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Guidelines for vulvar and vaginal surgery: Enhanced Recovery After Surgery Society recommendations

      This is the first collaborative Enhanced Recovery After Surgery Society guideline for optimal perioperative care for vulvar and vaginal surgeries. An Embase and PubMed database search of publications was performed. Studies on each topic within the Enhanced Recovery After Surgery vulvar and vaginal outline were selected, with emphasis on meta-analyses, randomized controlled trials, and prospective cohort studies. All studies were reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation system. All recommendations on the Enhanced Recovery After Surgery topics are based on the best available evidence. The level of evidence for each item is presented.

      Key words

      Introduction

      Enhanced Recovery After Surgery (ERAS) is regarded as a global surgical quality improvement initiative that results in clinical
      • Ljungqvist O.
      • Scott M.
      • Fearon K.C.
      Enhanced recovery after surgery: a review.
      and cost benefits.
      • Ljungqvist O.
      • Thanh N.X.
      • Nelson G.
      ERAS-value based surgery.
      The ERAS gynecologic oncology guidelines
      • Nelson G.
      • Altman A.D.
      • Nick A.
      • et al.
      Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations—part I.
      ,
      • Nelson G.
      • Altman A.D.
      • Nick A.
      • et al.
      Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations—part II.
      were first published in 2016 and updated in 2019.
      • Nelson G.
      • Bakkum-Gamez J.
      • Kalogera E.
      • et al.
      Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update.
      The ERAS gynecology protocols to date, however, have focused mainly on intraabdominal surgery, with no recommendations for vulvar and vaginal surgeries, often performed in the oncology and urogynecology settings, respectively. To address this gap, the ERAS Society Gynecology Chapter convened to critically review the existing evidence and make recommendations for the elements of pre-, intra-, and postoperative care as it relates to vulvar and vaginal surgeries.

