Enhanced recovery program for minimally invasive and vaginal urogynecologic surgery.

INTRODUCTION AND HYPOTHESIS: Enhanced recovery protocols (ERPs) are evidenced-based interventions designed to standardize perioperative care and expedite recovery to baseline functional status after surgery. There remains a paucity of data addressing the effect of ERPs on pelvic reconstructive surgery patients. METHODS: An ERP was implemented at our institution including: patient counseling, carbohydrate loading, avoidance of opioids, goal-directed fluid resuscitation, immediate postoperative feeding and early ambulation. Patients undergoing elective pelvic reconstructive surgery before and after implementation of the ERP were identified in this cohort study. RESULTS: One hundred eighteen patients underwent pelvic reconstructive surgery within the ERP compared with 76 historic controls. Reductions were seen in length of hospital stay (29.9 vs. 27.9 h, p = 0.04), total morphine equivalents (37.4 vs. 19.4 mg, p < 0.01) and total intravenous fluids administered (2.7 l vs. 1.5 l, p < 0.0001). Hospital discharges before noon doubled (32.9 vs. 60.2%, p < 0.01). More patients in the ERP group ambulated on the day of surgery (17.1 vs. 73.7%, p < 0.01) and ambulated at least two times the day following surgery (34.2 vs. 72.9%, p < 0.01). No differences were seen in average pain scores (highest pain score 7.39 vs. 7.37, p = 0.95), hospital readmissions (3.9 vs. 3.4%, p = 0.84), or postoperative complications (6.58 vs. 8.47%, p = 0.79). Patient satisfaction significantly improved. ERP was not associated with an increase in 30-day total hospital costs. CONCLUSIONS: Implementation of ERP for pelvic reconstructive surgery patients was associated with a reduced length of hospital stay, improved patient satisfaction, and decreased administration of intravenous fluids and opioids without an increase in complications, readmissions, or hospital costs.

Effects of aging on lower urinary tract and pelvic floor function in nulliparous women.

OBJECTIVE: To evaluate the effects of aging, independent of parity, on pelvic organ and urethral support, urethral function, and levator function in a sample of nulliparous women. METHODS: A cohort of 82 nulliparous women, aged 21-70 years, were recruited from the community through advertisements. Subjects underwent pelvic examination using pelvic organ prolapse quantification, urethral angles by cotton-tipped swab, and multichannel urodynamics and uroflow. Vaginal closure force was quantified using an instrumented vaginal speculum. Subjects were grouped into five age categories and analyses performed using t tests, Fisher exact tests, Kruskal-Wallace, and Pearson correlation coefficients. Multiple linear regression modeling was performed to adjust for factors that might confound the results of our primary outcomes. RESULTS: Increasing age was associated with decreasing maximal urethral closure pressure (r=-0.758, P<.001) with a 15-cm-H(2)O decrease in pressure per decade. Pelvic organ support as measured by pelvic organ prolapse quantification did not differ by age group. Levator function as measured by resting vaginal closure force and augmentation of vaginal closure force also did not change with increasing age. CONCLUSION: In a sample of nulliparous women between 21 and 70 years of age maximal urethral closure pressure in the senescent urethra was 40% of that in the young urethra; increasing age did not affect clinical measures of pelvic organ support, urethral support, and levator function. LEVEL OF EVIDENCE: III.

Practicalities and pitfalls of pessaries in older women.

Pelvic floor disorders are known to increase with age. With the number of elderly women more than doubling in the coming decades, gynecologists will need to be skilled in the assessment and treatment of these conditions. Conservative forms of therapy such as pessaries can often be successfully employed. These devices are well suited for elderly patients as they are noninvasive with minimal risk, provide immediate relief of symptoms, and are cost-effective compared with surgery. Although there are some downsides in using pessaries in clinical practice, many of these pitfalls can be appropriately addressed with education and training of clinician and patients.