AUGS-IUGA Joint Clinical Consensus Statement on Enhanced Recovery After Urogynecologic Surgery: Developed by the Joint Writing Group of the International Urogynecological Association and the American Urogynecologic Society. Individual writing group members are noted in the Acknowledgements section.

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.

Sacrocolpopexy using autologous rectus fascia: Cohort study of long-term outcomes and complications.

OBJECTIVE: To evaluate objective and subjective outcomes of patients who underwent sacrocolpopexy using autologous rectus fascia to provide more data regarding non-mesh alternatives in pelvic organ prolapse surgery. DESIGN: Ambispective cohort study with retrospective and prospective data. SETTING: A single academic medical centre. POPULATION: Women who underwent abdominal sacrocolpopexy using autologous rectus fascia between January 2010 and December 2019. METHODS: Patients were recruited for a follow-up visit, including completing the Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Organ Prolapse Quantification (POP-Q) examination. Demographic and clinical characteristics were collected. MAIN OUTCOME MEASURES: Composite failure, anatomic failure, symptomatic failure and retreatment. RESULTS: During the study period, 132 women underwent sacrocolpopexy using autologous rectus fascia. The median follow-up time was 2.2 years. Survival analysis showed that composite failure was 0.8% (95% CI 0.1%-5.9%) at 12 months, 3.5% (95% CI 1.1%-10.7%) at 2 years, 13.2% (95% CI 7.0%-24.3%) at 3 years and 28.3% (95% CI 17.0%-44.8%) at 5 years. The anatomic failure rate was 0% at 12 months, 1.4% (95% CI 0.2%-9.2%) at 2 years, 3.1% (95% CI 0.8%-12.0%) at 3 years and 6.8% (95% CI 2.0%-22.0%) at 5 years. The symptomatic failure rate was 0% at 12 months, 1.3% (95% CI 0.2%-9.0%) at 2 years, 2.9% (95% CI 0.7%-11.3%) at 3 years and 13.1% (95% CI 5.3%-30.3%) at 5 years. The retreatment rate was 0.8% (95% CI 0.1%-5.9%) at 12 months and 2 years, 9.4% (95% CI 4.2%-20.3%) at 3 years and 13.0% (95% CI 6.0%-27.2%) at 5 years. CONCLUSION: Autologous rectus fascia sacrocolpopexy may be considered a safe and effective alternative for patients who wish to avoid synthetic mesh. TWEETABLE ABSTRACT: Sacrocolpopexy using autologous rectus fascia is a safe and effective alternative to synthetic mesh.

Postoperative Opioid Prescribing After Female Pelvic Medicine and Reconstructive Surgery.

OBJECTIVE: This study aimed to provide female pelvic medicine and reconstructive surgery (FPMRS) providers with evidence-based guidance on opioid prescribing following surgery. METHODS: A literature search of English language publications between January 1, 2000, and March 31, 2021, was conducted. Search terms identified reports on opioid prescribing, perioperative opioid use, and postoperative pain after FPMRS procedures. Publications were screened, those meeting inclusion criteria were reviewed, and data were abstracted. Data regarding the primary objective included the oral morphine milligram equivalents of opioid prescribed and used after discharge. Information meeting criteria for the secondary objectives was collected, and qualitative data synthesis was performed to generate evidence-based practice guidelines for prescription of opioids after FPMRS procedures. RESULTS: A total of 6,028 unique abstracts were identified, 452 were screened, and 198 full-text articles were assessed for eligibility. Fifteen articles informed the primary outcome, and 32 informed secondary outcomes. CONCLUSIONS: For opioid-naive patients undergoing pelvic reconstructive surgery, we strongly recommend surgeons to provide no more than 15 tablets of opioids (roughly 112.5 morphine milligram equivalents) on hospital discharge. In cases where patients use no or little opioids in the hospital, patients may be safely discharged without postoperative opioids. Second, patient and surgical factors that may have an impact on opioid use should be assessed before surgery. Third, enhanced recovery pathways should be used to improve perioperative care, optimize pain control, and minimize opioid use. Fourth, systemic issues that lead to opioid overprescribing should be addressed. Female pelvic medicine and reconstructive surgery surgeons must aim to balance adequate postoperative pain control with individual and societal risks associated with excess opioid prescribing.

Predictive Factors of Postdischarge Narcotic Use After Female Pelvic Reconstructive Surgery.