      Methods

      Literature search

      The guideline was developed according to published methodology from the ERAS Society.
      • Brindle M.
      • Nelson G.
      • Lobo D.N.
      • Ljungqvist O.
      • Gustafsson U.O.
      Recommendations from the ERAS® Society for standards for the development of enhanced recovery after surgery guidelines.
      The authors convened in September 2019 to discuss topics for inclusion; the topic list was based on the ERAS gynecologic oncology guidelines,
      • Nelson G.
      • Altman A.D.
      • Nick A.
      • et al.
      Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations—part I.
      • Nelson G.
      • Altman A.D.
      • Nick A.
      • et al.
      Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations—part II.
      • Nelson G.
      • Bakkum-Gamez J.
      • Kalogera E.
      • et al.
      Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update.
      which were used as a template, and expanded to include topics unique to vulvar and vaginal surgeries. The topics were then allocated among the group according to expertise. The Embase and PubMed databases were searched for medical subject headings between 1975 and 2020, including “gynecology,” “gynecologic oncology,” “urogynecology,” and all pre-, intra-, and postoperative ERAS items (Table 1). Reference lists of all eligible articles were cross-checked for other relevant studies. Meta-analyses, systematic reviews, randomized controlled trials (RCTs), nonrandomized controlled studies, reviews, and case series were considered for each individual topic. In this study, 2 to 3 authors reviewed the evidence base for each item. The quality of evidence for each item was then reviewed and cross-checked by the senior editorial team (A.D.A., G.N., and S.C.D.). The final manuscript was then reviewed by all authors to assess the quality of evidence and relevant studies for final inclusion; all papers that were examined for inclusion are listed in the Supplemental Appendix (Supplement #1). The search strategy was focused on relevant papers and supplemented by expert citation searches to identify further important studies. The purpose of the search strategy and guideline formation was not to obtain a comprehensive summary of all literature but to ensure that the most important and current work is highlighted.
      • Brindle M.
      • Nelson G.
      • Lobo D.N.
      • Ljungqvist O.
      • Gustafsson U.O.
      Recommendations from the ERAS® Society for standards for the development of enhanced recovery after surgery guidelines.
      Table 1Recommendations, evidence level, and recommendation grade for individual ERAS elements
      ItemRecommendationEvidence levelRecommendation grade
      VulvarVaginalVulvarVaginal
      Preadmission information, education, and counselingPatients should routinely receive dedicated preoperative information, education, and counselingLowLowStrongStrong
      Preoperative optimizationRoutine removal of pubic hair should not be used to decrease infection ratesLowN/AStrongN/A
      If hair is removed, it should be clipped and not shavedHighN/AStrongN/A
      Use of preoperative vaginal estrogen in postmenopausal women decreases postoperative complicationsN/ALowN/AWeak
      Preoperative bowel preparationPreoperative bowel preparation should not be used before vulvar and vaginal surgeryModerateLowStrongWeak (may consider enema to reduce stool burden)
      Prophylaxis against thromboembolismPatients undergoing malignant procedures lasting >30 min should receive dual mechanical prophylaxis and chemoprophylaxis with either low-molecular-weight heparin or unfractionated heparinModerateModerateStrongStrong
      Prophylaxis should be initiated preoperatively and continued throughout the hospital stay for malignant surgeryModerateLowStrongStrong
      Prophylaxis should be initiated preoperatively and continued throughout the hospital stay for benign surgeryLowLowWeakWeak
      Extended postoperative prophylaxisLowLowWeakWeak
      Antimicrobial prophylaxisIV antibiotics should be administered routinely within 60 min before vaginal hysterectomyN/AHighN/AStrong
      Antibiotic prophylaxis may be considered for vaginal surgery without hysterectomyN/ALowN/AWeak
      Antibiotic prophylaxis may be considered for vulvar surgeryLowN/AStrong (radical vulvectomy)N/A
      Standard anesthetic protocol and fluid managementUse of short-acting anestheticsLowLowStrongStrong
      Objective monitoring of the level of neuromuscular block and ensuring complete reversalHighHighStrongStrong
      Fluid balance to achieve euvolemiaModerateModerateStrongStrong
      Preemptive analgesia is recommended for vaginal surgeryN/AModerateN/AStrong
      Urinary drainageRetrograde bladder fill for voiding trial should be considered for vaginal proceduresN/AHighN/AStrong
      Urinary catheters should be removed as soon as possible for vaginal proceduresN/AHighN/AStrong
      Urinary catheters should be removed as soon as possible for vulvar proceduresLowN/AStrongN/A
      Postoperative analgesiaA multimodal postoperative analgesic protocol should be used routinely, and home-going opioid prescriptions should be minimizedHighHighStrongStrong
      Combination of acetaminophen and nonsteroidal antiinflammatory drugs should be usedHighHighStrongStrong
      Preoperative and postoperative nutritionPatients should be encouraged to eat a light snack up until 6 h and clear fluids (including oral carbohydrate drinks) up until 2 h, before initiation of anesthesiaHighHighStrongStrong
      A regular diet within the first 24 h after vaginal or vulvar surgery is recommendedModerate (by indirectness)Moderate (by indirectness)StrongStrong
      Postoperative dressing careVaginal packing does not decrease postoperative bleeding and hematoma formation or increase postoperative painN/AHighN/AStrong
      If used, vaginal packing should not be left in for more than 24 hN/ALowN/AStrong
      Occlusive dressings may be used after laser treatment to promote healingLowN/AWeakN/A
      Postoperative drains and adjuvant therapiesInguinofemoral drains should continue until <30–50 cc/d of drainage (cancer surgery)ModerateN/AStrongN/A
      Saphenous vein preservation should be considered in all inguinofemoral lymph node dissections (cancer surgery)ModerateN/AStrongN/A
      ERAS, Enhanced Recovery After Surgery; IV, intravenous; N/A, not applicable.
      Altman. Enhanced Recovery After Surgery Society recommendations for vulvar and vaginal surgeries. Am J Obstet Gynecol 2020.

      Quality assessment

      The quality of evidence and recommendations were assessed on the basis of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system, presented in Table 2 as per previous guidelines.
      • Nelson G.
      • Altman A.D.
      • Nick A.
      • et al.
      Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations—part I.
      • Nelson G.
      • Altman A.D.
      • Nick A.
      • et al.
      Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations—part II.
      • Nelson G.
      • Bakkum-Gamez J.
      • Kalogera E.
      • et al.
      Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update.
      ,
      • Guyatt G.H.
      • Oxman A.D.
      • Vist G.E.
      • et al.
      GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
      Each study included was assessed according to the GRADE criteria, and the final list of referenced studies was decided on by the guideline development group; although not all papers are referenced in the final product, the studies chosen are representative of the best quality of evidence with the broadest scope of application.
      • Brindle M.
      • Nelson G.
      • Lobo D.N.
      • Ljungqvist O.
      • Gustafsson U.O.
      Recommendations from the ERAS® Society for standards for the development of enhanced recovery after surgery guidelines.
      The recommendations are based on the level of evidence as high, moderate, and low, equalized by desirable and deleterious effects. Strong recommendations mean that the ERAS group believed that the advantages of the recommendations outweighed the risks, whereas a weak recommendation indicates that the group believed that the advantages likely outweigh the risks but felt less confident in the overall strength of the evidence. As such, there may be cases in which strong recommendations are reached from low-evidence data and weak recommendations from strong-evidence data.
      Table 2GRADE system rating of quality and strength of evidence
      Adapted from Guyatt et al.
      • Guyatt G.H.
      • Oxman A.D.
      • Vist G.E.
      • et al.
      GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
      Evidence quality levelDefinition
      HighSubsequent research unlikely to change confidence in estimate of effect
      ModerateSubsequent research likely to have an impact on estimate of effect and may change estimate
      LowSubsequent research very likely to have an impact on estimate of effect and likely to change estimate
      Very lowAny estimate is uncertain
      Recommendation levelDefintion
      StrongDesirable effects of intervention clearly outweigh, or clearly do not outweigh, the undesirable effects
      WeakEffects are much more unclear
      GRADE, Grading of Recommendations, Assessment, Development and Evaluation.
      Altman. Enhanced Recovery After Surgery Society recommendations for vulvar and vaginal surgeries. Am J Obstet Gynecol 2020.

