Scoping review of evidence-based postoperative recommendations following urogynecology surgery

Introduction

Background

Most gynecologic and urogynecology surgeons recommend activity restriction in the immediate postoperative period. These activity restrictions often include lifting restrictions, pelvic rest and general limitations on activity. The goal of these restrictions is to improve surgical healing, decrease adverse events and surgical failures. Historically, these restrictions were thought to decrease the risk of surgical complications, such as vaginal cuff dehiscence and recurrent prolapse. More recent literature, however, brings this into question (1-3). A literature review conducted in 2013 looked at activity restrictions that are commonly imposed by gynecologic surgeons and found that at that time there were no randomized controlled trials or prospective cohort studies looking at associations between postoperative restrictions and surgical success following urogynecologic surgery (1). Presently, most postoperative recommendations are based on expert opinion and the belief that reducing intraabdominal pressure will decrease postoperative complications and prolapse recurrence without evidence to support these claims.

Rationale and knowledge gap

There is a growing body of evidence in the orthopedic literature that taking a more active approach to postoperative recovery, rather than activity restrictions, improves healing and overall return to function (4-7). In addition, there are now prospective and randomized trials looking at activity restrictions in urogynecology surgery. Despite these new studies, there is still a large variation in the postoperative recommendations given after gynecologic and pelvic reconstructive surgery (8). There is still minimal evidence guiding our postoperative restrictions and there is little known about the effect of activity on surgical success which leads to wide variations in prescribed postoperative recommendations.

Objective

The objective of this review is to synthesize the existing data on postoperative recommendations and restrictions within gynecologic and pelvic reconstructive surgery and to give a framework of evidence-based recommendations for postoperative recovery. We present this article in accordance with the PRISMA-ScR reporting checklist (available at https://gpm.amegroups.com/article/view/10.21037/gpm-23-51/rc).

Methods

We conducted a scoping review using a comprehensive search to identify studies discussing post-operative restrictions and recommendations after urogynecologic and benign minimally-invasive gynecologic surgery. Scoping reviews serve the purpose of identifying and mapping the available evidence, synthesizing that evidence and identifying gaps in knowledge (9).

Data from all study types were included. No article type restrictions were included in the search strategy. Only English-language articles were considered. Searches were conducted on November 5, 2023 in the electronic databases: PubMed (1946 to 5 Nov 2023), and the Cochrane Library (1996 to 5 Nov 2023). Articles were identified with a combination of free text and MeSH terms. The search strategy included all appropriate controlled vocabulary and keywords for minimally-invasive gynecologic surgery, urogynecologic surgery, post-operative restrictions, post-operative recommendations, pelvic rest, lifting restrictions, general activity restrictions, and bladder/bowel recommendations (Table 1). Abstracts and full-text articles were screened. Studies were categorized into six domains: general activity recommendations, lifting restrictions, pelvic rest, bowel and urinary function, postoperative opioid use, and postoperative visits. Eligible studies were categorized accordingly for potential analysis. A total of 741 articles resulted from the initial query. Reference lists of included studies were reviewed to identify any additional studies missed by database searches. All identified articles were fully recovered and evaluated separately by two reviewers (R.C., E.M.S.) for inclusion. Abstracts were screened manually. The subsequent review identified 73 papers. Full text review was completed by two authors (R.C., E.M.S.) with author (S.C.) available to resolve any conflicts about inclusion for this review.

Short-listed articles then were obtained in full text and were evaluated; the studies that met inclusion criteria were included. Risk of bias was assessed independently by two investigators and adjudicated by a third. Articles were screened for eligibility, and ultimately 24 studies were included in this review. The full search strategy is available from authors by request (Figure 1).

Figure 1 Flow diagram showing study selection.

Results

General activity recommendations

General activity recommendations are based on five different studies, including two randomized controlled trials, two prospective studies and one scoping review that included 34 articles.

