohol solution (high level of evidence) 

4. Blood transfusion (for hemoglobin 6-10) and fluids to maintain intraoperative euvolemia

5. Maintain normothermia 

6. Pain management - liposomal bupivicaine for laparotomy cases (moderate)  

Postoperative

1. Early mobilization - moderate level of evidence 

   • Has been shown to be beneficial and to avoid prolonged bedrest; basically meaning out off bed and mobilizing within 24 hours of surgery 

     • Reduces PEs and VTEs, also may protect against muscle atrophy and deconditioning 

2. Early alimentation 

   • Postoperative feeding - within 24 hours of surgery (can be as early as 4 hours after surgery with or without bowel resection) 

   • Two systematic reviews and 1 meta-analysis - early feeding is safe, well-tolerated and results in earlier return of bowel function and shorter LOS 

3. Early urinary bladder catheter removal (mod level evidence) 

   • Catheter use for < 24 hours, but appropriate to consider fall risk and necessity of urine output monitoring 

   • Uncomplicated surgeries: consider removal at 6 hours to balance rate of infection vs retention 

   • Complicated: morning after may be more appropriate (ie. urogyn or gyn onc cases) 

4. Prevention of ileus and accelerate return of bowel function

   • Use of postop laxatives (recommended for gyn surg, low level of evidence) 

     • Docusate sodium (Colace): more about its lack of utility here.

   • Chewing gum (high level of evidence) 

   • Alvimopan (novel peripheral u-opioid antagonist) - may not be beneficial in benign gyn 

     • However, may decrease ileus in ovarian cancer surgery and can be considered for use in patients undergoing bowel resection  

5. Early IV fluid discontinuation 

   • Discontinue maintenance IV fluids within 12-24 hours following surgery, especially with early PO intake (low level of evidence) 

     • Urine output as low as 20 mL/hour

       • Can be normal post op stress response 

       • Intervention not required 

6. Postoperative VTE: 

   • Mechanical prophylaxis for duration of hospitalization in all gyn surg patients 

   • Mechanical and/or pharmacologic prophy for gyn onc surgical patients (high level of evidence) 

     • Additionally, for oncology cases with laparotomy, should extend VTE prophylaxis for 4 weeks following surgery 

Uterovaginal Prolapse

Today we sit down with Dr. Julia Shinnick, one of our co-residents at Brown University and future FPMRS specialist, to talk through prolapse!

The POP-Q tool from AUGS is a helpful web-based tool (also with iPhone/iPad apps!) that can help you understand prolapse, as well as illustrate prolapse to patients in your practice.

One common quiz question are the levels of support. These are:

• Level I consists of the cardinal and uterosacral ligaments, and suspends the vaginal apex. Uterosacral/cardinal ligament complex, which suspends the uterus and upper vagina to the sacrum and lateral pelvic side wall. In a magnetic resonance imaging (MRI) study of asymptomatic women, the uterosacral ligaments were found to originate on the cervix in 33 percent, cervix and vagina in 63 percent, and vagina alone in 4 percent. Loss of level 1 support contributes to the prolapse of the uterus and/or vaginal apex.

• Level II consists of the paravaginal attachments, are what create the H shape of the vagina. The anterior vaginal wall is suspended laterally to the arcus tendineus fascia pelvis (ATFP) or “white line,” which is a thickened condensation of fascia overlying the iliococcygeus muscle. The anterior Level II supports suspend the mid-portion of the anterior vaginal wall creating the anterior lateral vaginal sulci. Detachment of these lateral supports can lead to paravaginal defects and prolapse of the anterior vaginal wall. There are also more posterior lateral supports at Level II. The distal half of the posterior vaginal wall fuses with the aponeurosis of the levator ani muscle from the perineal body along a line referred to as the arcus tendineus rectovaginalis. It converges with the ATFP at a point approximately midway between the pubic symphysis and the ischial spine. Along the proximal half of the vagina, the anterior and posterior vaginal walls are both supported laterally to the ATFP. 

• Level III consists of the perineal body and includes interlacing muscle fibers of the bulbospongiosus, transverse perinei, and external anal sphincter.  Loss of level 3 support can result in a distal rectocele or perineal descent.  

Remember — the treatments are generally conservative with pelvic floor PT; devices, such as pessaries; or surgeries.

Urinary Incontinence

On today’s episode, we visit with Dr. Kyle Wohlrab, who is an associate professor and urogynecologist at Brown University / Women and Infants Hospital of Rhode Island. He takes us through the basics of urinary incontinence.

Urinary incontinence is quite common: almost 1/3 of women in their lifetime. The Women’s Preventive Services Initiative even recommends annual standardized incontinence screening for women annually.

The mechanisms of incontinence include:
Stress - leakage with Valsalva (sneeze/laugh/cough/activity). Generally in small volumes.
Urge - aka overactive bladder; spasms or overactivity of bladder detrusor muscle that can prompt large volume leakage.
Mixed - a combination of the above; often one of the above types is “predominant.”

We review in the podcast many of the most important parts of a history and workup, but the most important aspect are the patient’s goals with respect to incontinence. This also will guide our therapy. Childbirth, obesity, and activities involving heavy weight bearing are some common risk factors.

One of the tests that can easily be performed, but many have limited experience with, is a simple cystometrogram. Essentially, one backfills the bladder. If during filling, one sees a rise in the meniscus, this is suggestive of detrusor overactivity. After filling with 200-300cc,, one can do a filled cough stress test to evaluate for stress incontinence.

Treatments vary by type of incontinence, but can be broken down into three categories for each type:
Stress - pelvic floor PT, vaginal inserts, and surgical therapy — midurethral sling, Burch urethropexy, urethral bulking.
Urge - pelvic floor PT and behavioral modification, medial therapies, and surgical therapies — neurostimulators.

For medical therapies for urge incontinence, antimuscarinic therapy is generally first line. Oxybutynin and trospium are the most commonly used medications in this class. Recall that antimuscarinic drugs have the “slow down” side effects of dry mouth/dry eyes, constipation, abdominal pain, and sedation. Newer medications in this class can have fewer side effects but can have difficulty with insurance coverage. Trospium is the newest medication that also doesn’t cross the blood-brain barrier, limiting neurologic side effects — especially useful in the elderly!

Beta agonists are another option for medical therapy with mirabegron. Rather than acting on muscarinic receptors, these act on beta agonists. These thus should be avoided in patients with uncontrolled hypertension.

When should someone refer to urogynecology? Dr. Wohlrab’s advice is to refer once someone has failed a line of therapy, or when patients begin looking for surgical therapy. Especially after listening today, we hope you’re comfortable with this workup and treatment!

Further reading from the OBG Project:
Urinary Incontinence – How to Make the Diagnosis in Your Office and When to Refer
Treating Urinary Incontinence Without Surgery: Options and Pearls
Prolapse and Stress Incontinence: Burch Procedure vs Midurethral Sling
Surgery for Urinary Incontinence – When the Sling’s the Thing