      Results

      The recommendations, evidence level, and recommendation grade are provided for each of the individual ERAS elements in Table 1, with summary descriptions of the evidence below with the associated level of evidence in parentheses.

      Preadmission information, education, and counseling

      The goal of preoperative education is not only to physically prepare the patient for surgery but also to prepare them for what to expect after the surgery. Preoperative preparation allows patients to better understand the procedure, feel more in control, and experience decreased postoperative pain and anxiety and can even reduce the length of hospital stay.
      • Powell R.
      • Scott N.W.
      • Manyande A.
      • et al.
      Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia.
      Information may be provided in many forms—verbal, written, or multimedia—and should be adapted to cultural and social aspects. Written information was found to be superior to verbal alone in 1 randomized trial for satisfaction, days of hospitalization, and pain.
      • Angioli R.
      • Plotti F.
      • Capriglione S.
      • et al.
      The effects of giving patients verbal or written pre-operative information in gynecologic oncology surgery: a randomized study and the medical-legal point of view.
      However, the addition of an educational video for pelvic reconstructive surgery did not improve patient preparedness for surgery.
      • Greene K.A.
      • Wyman A.M.
      • Scott L.A.
      • Hart S.
      • Hoyte L.
      • Bassaly R.
      Evaluation of patient preparedness for surgery: a randomized controlled trial.

      Recommendation

      Although there is limited evidence in this field, most studies from other specialties provide evidence of beneficial effects and no evidence of harm. It is therefore recommended that patients should routinely receive dedicated preoperative information, education, and counseling (Low).

      Preoperative optimization

      In the past, it has been postulated that as hair harbors bacteria, the removal of hair should decrease surgical site infection (SSI) rates. A Cochrane review showed lack of evidence supporting hair removal; however, there were no specific studies examining the removal of pubic hair.
      • Tanner J.
      • Norrie P.
      • Melen K.
      Preoperative hair removal to reduce surgical site infection.
      A small study comparing perineal shaving with no hair removal showed no difference in infection rates.
      • Adeleye J.A.
      Perineovulvovaginal preoperative preparation in minor gynecological surgery.
      However, if pubic hair is removed to improve visualization of the surgical field, clipping should be used over shaving to reduce the rate of SSIs.
      • Tanner J.
      • Norrie P.
      • Melen K.
      Preoperative hair removal to reduce surgical site infection.
      The use of preoperative vaginal estrogen in postmenopausal women has been shown to increase the maturation index and vaginal epithelial thickness, but there is a lack of evidence that this translates to improved outcomes in prolapse surgery.
      • Rahn D.D.
      • Ward R.M.
      • Sanses T.V.
      • et al.
      Vaginal estrogen use in postmenopausal women with pelvic floor disorders: systematic review and practice guidelines.
      An RCT using vaginal estrogen before and 1 year after vaginal prolapse surgery with mesh found no estrogen to be noninferior to estrogen therapy when examining mesh erosion and anatomic success as endpoints.
      • Sun Z.
      • Zhu L.
      • Xu T.
      • Shi X.
      • Lang J.
      Effects of preoperative vaginal estrogen therapy for the incidence of mesh complication after pelvic organ prolapse surgery in postmenopausal women: is it helpful or a myth? A 1-year randomized controlled trial.

      Recommendation

      The routine removal of pubic hair for vulvar surgery does not decrease infection rates (Low). If hair is removed, it should be clipped and not shaved (High). There is little evidence to support the use of preoperative vaginal estrogen in postmenopausal women to decrease postoperative complications (Low).