Prior to discussing postoperative recommendations, it is prudent to define what the postoperative period is. There are multiple definitions and no consensus on what defines the postoperative period, however, most of the manuscripts included in this review defined the period between 6–12 weeks following surgery (1-3). Activity restrictions and the length of recommended restrictions are highly variable following gynecologic and pelvic reconstructive surgery (8). These activity restrictions range broadly from limiting high impact or vigorous physical activity to limiting housework that requires any pushing or lifting. These restrictions are vague and often confusing to patients. In 2013, Nygaard et al. conducted a review looking at postoperative restrictions and their effect on surgical success. They found no prospective or randomized trials to guide whether these restrictions have an effect on recurrent prolapse (1). In addition, there is no prospective data to guide the length of time that these restrictions should be prescribed for.

A mixed-methods trial looking retrospectively at a cohort of women who underwent prolapse reconstruction surgery and comparing prolapse recurrence in a prospective cohort of women undergoing prolapse reconstructive surgery and a shortened postoperative restrictions period was conducted in a Danish population between 1996–2000 (10). In the retrospective study, patients had been recommended a convalescence of median 6 weeks (range, 1–12 weeks) for most activities. The subjective recurrence rate was 22% within median 6 months (range, 0–24 months). In the prospective study, convalescence was median <1 week for most non-strenuous activities, <2 weeks for light work and <4 weeks for sexual intercourse, sports and work with lifts exceeding 10 kg and the 1-year subjective recurrence rate was 17% (10). This study supports the idea that activity does not increase prolapse recurrence or surgical failures. We can likely shorten the time of restrictions to allow for patients to return to normal activities more quickly without risking anatomic outcomes.

In addition, Mueller et al. conducted a randomized control trial comparing patient satisfaction and pelvic floor symptoms in patients with restrictive versus liberal postoperative recommendations (2). The participants in the study all underwent minimally invasive reconstructive pelvic surgery for pelvic organ prolapse. The participants were then randomized to either liberal or restricted postoperative activity recommendations. The liberal group was told to resume postoperative activities at their own pace and had no restrictions on lifting or high impact activity. The restrictive group was told to refrain from heavy lifting or high impact activity for 3 months. Their study found that patients are equally satisfied with their outcomes despite their postoperative restrictions, there were no differences in anatomic outcomes between the two groups and the group with liberal restrictions had fewer pelvic floor symptoms. This study further supports the idea that activity does not contribute to anatomic failures and further suggests that increasing activity may decrease pelvic floor symptoms in the postoperative period.

Another consideration is whether patients are compliant with our postoperative recommendations. If they are not, it is unlikely that our recommendations have a large effect on their postoperative outcomes. A randomized control trial conducted by Arunachalam et al. looked at the impact of postoperative instructions on activity measures in the postoperative period following prolapse reconstructive surgery. This study looked at physical activity measured on the Activities Assessment Scale (AAS) and accelerometers between patients who received liberal versus restrictive postoperative instructions and concluded that their activity did not defer despite which instructions they were given (3). This study suggests that patients are likely to return to activities based on other factors, rather than physician prescribed activity recommendations alone.

There is an overall lack of prospective evidence to guide activity recommendations in the postoperative period, although more research in this area is emerging. The limited data we have suggests that activity restrictions do not affect postoperative anatomic outcomes or prolapse recurrence, although these studies only have short term data (2,3). In addition, these studies suggest that more liberal activity restrictions may improve pelvic floor symptoms that patients often experience postoperatively. In addition to the considerations on prolapse recurrence and pelvic floor symptoms, we must consider the implications of inactivity on the general health of the patient. Patients are at increased risk of venous thromboembolism, atelectasis and mental health decline in the postoperative period and ambulation is known to decrease these risks. Therefore, based on the available data we recommend daily walking and ambulation to the patient’s ability with liberal postoperative activity recommendations including restarting high impact activities and lifting as able.

Lifting restrictions

This section includes three studies, including one randomized controlled trial, one prospective study and one scoping review that cites 34 other studies.

