Thorough preoperative evaluation and perioperative care is essential in preparing a patient for urogynecologic surgery. The goal of preoperative care should not be to simply “clear the patient for surgery.” Rather, the purpose is to evaluate the patient’s overall health and optimize medical conditions in order to reduce surgical morbidity and ensure a rapid return to normal function in the postoperative period. Urogynecologic surgery differs from gynecologic oncology and other urgent or emergency surgery in that these cases are elective procedures treating conditions that have a major impact on a patient’s quality of life. Varied treatment options to choose from makes the informed consent process challenging and time consuming. This chapter will review the important components of informed consent, pertinent preoperative evaluation that will aid in risk stratification, and perioperative management to improve patient safety.

Informed consent prior to surgery is an ethical and legal requirement involving direct physician–patient communication in order to arrive at the best treatment for each individual patient.¹ The surgical consent process has two essential components: informed consent and patient comprehension. The patient is given sufficient information to arrive at a voluntary decision regarding acceptance or rejection of the surgical treatment plan. Following this discussion, the patient’s understanding of the procedures, risks, benefits, and alternatives should be confirmed. The consent process ensures patient autonomy by protecting against unwanted procedures and encouraging active involvement in her medical decisions and care. When an individual is suspected to have limited comprehension, a psychiatric capacity assessment is required. If a patient is deemed incapable of informed consent, an appropriate surrogate must be assigned to complete the informed consent process.

Informed consent should be a process of open communication describing the benefits and risks of the proposed procedure as well as the surgical and nonsurgical alternatives. Physicians must advise their patients with accurate and unbiased information. Potential complications of the proposed surgery should be discussed including anesthesia risks, injury to adjacent organs, infection, pain, bleeding, blood transfusion, deep vein thrombosis and pulmonary embolism, and postoperative complications. If grafts are being utilized, a detailed evidence-based discussion should be held regarding the risks and benefits of the medical devices and implants including relevant FDA warnings. When new devices are used, patients should be made aware of the surgeons’ experience with the device and the limited outcome data.

The possibility of unexpected findings at surgery should also be discussed, such as conversion from laparoscopy to laparotomy in cases of severe pelvic adhesive disease or other conditions making conversion necessary to complete the procedure. If an intraperitoneal approach is planned, ovarian conservation issues should be reviewed including family history of ovarian cancer, lifetime risk of ovarian cancer, and hormonal status if one or both ovaries are removed. This discussion should include a plan for incidental findings of ovarian pathology.

Another important aspect of informed consent involves a discussion about operating room personnel.¹ Patients should be made aware of the presence and degree of involvement of surgical assistants, residents, and medical students, especially at teaching institutions. If a patient declines trainee participation in their surgery, this needs to be reconciled between the primary surgeon and the patient prior to the procedure.

Consent requirements vary by state and institution. As a result, physicians must be familiar with federal and state legal requirements for informed consent as well as their institutions’ policies.¹ The patient’s informed consent should be documented and signed preoperatively in the medical record with appropriate witnesses.

History and Physical Examination

A complete history and physical examination should be performed on all patients undergoing urogynecologic surgery. This should be done within 30 days prior to surgery and updated with any changes on the day of the procedure. The preoperative evaluation may be performed by the surgeon, the patient’s primary care physician, or a medical provider at a preoperative clinic. A detailed history should include underlying medical conditions, prior surgeries and anesthesia complications, prior transfusions, and allergies. The physician should also perform a complete updated review of systems to make sure there are no acute changes prior to surgery. Symptoms such as dyspnea, angina, palpitations, or leg swelling may identify serious underlying cardiac conditions. The patient’s family history should be obtained, with special attention to coagulopathies or adverse reactions to anesthesia. A complete list of current medications with the timing of each dosage should be recorded, including use of herbal and over-the-counter medications.² Substance use and dependence should be documented, such as tobacco, alcohol use, and illicit drugs. Also, the patient’s current living situation and access to postoperative support should be considered for major operations where functional status may be compromised for days to weeks after surgery.

The medical history should also seek to determine the patient’s functional capacity, which allows better risk stratification prior to surgery.^2,3 The Duke Activity Status Index is a questionnaire that can be used to illustrate functional capacity based on common daily tasks performed by the patient.⁴ Common daily tasks, such as those listed in Table 24-1, have estimated energy requirements known as metabolic equivalents (METs). A MET score <4 indicates poor functional capacity (class III or IV) and places the patient at higher risk of perioperative morbidity and cardiac events.^3,4 Generally, patients planning to undergo elective urogynecologic surgery should have MET scores ≥4 corresponding to a functional class I or II unless the procedure is so minimally invasive that the risk will be limited (colpocleisis, sling, periurethral injections, etc) or they have been evaluated adequately by their cardiologist who supports that the risk of an elective procedure does not outweigh the potential benefits of an elective procedure.

Physical examination should include complete vital signs with temperature, blood pressure, heart rate, height, and weight. Cardiac and pulmonary examination should include assessment of jugular venous pressure, auscultation of the heart, lungs, and carotids, and examination of the extremities for edema and vascular perfusion.²

The physician should also palpate the thyroid, perform a baseline neurologic survey, and do an abdominal examination including wound/scar assessment. The appropriate pelvic and genitourinary examination should be performed depending on the proposed surgery.