      Preoperative bowel preparation

      Traditionally, mechanical bowel preparation (MBP) in gynecologic surgery, especially in anticipation of potential bowel resection, was believed to decrease the risk of anastomotic leak and prevent perioperative infectious morbidity.
      • Fanning J.
      • Valea F.A.
      Perioperative bowel management for gynecologic surgery.
      In 2018, a meta-analysis of 21,568 patients undergoing colorectal surgery showed that MBP was not associated with any difference in anastomotic leak rates, SSI, intraabdominal collection, reoperation, or hospital length of stay when compared with no MBP.
      • Rollins K.E.
      • Javanmard-Emamghissi H.
      • Lobo D.N.
      Impact of mechanical bowel preparation in elective colorectal surgery: a meta-analysis.
      Similar conclusions were reached in a 2015 meta-analysis of 5 RCTs in gynecologic surgery.
      • Arnold A.
      • Aitchison L.P.
      • Abbott J.
      Preoperative mechanical bowel preparation for abdominal, laparoscopic, and vaginal surgery: a systematic review.
      There are limited data in vaginal surgery with the exception of a recent RCT that showed that women who underwent MBP before minimally invasive sacrocolpopexy demonstrated benefit to postoperative defecatory function and improved surgeon’s perceptions of the case.
      • Sassani J.C.
      • Kantartzis K.
      • Wu L.
      • Fabio A.
      • Zyczynski H.M.
      Bowel preparation prior to minimally invasive sacrocolpopexy: a randomized controlled trial.
      Enemas, however, do not seem to adversely affect recovery or electrolytes and may be useful to reduce the stool burden at the time of vaginal or vulvar procedures, although no further data exist on the rates of infection.

      Recommendation

      Preoperative bowel preparation is not recommended before vulvar (Moderate) and vaginal (Low) surgeries; enemas may be considered to reduce the stool burden at the time of vaginal surgery.

      Prophylaxis against venous thromboembolism

      The literature suggests that the risk of venous thromboembolism (VTE) in vulvar and vaginal cancer surgeries is similar to that observed among patients undergoing surgery for other gynecologic cancers.
      • Ye S.
      • Zhang W.
      • Yang J.
      • et al.
      Pattern of venous thromboembolism occurrence in gynecologic malignancy: incidence, timing, and distribution a 10-year retrospective single-institutional study.
      The formulation of guidelines is complicated by wide variations in surgical complexity for vulvar procedures, ranging from outpatient laser ablation and limited wide local excisions to radical resections with inguinal lymphadenectomy and potential reconstruction. In an evaluation using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, the 30-day rate of deep vein thrombosis and/or pulmonary embolism was 1.2% in 497 patients undergoing surgery for vulvar cancer compared with 3.0%, 1.4%, and 1.5% for ovarian, cervical, and endometrial cancers, respectively.
      • Graul A.
      • Latif N.
      • Zhang X.
      • et al.
      Incidence of venous thromboembolism by type of gynecologic malignancy and surgical modality in the National Surgical Quality Improvement Program.
      However, less than a third of patients undergoing vulvar resection had a concurrent inguinal lymphadenectomy, suggesting that many of these patients had preinvasive or microinvasive disease, and the VTE rate may therefore be underestimated. A single-institution study over a 10-year period reported on 219 patients with vulvar cancer and 141 with vaginal cancer (including resection for Paget disease), only 5 of whom were not comprehensively staged.
      • Ye S.
      • Zhang W.
      • Yang J.
      • et al.
      Pattern of venous thromboembolism occurrence in gynecologic malignancy: incidence, timing, and distribution a 10-year retrospective single-institutional study.
      Perhaps because of a higher rate of lymphadenectomy or longer follow-up, the rates of VTE were higher than those reported in the ACS-NSQIP, 3.7% for vulvar cancer and 0.7% for vaginal cancer. Patients were purported to have received prophylaxis with stockings and low-molecular-weight heparin (LMWH) from 48 hours to 14 days postoperatively, but no assessment of compliance was provided.
      Patients undergoing surgery for vulvar or vaginal cancer should therefore receive dual VTE mechanical prophylaxis and chemoprophylaxis with either LMWH or unfractionated heparin (UFH) to begin before the induction of anesthesia as recommended by the American Society of Clinical Oncology (ASCO).
      • Lyman G.H.
      • Khorana A.A.
      • Kuderer N.M.
      • et al.
      Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update.
      Dual prophylaxis should continue throughout the hospital stay. In keeping with ASCO recommendations, procedures lasting >30 minutes should be managed as described above. In contrast to patients with advanced ovarian cancer, the residual tumor burden for patients with vulvar and vaginal cancers is quite low; no data exist for prolapse or benign procedures. For this reason, it is premature to recommend routine extended prophylaxis for these patients, although it may be considered in elderly, frail, and immobile patients depending on their Caprini scores.
      • Caprini J.A.
      • Arcelus J.I.
      • Hasty J.H.
      • Tamhane A.C.
      • Fabrega F.
      Clinical assessment of venous thromboembolic risk in surgical patients.
      In benign vaginal surgery, the data continue to be limited as well. In a large retrospective analysis of NSQIP data, 26,103 women who underwent surgery for pelvic organ prolapse were evaluated for VTE; 81.7% had a vaginal approach. The overall rate of VTE in this population was <1% for all groups, with the vaginal group having the lowest rate of 0.17% (P<.01).
      • Hokenstad E.D.
      • Habermann E.B.
      • Glasgow A.E.
      • Occhino J.A.
      Risk of venous thromboembolism in patients undergoing surgery for pelvic organ prolapse.
      A second similar study for 20,687 women with pelvic reconstructive surgery showed a rate of VTE of 0.1%.
      • Mueller M.G.
      • Pilecki M.A.
      • Catanzarite T.
      • Jain U.
      • Kim J.Y.S.
      • Kenton K.
      Venous thromboembolism in reconstructive pelvic surgery.