Postoperative restrictions on heavy lifting are common within benign gynecologic and reconstructive pelvic surgery. These restrictions again vary widely in terms of the amount of lifting (weight) and the length of implementation. For example, a survey of Danish gynecologists regarding post-operative restrictions after uncomplicated anterior or posterior vaginal prolapse repair found substantial variability in post-operative recommendations. Recommended lifting restrictions were median 3 kg (range, 0–20 kg) for median 4 weeks (range, 1–12 weeks). The recommended convalescence was median 4–5 weeks for strenuous activities, and median 1–2 weeks for non-strenuous activities, with ranges from 0–24 weeks (8). Restrictions on lifting are thought to decrease the intraabdominal pressure and therefore decrease the risk of surgical complications and surgical failure of prolapse or incontinence repair. However, there is limited data on the effectiveness of restricting weightlifting on surgical success or the amount or length of time that should be restricted (1,11).

Studies have tried to quantify the amount of intrabdominal pressure that is generated by lifting heavy objects. A study conducted by Weir et al. looked at intraabdominal pressures generated by different activities including lifting an 8-pound weight from the counter to overhead, lifting a 35-pound weight from the ground to overhead, walking briskly, going upstairs and doing abdominal crunches. These were then compared to intraabdominal pressures produced by activities that cannot be restricted (i.e., going from sitting to standing position) (11). They found that there is considerable overlap in the intraabdominal pressures between these activities. For example, the intrabdominal pressure generated from lifting 35 pounds from the ground to overhead ranged from 65–335 cmH2O compared with a range of 36–229 cmH2O generated from going to sit to stand. These findings further question whether there is any evidence to support these restrictions.

Lifting restrictions in the postoperative period are based primarily on the theory that elevated intraabdominal pressures will increase the risk of surgical failures and prolapse recurrence. The current evidence shows that the intraabdominal pressures generated by heavy lifting vary widely and overlap significantly with the intraabdominal pressures generated by everyday activities that cannot or are not usually restricted (11). In addition, there is no current evidence that guides the length of lifting restrictions (although typically 6–12 weeks) or the amount of weight (commonly 10–20 pounds). Since there is no current evidence to recommend weightlifting restrictions or an appropriate weight or length of time, current recommendations are based on expert opinion and typically include restricting heavy lifting (greater than 10–20 pounds) for 6–12 weeks.

Pelvic rest

The section on pelvic rest recommendations is based on two studies, one prospective study and one guidelines paper.

Pelvic rest refers to a set of restrictions typically involving abstaining from penetrative vaginal intercourse and sometimes other pelvic-related activities (like inserting tampons or devices in the vagina) for a specified period. The specific recommendations may vary depending on the type of surgery performed and individual patient factors. Data regarding evidence for these restrictions are limited and based on Expert Opinion.

A 6-week minimum period of pelvic rest is recommended on the basis of expert opinion (12) following any surgery where there are vaginal incisions or removal of the uterus with vaginal cuff closure. The recommendation for a period of pelvic rest is based on the need for adequate healing of the surgical site and to reduce the risk of complications, including infection, bleeding, hematoma formation, and vaginal cuff dehiscence. The specific duration may vary depending on the type of hysterectomy performed and individual patient factors.

A survey of Danish gynecologists regarding post-operative restrictions after uncomplicated anterior or posterior vaginal prolapse repair found substantial variability in post-operative recommendations regarding pelvic rest. The recommended time till recommencement of sexual intercourse was median 4 weeks (range, 0–12 weeks) (8).

The 6-week minimum period of pelvic rest is commonly advised to reduce the risk of complications, such as bleeding or infection, to promote wound healing, to minimize strain on the surgical area. The 6-week pelvic rest recommendations also align with postoperative follow-up appointments. During these visits, healthcare providers can assess the healing progress, address any concerns, and provide further guidance on resuming normal activities.

Pelvic rest is based on expert opinion and there is no level 1 evidence to support its use. However, due to the large potential for morbidity in the setting of vaginal cuff dehiscence or pelvic infection, we support continued recommendations for pelvic rest. There is no prospective data to guide the length of pelvic rest. It is reasonable to correlate pelvic rest with follow up visits in order to fully assess the vaginal cuff and ensure complete healing.

