Gynecologic reconstructive surgery: tailoring the postoperative care to the patient

Reconstructive surgery represents a crucial field in gynecological surgery. The sharp percentage increase of the elderly population in western countries, as well as the growing attention to the women’s wellbeing after reproductive age produced a boost both in clinical research and in surgical innovation in this particular field. Thanks to the surge of minimally invasive surgery, many patients with pelvic organ prolapse (POP) can nowadays opt for less invasive procedures, thus having to confront less surgical complications and a faster recovery. Considering the relatively small percentage of complications in this kind of surgery (1), the uncertainty on the clinical utility of postoperative laboratory after reconstructive pelvic surgery emerged (2). Despite the small sample size, compared to the large number of surgical procedures for POP performed worldwide every year (3), the results of this study enlighten the importance of clinical observation rather than postoperative laboratory results on assessing the patient’s status after surgery. It may be useful to emphasize also the role of a proper preoperative evaluation for gynecological patients, based on patients’ personal history, imaging, physical exam and, often, on laboratory testing (4). The importance of a correct preoperative assessment of patients undergoing surgery is high, despite the fact that a long-time interval between the pre-surgical evaluation and the surgical intervention may intervene, thus potentially diminishing the diagnostic value. Nevertheless, the simple knowledge of preoperative anaemia can help to classify patients in different class of risk depending on their hemoglobin (Hb) levels (5). We may observe that the patients included in this study underwent a relatively wide range of different surgical procedures, all related with different surgical risks one another, as the authors properly reported. In relation to the aforementioned, we observed that in recent years, some researchers focused on finding the right surgical approach for POP surgery (mainly for apical prolapse), aiming to highlight the differences between different procedures in terms of surgical efficacy and complications (6). Regarding acute kidney injury (AKI) and lower urinary tract injury in gynecological surgery, the literature shows a low risk overall, as reported in the present study, therefore doubts on the clinical benefit of postoperative serum creatinine can arise. In relation with this principle, it is well renown that cystoscopy, performed at the time of POP reconstructive surgery, can help to assess urinary tract injuries, and its execution at the time of surgery is now recommended for all this kind of operations by the American Urogynecologic Society (AUGS), with the exception of operations aimed solely for posterior compartment defects (7). However, given the low rates of complications during these surgical procedures, in our clinical experience, we do not perform routinary cystoscopy, with an overall rate of lower urinary tract injuries of 0.4% in 314 consecutive patients treated surgically in our department for apical prolapse. In addition to this topic, it is mandatory to mention ureteral damage, a much-feared complication in gynecologic surgery, particularly in procedures that include hysterectomy. This complication is also often the subject of medical-legal litigation. However, in these cases, what is most challenged to the defendants is failure to properly obtain informed consent or underestimating the postoperative symptoms complained of by patients such as postoperative abdominal pain. In a significant portion of cases of patients with ureteral damage, the clinical symptom is the warning sign of ureteral damage (8). Special attention should be paid to ureteral damage in case of laparoscopic hysterectomy. Most of the injuries associated with laparoscopic surgery are caused by instruments involved in electrocoagulation. In this case, careful postoperative clinical observation is critical because the damage may be unrecognized intraoperatively (9). As regards the article, the authors observed no statistically significant differences in the percentages of asymptomatic and symptomatic patients (and therefore no differences in the number of patients needing postoperative blood testing) in relation with the surgical procedures they underwent, but they reported an increase in the percentage of symptomatic patients undergoing a prior hysterectomy during the surgical intervention. This result must be put in correlation with the evidence that there seem to be no clinical benefits for laboratory postoperative assessment after a hysterectomy, even for oncological indications (10). Nevertheless, it seems reasonable, at the time of the preoperative assessment, to take into consideration also the dimensions of the uterus, if a prior hysterectomy is needed, because it has been observed that the complications rate (including excessive intraoperative bleeding) increases at the increasing of uterine size (11). In conclusion, one of the most important concerns for modern medicine is to limit intervention to where is needed. The postoperative clinical assessment of patients seems to be an effective tool in many gynecological procedures (12), permitting to limit the need for routinary postoperative blood exams.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gynecology and Pelvic Medicine. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-23-40/coif). The 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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