      Summary and recommendation

      Patients undergoing procedures lasting >30 minutes should receive dual mechanical prophylaxis and chemoprophylaxis with either LMWH or UFH for cancer surgery (Moderate). Prophylaxis should be initiated preoperatively and continued throughout the hospital stay for malignant surgery (vulva, Moderate; vaginal, Low). In benign vaginal and vulvar surgeries, the rates of VTE are very low, but prophylaxis may still be considered (Low). Studies on extended postoperative prophylaxis are needed in vulvar and vaginal surgeries for both malignant and benign indications (Low).

      Antimicrobial prophylaxis

      It is well established that patients undergoing vaginal hysterectomy, similar to abdominal hysterectomy, should receive single-dose antimicrobial prophylaxis within 1 hour of incision.
      American College of Obstetricians and Gynecologists
      ACOG Practice Bulletin no. 195 summary: prevention of infection after gynecologic procedures.
      A Cochrane review showed that compared with placebo, women who received antimicrobial prophylaxis for vaginal hysterectomy had a reduction in total postoperative infections, including urinary tract infections (UTIs).
      • Ayeleke R.O.
      • Mourad S.
      • Marjoribanks J.
      • Calis K.A.
      • Jordan V.
      Antibiotic prophylaxis for elective hysterectomy.
      For patients undergoing vaginal surgery without hysterectomy, such as with anterior or posterior colporrhaphy, the evidence for antimicrobial prophylaxis is less clear. Although theoretically there could be benefit from prophylaxis in these cases given that they are classified as clean-contaminated, at the present time, there is insufficient evidence to make concrete recommendations; thus, the decision is left to the discretion of the surgeon.
      • Morrill M.Y.
      • Schimpf M.O.
      • Abed H.
      • et al.
      Antibiotic prophylaxis for selected gynecologic surgeries.
      Although this appears to be similar for patients undergoing a vaginal surgery with the use of mesh (eg, midurethral sling) where infection rates are very low,
      • Harmanli O.
      • Hong E.K.
      • Rubin R.
      • Jones K.A.
      • Boyer R.L.
      • Metz S.
      Is antibiotic prophylaxis necessary for midurethral sling procedures? A series of 174 cases without preoperative antibiotics.
      ,
      • Shepherd J.P.
      • Jones K.A.
      • Harmanli O.
      Is antibiotic prophylaxis necessary before midurethral sling procedures for female stress incontinence? A decision analysis.
      93% of surgeons said they administered some form of antibiotic prophylaxis when graft material was used in prolapse surgery.
      • Schimpf M.O.
      • Morrill M.Y.
      • Margulies R.U.
      • Ward R.M.
      • Carberry C.L.
      • Sung V.W.
      Surgeon practice patterns for antibiotic prophylaxis in gynecologic surgery.
      Vulvar procedures such as vulvectomy, which are typically performed for cancer, are associated with a high risk of infection. Radical vulvectomy has an SSI rate comparable with that of patients undergoing abdominal hysterectomy with a type IV wound.
      • Mert I.
      • Cliby W.A.
      • Bews K.A.
      • Habermann E.B.
      • Dowdy S.C.
      Evidence-based wound classification for vulvar surgery: implications for risk adjustment.
      ,
      • Leminen A.
      • Forss M.
      • Paavonen J.
      Wound complications in patients with carcinoma of the vulva. Comparison between radical and modified vulvectomies.
      Similar to vaginal surgery without hysterectomy, there is no randomized evidence supporting antimicrobial prophylaxis in this setting. However, given the high rate of SSI, it seems reasonable to give a single dose of antibiotic, consistent with other published guidelines.
      American College of Obstetricians and Gynecologists
      ACOG Practice Bulletin no. 195 summary: prevention of infection after gynecologic procedures.