Bowel and urinary function

Bowel and urinary function results were synthesized from eight different articles. These articles included six randomized controlled trials and two reviews articles, one of which was a systematic review.

After gynecological surgery, there can be temporary restrictions on activities, including those related to bowel and bladder function. The specific restrictions can vary depending on the type of surgery performed, individual patient factors, and the surgeon’s preferences.

All patients undergoing pelvic surgery, especially for the correction of incontinence or prolapse, should have an assessment of voiding function prior to discharge (13). There are several ways to assess voiding function—the gold standard is by measuring a postvoid residual. A systematic review by Dieter investigated postoperative voiding trial methodology and timing of postoperative voiding trial following benign gynecologic or urogynecologic surgery. They found similar outcomes between backfill-assisted voiding trial and autofill voiding trial, including time to discharge, time to spontaneous void, duration of catheterization, patient burden, UTI rate, and rate of urinary retention, with insufficient evidence to recommend an optimal voiding trial methodology (14). The literature does support completion of a voiding trial when appropriate in an early (i.e., POD#0) time frame after surgery. Ishino et al. evaluated active versus passive voiding protocols in the setting of a same-day benign gynecologic minimally invasive hysterectomy. They found that patients who underwent passive voiding trials compared with those who underwent active voiding trials were discharged home from the PACU after a shorter duration. In addition, a larger proportion of the patients who underwent passive voiding trials were discharged home without a urinary catheter (15).

When patients fail voiding trials, several strategies exist to manage the retention: clean intermittent catheterization or transurethral catheters which can either be continuously drained or plug-unplugged. Boyd et al. compared effects on activity between two catheter management systems (plug-unplug or continuous drainage catheters) after failed voiding trial after pelvic reconstructive surgery. They performed an randomised controlled trial (RCT) which found that postoperative activity does not differ in patients discharged with plug-unplug or continuous drainage catheters, but those with plug-unplug reported easier management and ability to complete activities of daily living (16). Therefore, all patients should be assessed for urinary retention in the immediate postoperative period and prior to discharge home. There is no evidence to recommend an active or passive voiding trial.

Additional weak post-operative recommendations pertain to decreasing the risk of lower urinary tract symptoms. Russo et al. performed a RCT that demonstrated that the use of an oral supplement containing cranberry, D-mannose and anti-inflammatory molecules decreases the perception of lower urinary tract symptoms in postmenopausal women after anterior colporrhaphy (17). It is reasonable to consider a cranberry and D-mannose supplement in the postoperative period.

There is a growing evidence base to support bowel regimens in the post-operative period. Stool softeners or laxatives may be prescribed to prevent constipation, which can be common after surgery.

An RCT conducted by Edenfield evaluated time to first bowel movement between women receiving docusate sodium alone compared with a regimen of polyethylene glycol 3350 (Miralax) and docusate sodium after urogynecologic surgery. They found that the addition of Miralax did not significantly reduce time to first bowel movement after surgery compared with placebo (18). Chewing gum was found to have beneficial effects on bowel motility and postoperative pain in patients undergoing laparoscopic hysterectomy (19,20). A prospective randomized study demonstrated that chewing gum combined with an oral intake of a semi-liquid diet is safe and accelerates the postoperative recovery of bowel function (20). While it is common practice to prescribe stool softeners and laxatives to prevent constipation, there is little evidence to support its use in prevention. Stool softeners and laxatives are commonly used in the treatment of constipation in the postoperative period and this has been well-studied. It is reasonable to recommend chewing gum to accelerate return to bowel function.

Postoperative opioid use

The postoperative opioid use section is based on two studies, one prospective study and one guideline paper that included information from 47 articles.