Laboratory Tests

Preoperative laboratory testing should only be ordered when necessary. A routine test is defined as a test that is ordered without a specific clinical indication. The American Society of Anesthesiologists does not recommend routine laboratory tests unless clinically indicated.⁵ The criteria for determining whether a preoperative laboratory test is indicated include whether the test will properly identify abnormalities, change the diagnosis, change the physician’s management, or affect the patient’s outcome.⁶ Ordering unnecessary laboratory tests is expensive and can lead to additional testing. When incidental abnormal findings are noted, this can increase patient anxiety, and delay surgical scheduling.⁶

Preoperative testing should be individualized based on the patient’s underlying risk factors such as age and comorbid conditions. There are no standardized routine guidelines for preoperative laboratory testing. All tests should be justified based on a specific sign, symptom, or diagnosis.³ A blood type and screen or type and cross should be considered for cases with increased surgical bleeding risk or for those with a history of transfusion that may have acquired abnormal blood antibodies. Other tests to consider include a complete blood count, chemistry profile, coagulation studies, liver function tests, urinalysis, and a pregnancy test. Table 24-2 displays suggested clinical indications for specific laboratory tests. Hemoglobin A1C levels should be measured in diabetic patients to assess overall glycemic control on their diabetic medical regimen.

Pregnancy testing in reproductive-aged women should be considered if there is a possibility of pregnancy.^5,6 History and physical examination may fail to detect early pregnancy, and therefore testing in all reproductive-aged women is advised. A positive pregnancy test will likely change management and the scheduled procedure could be delayed or cancelled depending on the indication for surgery.

Radiographic Studies

Radiographic studies should not be routinely performed unless clinically indicated. The physician should consider ordering a chest x-ray if the patient has active signs or symptoms of pulmonary disease or cardiac disease, or a recent acute episode of asthma or chronic obstructive pulmonary disease.^3,5 Other imaging studies, such as computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound, may be ordered if clinically indicated to further evaluate a suspected condition or for preoperative planning in certain cases.

Cardiovascular Evaluation

Patients undergoing noncardiac surgery are at risk of cardiovascular morbidity and mortality. Perioperative myocardial infarction is attributed to the individual’s underlying cardiovascular risks in addition to cardiac stress from the surgery and postoperative fluid shifts. Advancing age is a risk factor for perioperative cardiac events due to underlying ischemic heart disease.^7,8 Elderly women ≥75 years old undergoing urogynecologic surgery are at increased risk of perioperative complications if they have a history of coronary artery disease or peripheral vascular disease.⁹ Although overall mortality risk after urogynecologic surgery is low (0.04%), the risk of death increases with age with an odds ratio (OR) of 3.4 for women ages 60 to 69, OR 4.9 for ages 70 to 79, and OR of 13.6 for ages ≥80.¹⁰ As the aging population continues to expand along with an increase in the prevalence of pelvic floor disorders and demand for urogynecologic procedures, thorough preoperative cardiac evaluation is important to decrease perioperative and postoperative morbidity and mortality.¹¹ Communication and close coordination of care between the surgeon, anesthesiologist, primary care physician, and cardiologist is critical for women with high cardiac risk undergoing urogynecologic surgery.

The surgeon or consulting physician must determine who is a candidate for baseline cardiovascular evaluation. Preoperative cardiac testing is recommended if the test results will change perioperative management.⁷ Routine ordering of electrocardiograms (ECGs) is not recommended and is not necessarily predictive of postoperative complications.⁶ The American College of Cardiology and the American Heart Association (ACC/AHA) published guidelines in 2007 for perioperative cardiovascular evaluation for noncardiac surgery.¹² Cardiac risk stratification is defined by the type of procedure including vascular surgery and intermediate- and low-risk procedures. Intermediate-risk procedures include those that involve intraperitoneal surgery. Low-risk procedures are defined as endoscopic procedures, superficial procedures, and ambulatory surgery. For urogynecologic surgery, those surgeries that are short with minimal fluid shifts may be classified as low risk, whereas those surgeries that are prolonged, or intraperitoneal, with large fluid shifts and greater potential for cardiac complications and respiratory depression may be classified as intermediate risk.

ACC/AHA guidelines state preoperative ECGs are reasonable to order for patients with at least one clinical risk factor who are undergoing intermediate-risk operative procedures.¹² Clinical risk factors are listed in Table 24-3 and include patients with diabetes mellitus and renal insufficiency. ECG is also recommended for patients with known coronary heart disease, peripheral arterial disease, or cerebrovascular disease planning to undergo intermediate-risk procedures. Preoperative ECG is not indicated in asymptomatic patients undergoing low-risk surgical procedures. Routine age-based criteria for ordering preoperative ECG are controversial. However, many institutions report age-based criteria for preoperative ECG starting at age 50.^3,6 Noninvasive stress testing may be indicated in patients with underlying cardiac conditions or abnormalities on their resting ECG, as well as for patients with clinical risk factors combined with poor functional capacity or METs <4.

Patients with active cardiac conditions, such as unstable or severe angina, recent myocardial infarction, heart failure, cardiac arrhythmias, and severe valvular disease, should be evaluated more extensively in conjunction with the patient’s primary care physician and cardiologist. Patients suffering from a recent myocardial infarction should wait a minimum of four to six weeks to proceed with elective surgery.² Patients with active cardiac conditions will likely require more invasive cardiac testing to clear them for surgery and their condition may result in a delay or cancellation of the surgery unless the proposed surgery is urgent.

Many hospitals have prepared order sets for preoperative care to improve compliance with such important items as antibiotic and thromboembolic prophylaxis. These sets usually include intravenous orders, tests to be done on the day of surgery such as glucose monitoring for diabetics, and medications to take or avoid on the morning of surgery. Some sets will also include information about advance directives. Patients should be encouraged to bring a copy of their advanced directives when available.