      Recommendation

      Intravenous (IV) antibiotics should be administered routinely within 60 minutes before vaginal hysterectomy (High). IV antibiotics should be considered for vaginal surgery without hysterectomy (Low) and vulvar procedures (Low), particularly radical vulvectomy (contaminated wound), where SSI rates are high.

      Standard anesthetic protocol and fluid management

      The anesthetic protocol for patients undergoing major vulvar and vaginal surgeries is conducted with the aim of providing anesthesia that reduces the surgical stress response, provides analgesia, and encourages the rapid return of mobilization, eating, and drinking. In addition, postoperative nausea and vomiting (PONV) with multimodal prophylaxis in this high-risk group of patients is required. Extremes of fluid balance and organ dysfunction should be avoided.
      • Trowbridge E.R.
      • Dreisbach C.N.
      • Sarosiek B.M.
      • et al.
      Review of enhanced recovery programs in benign gynecologic surgery.
      ,
      • Feldheiser A.
      • Aziz O.
      • Baldini G.
      • et al.
      Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice.
      For many patients, either general or regional anesthesia can be used; there is little evidence to recommend one technique over the other. If general anesthesia is chosen, maintenance can be provided with either a volatile-based approach or total IV anesthesia (TIVA). Nitrous oxide is not recommended because of increased nausea and vomiting.
      • Fernández-Guisasola J.
      • Gómez-Arnau J.I.
      • Cabrera Y.
      • del Valle S.G.
      Association between nitrous oxide and the incidence of postoperative nausea and vomiting in adults: a systematic review and meta-analysis.
      ,
      • Myles P.S.
      • Leslie K.
      • Chan M.T.
      • et al.
      The safety of addition of nitrous oxide to general anaesthesia in at-risk patients having major non-cardiac surgery (ENIGMA-II): a randomised, single-blind trial.
      There is much enthusiasm for TIVA over volatile anesthesia because it reduces the incidence of PONV and may improve long-term survival in patients with malignancy.
      • Wigmore T.J.
      • Mohammed K.
      • Jhanji S.
      Long-term survival for patients undergoing volatile versus IV anesthesia for cancer surgery: a retrospective analysis.
      If TIVA is used, processed electroencephalogram monitoring (eg, bispectral index) is recommended to ensure appropriate depth of intraoperative anesthesia, permitting rapid return of consciousness.
      • Punjasawadwong Y.
      • Phongchiewboon A.
      • Bunchungmongkol N.
      Bispectral index for improving anaesthetic delivery and postoperative recovery.
      If neuromuscular (NM) blocking drugs are used, then complete reversal of NM function must be confirmed at the end of the procedure with objective NM monitoring. The use of protective mechanical ventilation with tidal volume of 6 to 8 mL/kg and the use of positive end-expiratory pressure may be of benefit.
      • Nelson G.
      • Bakkum-Gamez J.
      • Kalogera E.
      • et al.
      Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update.
      Regional anesthesia (such as intrathecal or epidural) can provide excellent intraoperative and postoperative analgesia. However, side effects such as motor block, hypotension, and urinary retention limit their postoperative use. If an epidural catheter has been used, it should be discontinued soon after the surgery because analgesic requirements are generally modest. There is little evidence to support other modalities such as ketamine, lidocaine, alpha-2 agonists, and pregabalin, although some advocate the use of these drugs if undertaking opioid-free anesthesia to reduce the problems associated with opioids, particularly opioid tolerance and opioid-induced hyperalgesia.
      • Liu H.
      • Brown M.
      • Sun L.
      • et al.
      Complications and liability related to regional and neuraxial anesthesia.
      Three small RCTs have shown efficacy of preemptive paracervical block in patients undergoing vaginal hysterectomy.
      • O’Neal M.G.
      • Beste T.
      • Shackelford D.P.
      Utility of preemptive local analgesia in vaginal hysterectomy.
      ,
      • Hristovska A.M.
      • Kristensen B.B.
      • Rasmussen M.A.
      • et al.
      Effect of systematic local infiltration analgesia on postoperative pain in vaginal hysterectomy: a randomized, placebo-controlled trial.
      A number of series have indicated that local anesthesia with sedation can be successfully used for vaginal prolapse surgery.
      • Buchsbaum G.M.
      • Duecy E.E.
      Local anesthesia with sedation for transvaginal correction of advanced genital prolapse.
      Fluid management should be directed toward replacing intraoperative blood loss while aiming for euvolemia to avoid the problems associated with fluid overload (eg, edema, ileus) or hypovolemia (eg, acute kidney injury). Maintenance of blood pressure once euvolemia is achieved should be with vasoactive drugs to avoid fluid overload. The use of cardiac output monitoring and/or goal directed therapy is not routinely recommended.
      • Miller T.E.
      • Roche A.M.
      • Mythen M.
      Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS).