Postoperative pain control is an important component of postoperative care as it affects postoperative healing and function, as well as patient satisfaction. Most patients will use opioid medications for pain control in the immediate postoperative period, however, opioid medications have known disadvantages including increased risk of constipation, cognitive changes and opioid dependence. There is a large body of evidence looking at postoperative opioid use, its associated effects and the typical needs following gynecologic surgery. In 2021, the American Urogynecologic Society (AUGS) published a literature review on opioid use in pelvic reconstructive surgery with the aim of providing evidence-based guidance on opioid prescribing following surgery. This review found 47 articles that informed the following guidelines on opioid use following pelvic reconstructive surgery: (I) in opioid-naïve patients, they should receive no more than 15 tablets of opioids (approximately 112.5 morphine equivalents), (II) factors that may affect the amount of opioids used (i.e., age, history of chronic pain or chronic opioid use) should be assessed prior to surgery, (III) enhanced recovery pathways should be used to improve pain control and decrease opioid use, (IV) systemic issues that lead to opioid overprescribing should be addressed (21). Importantly some patients may not even require narcotics in the post-operative period and one way to assess this is baseline use/need during hospitalization. Following these guidelines, there have been studies supporting standardized postoperative prescribing. Specifically, a long-term follow-up study of implementation of standardized opioid prescribing showed that it is associated with a decrease in opioid prescriptions without a significant increase in prescribed refills or presentation for pain (22).

Postoperative visits

The postoperative visit results were informed by two randomized controlled trials.

Postoperative visits provide an opportunity for healthcare providers to address any concerns, optimize the healing process, and support the patient in achieving the best possible outcomes. An RCT conducted by Thompson et al. examined whether postoperative telephone follow-up was noninferior to in-person clinic visits based on patient satisfaction, safety, and clinical outcomes. They found that telephone follow-up after pelvic floor surgery resulted in noninferior patient satisfaction, without differences in clinical outcomes or adverse events (23). Lee et al. conducted an RCT to study patient satisfaction of virtual clinical encounters compared to traditional in-office clinical encounters for postoperative follow-up after reconstructive surgery for pelvic organ prolapse. They determined that postoperative virtual clinical encounters via video conference technology were noninferior to traditional in-office clinical encounters, with high levels of short-term patient satisfaction and no differences in postoperative health care utilization and complications rates (24). Both telephone follow-up and virtual clinical encounters may improve healthcare quality and decrease patient and provider burden for postoperative care. In appropriately selected patients, it is reasonable to consider these visit modalities for postoperative care.

Discussion

This is an updated scoping review on postoperative recommendations for urogynecology and reconstructive pelvic surgery including recent randomized trials and prospective data. This review further attempts to interpret some of the data and give recommendations for various postoperative considerations (Table 2). Similar to other reviews in this area, there is an overall lack of prospective studies or long-term follow-up and therefore making definitive conclusions or recommendations is difficult. We recommend the following areas for further research and development: long-term safety data on liberal postoperative recommendations and further, we should begin to build on the current evidence for more liberal restrictions and conduct innovative research on active recovery protocols and how we can improve the postoperative recovery process.

Conclusions

Sedentary behavior is known to have detrimental health outcomes with risks in the postoperative period, including venous thromboembolism (VTE), pulmonary atelectasis/infections and mental health decline (1,25). Postoperative activity restrictions are widely implemented in the postoperative period following benign gynecologic surgeries and pelvic reconstructive surgeries with the hope of decreasing postoperative surgical complications and prolapse recurrence. There is little evidence to support the use of activity restrictions and even less data to guide type of activities that should be limited and for how long. More research is needed in this area to better guide gynecologic surgeons on the best evidence-based recommendations in the postoperative period. In addition to understanding the role of activity restrictions in the postoperative period, research should begin to focus on whether a more active recovery may benefit patients in returning to function more rapidly.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the PRISMA-ScR reporting checklist. Available at https://gpm.amegroups.com/article/view/10.21037/gpm-23-51/rc

Peer Review File: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-23-51/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-23-51/coif). S.C. reports grant from PCORI unrelated to topic presented in this article. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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