AUGS-IUGA joint clinical consensus statement on enhanced recovery after urogynecologic surgery

ABSTRACT

Introduction and hypothesis: Enhanced recovery after surgery (ERAS) evidence-based protocols for perioperative care can lead to improvements in clinical outcomes and cost savings. This article aims to present consensus recommendations for the optimal perioperative management of patients undergoing urogynecological surgery.

Methods: A review of meta-analyses, randomized clinical trials, large nonrandomized studies, and review articles was conducted via PubMed and other databases for ERAS and urogynecological surgery. ERAS protocol components were established, and then quality of the evidence was both graded and used to form consensus recommendations for each topic. These recommendations were developed and endorsed by the writing group, which is comprised of the American Urogynecologic Society and the International Urogynecological Association members.

Results: All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. The components of ERAS with a high level of evidence to support their use include fasting for 6 h and taking clear fluids up to 2 h preoperatively, euvolemia, normothermia, surgical site preparation, antibiotic and antithrombotic prophylaxis, strong antiemetics and dexamethasone to reduce postoperative nausea and vomiting, multimodal analgesia and restrictive use of opiates, use of chewing gum to reduce ileus, removal of catheter as soon as feasible after surgery and avoiding systematic use of drains/vaginal packs.

Conclusions: The evidence base and recommendations for a urogynecology-relevant ERAS perioperative care pathway are presented in this consensus review. There are several elements of ERAS with strong evidence of benefit in urogynecological surgery.

BACKGROUND

In urogynecology/female pelvic medicine and reconstructive surgery (FPMRS), a field dedicated to the improvement in quality of life of women who suffer from pelvic floor disorders, there is an inherent drive to minimize risk and maximize efficacious treatments. There are local, regional, national, and international differences in the setting for surgery, number of days of hospitalization, duration of catheterization and vaginal packing, and postoperative analgesia utilized after pelvic floor surgery. It is well known that surgical stress induces a catabolic state that leads to increased cardiac demand, relative tissue hypoxia, increased insulin resistance, and altered pulmonary and gastrointestinal function. Enhanced recovery after surgery (ERAS) is an evidence-based paradigm shift in perioperative care, proven to reduce both recovery time and postoperative complication rates, while also being cost-effective.^1,2 The goal of ERAS programs is to promote rapid recovery (by maintaining normal physiology in the perioperative period), as quantified by decreasing the length of hospital stay, complications, and cost of specific surgical interventions.³ ERAS is a multimodal, multidisciplinary approach to the care of the surgical patient. The process implementation involves a team consisting of surgeons, anesthetists, an ERAS coordinator (often a nurse or a physician assistant), and nursing staff from units that care for the surgical patient. ERAS pathways focus on counseling preoperatively, optimizing nutrition, standardizing analgesia and avoiding opioid use, minimizing electrolyte and fluid imbalance and using primarily minimally invasive surgical routes. After ERAS implementation, gynecological oncology patients experienced decreased length of admission, early return of bowel function and decreased narcotic use, resulting in high patient satisfaction.2 Adopting these protocols in urogynecology could benefit patients by reducing pain and hastening recovery⁴ —especially in the current climate of increased risk of hospital-acquired infections with prolonged hospitalization. The objective of this report is to evaluate the existing evidence in urogynecology and gynecology, and from other fields such as colorectal or general surgery, where specific evidence is unavailable regarding gynecological surgery on implementation of an ERAS pathway and develop recommendations for practice.

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Latthe P, Panza J, Marquini GV, et al.Urogynecology. 2022 Nov 1;28(11):716-734. doi: 10.1097/SPV.0000000000001252

REFERENCES

1. Perioperative Pathways: Enhanced Recovery After Surgery [Internet]. 2018 [cited 2020 Dec 12]. Available from: https://www.acog.org/ clinical/clinical-guidance/committee-opinion/articles/2018/09/ perioperative-pathways-enhanced-recovery-after-surgery

2. Nelson G, Bakkum-Gamez J, Kalogera E, et al. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations—2019 update. Int J Gynecol Cancer [Internet] 2019; [cited 2021 Feb 15];ijgc–2019– 000356. Available from: https://ijgc.bmj.com/content/early/2019/03/ 15/ijgc-2019-000356.

3. Smith TW, Wang X, Singer MA, et al. Enhanced recovery after surgery: A clinical review of implementation across multiple surgical subspecialties. Am J Surg 2020;219(3):530–534.

4. Carter-Brooks CM, Du AL, Ruppert KM, et al. Implementation of a urogynecology-specific enhanced recovery after surgery (ERAS) pathway. Am J Obstet Gynecol [Internet] 2018 [cited 2020 Dec 12]; 219(5):495.e1–495.e10. Available from: https://www.ajog.org/ article/S0002-9378(18)30496-4/abstract.