      Recommendation

      The use of short-acting anesthetics (Low), monitoring of NM block depth, and complete reversal (High) is recommended. Fluid balance should be directed with the goal of euvolemia (Moderate). Preemptive analgesia is recommended for vaginal hysterectomy and can be considered for vaginal prolapse surgery (Moderate).

      Urinary drainage

      Immediate postoperative voiding dysfunction is potentially a complication of most pelvic surgeries. It is a particular problem for procedures targeting the urethra such as surgeries for stress urinary incontinence. It is such a common issue that some centers routinely teach patients how to perform clean intermittent self-catheterization as part of the preoperative teaching. After stress incontinence surgeries such as midurethral sling, bladder emptying is assessed with a voiding trial (VT). VT involves measuring voided volume followed by an assessment of the postvoid residual volume. There are multiple methods of filling the bladder before a VT, such as filling the bladder in the operating room (OR) to a defined volume, retrograde catheter fill in the postanesthesia care unit (PACU), or awaiting spontaneous bladder fill in the PACU. Foster et al
      • Foster Sr., R.T.
      • Borawski K.M.
      • South M.M.
      • Weidner A.C.
      • Webster G.D.
      • Amundsen C.L.
      A randomized, controlled trial evaluating 2 techniques of postoperative bladder testing after transvaginal surgery.
      performed a randomized trial evaluating bladder function after outpatient vaginal surgery and found that patients were more likely to successfully void after a retrograde fill compared with spontaneous bladder fill (61.5% vs 32.1%, respectively; P=.02). In a subsequent trial, Myers et al
      • Myers E.M.
      • Matthews C.A.
      • Crane A.K.
      • Connolly A.
      • Wu J.M.
      • Geller E.J.
      Two techniques for assessing postoperative voiding function, a randomized trial.
      documented that retrograde filling the bladder in the OR rather than in the PACU was an effective strategy for the postoperative VT. However, this approach did not significantly reduce total PACU time. In both studies, the retrograde bladder fill method was demonstrated to be more accurate and preferred by patients and also enabled women to be discharged from the PACU up to 27 minutes earlier.
      A small randomized prospective study examined catheterization in 100 women undergoing vaginal hysterectomy and found that catheterization after surgery was unnecessary, but there were no increased complications if left in for 24 hours.
      • Summitt Jr., R.L.
      • Stovall T.G.
      • Bran D.F.
      Prospective comparison of indwelling bladder catheter drainage versus no catheter after vaginal hysterectomy.
      In women undergoing Burch colposuspension, a randomized trial reviewed the removal of catheter on postoperative days 1 vs 5 and found no benefit for prolonged catheterization.
      • Sun M.J.
      • Chang S.Y.
      • Lin K.C.
      • Chen G.D.
      Is an indwelling catheter necessary for bladder drainage after modified Burch colposuspension?.
      A randomized trial in patients undergoing vaginal prolapse surgery, with the removal of catheter on postoperative days 1 vs 5, again found no benefit to prolonged catheterization, with a higher rate of positive cultures, prolonged hospitalization, and increased recatherization rate in the day 5 group.
      • Hakvoort R.A.
      • Elberink R.
      • Vollebregt A.
      • Ploeg T.
      • Emanuel M.H.
      How long should urinary bladder catheterisation be continued after vaginal prolapse surgery? A randomised controlled trial comparing short term versus long term catheterisation after vaginal prolapse surgery.
      A Cochrane review was performed in 2006
      • Phipps S.
      • Lim Y.N.
      • McClinton S.
      • Barry C.
      • Rane A.
      • N’Dow J.
      Short term urinary catheter policies following urogenital surgery in adults.
      on short-term catheterization policies and included 39 RCTs with a heterogeneous mixture of surgeries, including vaginal or abdominal hysterectomy, anterior or posterior repairs, Burch colposuspension, and urological surgery; the length of catheterization also varied from 1 to 28 days. The review found that not using a catheter had an increased risk of recatheterization; similarly urethral catheterization had a high risk of recatheterization compared with a suprapubic approach after removal.
      • Phipps S.
      • Lim Y.N.
      • McClinton S.
      • Barry C.
      • Rane A.
      • N’Dow J.
      Short term urinary catheter policies following urogenital surgery in adults.
      ,
      • Kidd E.A.
      • Stewart F.
      • Kassis N.C.
      • Hom E.
      • Omar M.I.
      Urethral (indwelling or intermittent) or suprapubic routes for short-term catheterisation in hospitalised adults.
      In 11 trials, shorter catheterization resulted in a lower rate of infections. Finally, using a clamp-release protocol resulted in a higher risk of infection and delay of normal urination than an immediate release policy.
      • Phipps S.
      • Lim Y.N.
      • McClinton S.
      • Barry C.
      • Rane A.
      • N’Dow J.
      Short term urinary catheter policies following urogenital surgery in adults.

