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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.
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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.
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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.
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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. ...