OBJECTIVE: The aim of the study was to evaluate the association of patient factors, amount of in-hospital postoperative narcotics, and pain scores on postdischarge narcotic use (PDNU). METHODS: This is a secondary analysis of a randomized controlled trial comparing a postoperative usual-care regimen with multimodal pain regimen after pelvic reconstructive surgery. This analysis evaluated patients in the multimodal arm. Postdischarge narcotic use (as mg oral morphine equivalents, MME, calculated from narcotic tablets remaining) was assessed postoperative days 7 to 10. Brief Pain Inventory (BPI) surveys were collected preoperatively and at postoperative day 1. Patient factors were evaluated using univariate and multivariate analysis. Correlations examined the relationships between PDNU and postoperative in-hospital narcotic use and BPI scores. RESULTS: Sixty-eight patients randomized to the multimodal pain regimen arm had median (interquartile range) PDNU of 22.5 (0-159.4) MME. After excluding postdischarge narcotic nonusers (34.8%), the median PDNU was 127.5 (22.5-180.0) MME. The median PDNU was 172.5 (150.0-180.0) MME after abdominal reconstructive surgery (n = 7), 82.5 (28.1-180.0) MME after laparoscopic reconstructive surgery (n = 22), and 37.5 (13.1-181.2) MME after vaginal reconstructive surgery (n = 14). A linear correlation was noted between the amount of postoperative narcotics used in-hospital and the amount needed postdischarge after abdominal (r = 0.588, P = 0.057), laparoscopic (r = 0.439, P = 0.019), and vaginal (r = 0.455, P = 0.017) reconstructive surgeries. The BPI scores on postoperative day 1 for "average" pain (r = 0.388, P = 0.002) and "now" pain (r = 0.490, P < 0.001), and on postoperative week 1 for "average" pain (r = 0.383, P = 0.002) and "now" pain (r = 0.389, P = 0.002) correlated with PDNU. CONCLUSIONS: Amount of postoperative in-hospital use of narcotic medications and BPI scores can be valuable predictors of PDNU in patients undergoing pelvic reconstructive surgery.

Decreasing postoperative narcotics in reconstructive pelvic surgery: a randomized controlled trial.

BACKGROUND: Postoperative pain control is crucial to any successful recovery plan. Many currently used medication regimens are narcotic-focused. OBJECTIVE: The objective of our study was to evaluate the efficacy of a multimodal pain regimen after pelvic reconstructive surgery. STUDY DESIGN: The primary outcome measure was narcotic use. Secondary outcomes included pain, nausea, and constipation. Patients were randomized to either usual care postoperative treatment or multimodal pain regimen. Usual care included no specific preoperative or intraoperative medications, and postoperative narcotics with ibuprofen. Multimodal pain regimen included preoperative and postoperative celecoxib, gabapentin, intraoperative and postoperative intravenous and oral acetaminophen and ibuprofen, and narcotics as needed. All narcotics were converted to milligram equivalents of oral morphine for standardization according to Centers for Disease Control and Prevention guidelines where conversion factors for oral hydrocodone = 1, oral oxycodone = 1.5, and oral hydromorphone = 4. Patients were given the validated Brief Pain Inventory survey preoperatively (baseline), at postoperative day 1, and 1 week postoperatively. At 1 week, bowel function and narcotics usage was assessed. RESULTS: Seventy patients were randomized to the usual care arm and 68 to the multimodal pain regimen arm. Patients in the multimodal pain regimen arm used significantly fewer intravenous narcotics in the operating room (90.7 ± 39.1 mg vs 104.6 ± 33.5 mg; P = .026) and while in the hospital (10.8 ± 15.1 mg vs 31.2 ± 29.6 mg; P < .001) and were more likely to use 0 oral narcotics after discharge to home (34.8% of patients vs 10.6%; P = .001). Of the patients who did use oral narcotics after discharge to home, there was no difference in amount used between groups (121.3 ± 103.7 mg in the multimodal pain regimen arm vs 153.0 ± 113.8 mg in the usual care arm; P = .139). Total narcotic usage (operating room + hospital + home) was significantly less in the multimodal pain regimen arm of the study (195.5 ± 147.2 mg vs 304.0 ± 162.1 mg; P < .001). There were no significant differences in pain scores between the 2 arms of the study on either postoperative time point. There were no significant differences in antiemetic use while in hospital, consistency of first bowel movement, length of stay, or number of telephone calls to nurses in first 3 weeks postoperatively. CONCLUSION: A multimodal pain regimen in pelvic reconstructive surgery was found to decrease postoperative opioid requirements, while providing equivalent pain control.

Readability of patient information pamphlets in urogynecology.

OBJECTIVE: The purpose of this study was to determine the reading level of frequently used patient information pamphlets and documents in the field of urogynecology. METHODS: Urogynecology pamphlets were identified from a variety of sources. Readability was determined using 4 different accepted formulas: the Flesch-Kincaid Grade Level, the simple measure of gobbledygook Index, the Coleman-Liau Index, and the Gunning Fog index. The scores were calculated using an online calculator (http://www.readability-score.com). Descriptive statistics were used for analysis. The average of the 4 scores was calculated for each pamphlet. Subsequently, Z-scores were used to standardize the averages between the reading scales. RESULTS: Of the 40 documents reviewed, only a single pamphlet met the National Institutes of Health-recommended reading level. This document was developed by the American Urological Association and was specifically designated as a "Low-Literacy Brochure." The remainder of the patient education pamphlets, from both industry-sponsored and academic-sponsored sources, consistently rated above the recommended reading level for maximum comprehension. CONCLUSIONS: The majority of patient education pamphlets, from both industry-sponsored and academic-sponsored sources, are above the reading level recommended by the National Institutes of Health for maximum patient comprehension. Future work should be done to improve the educational resources available to patients by simplifying the verbiage in these documents.