      Recommendation

      Retrograde bladder filling for VT should be considered in vaginal surgery because it seems to be preferred by patients and may shorten time in the PACU (High). Urinary catheters should be used for postoperative bladder drainage in complex vaginal surgery but may be safely eliminated in simple vaginal hysterectomy. Removal after a short period postoperatively seems to be associated with lower rates of recatheterization, bladder infection, and length of stay (vaginal, High; vulvar, Low). The suprapubic route is associated with a lower rate of bladder infection but higher rate of catheter-related complications and may be considered if prolonged catheterization is expected. There remain insufficient data on urinary drainage in vulvar surgery.

      Postoperative analgesia

      Patients presenting with vulvar and vaginal abnormalities requiring surgical resection frequently complain of pain; in particular, those with ulcerative or malignant lesions may already be receiving preoperative analgesics and are often anxious about control of their postoperative pain. However, removal of the lesion usually reduces pain significantly, even when large resections are needed, and postoperative pain control is rarely problematic. Published studies evaluating optimal control of postoperative pain in patients undergoing vulvar procedures are nonexistent, but the paradigm of multimodal, opioid-sparing postoperative analgesia used commonly within the ERAS pathways should also be used for these patients as well.
      • Meyer L.A.
      • Lasala J.
      • Iniesta M.D.
      • et al.
      Effect of an enhanced recovery after surgery program on opioid use and patient-reported outcomes.
      In addition, the postoperative strategy should be reviewed with patients before surgery to aid optimal pain control and functional recovery and to minimize nausea, sedation, fatigue, and risk of opioid addiction.
      • Dolin S.J.
      • Cashman J.N.
      Tolerability of acute postoperative pain management: nausea, vomiting, sedation, pruritus, and urinary retention. Evidence from published data.
      The use of preoperative oral acetaminophen and an antiinflammatory drug (if not contraindicated) has been shown to reduce opioid requirements and should be a routine element in all ERAS pathways.
      • Ong C.K.S.
      • Seymour R.A.
      • Lirk P.
      • Merry A.F.
      Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain.
      ,
      • Long J.B.
      • Bevil K.
      • Giles D.L.
      Preemptive analgesia in minimally invasive gynecologic surgery.
      Because patients undergoing vulvar procedures, particularly patients with vulvar cancer, tend to be elderly, anticonvulsant medications and chronic pain drugs should not routinely be used in the PACU.
      • Doleman B.
      • Heinink T.P.
      • Read D.J.
      • Faleiro R.J.
      • Lund J.N.
      • Williams J.P.
      A systematic review and meta-regression analysis of prophylactic gabapentin for postoperative pain.
      ,
      • Weingarten T.N.
      • Jacob A.K.
      • Njathi C.W.
      • Wilson G.A.
      • Sprung J.
      Multimodal analgesic protocol and postanesthesia respiratory depression during phase I recovery after total joint arthroplasty.
      The use of local anesthetic medication may be feasible into the wound edges, but its use in regional anesthetic techniques, for example, caudal epidural anesthesia is not advocated, as it may be associated with postoperative problems such as hypotension and urinary retention for vulvar procedures. For vaginal surgery, there is some support for using local anesthetics, especially for paracervical and vaginal cuff blocks
      • Long J.B.
      • Bevil K.
      • Giles D.L.
      Preemptive analgesia in minimally invasive gynecologic surgery.
      ,
      • Blanton E.
      • Lamvu G.
      • Patanwala I.
      • et al.
      Non-opioid pain management in benign minimally invasive hysterectomy: a systematic review.
      ; liposomal bupivacaine may be helpful but still requires further study.
      • Long J.B.
      • Bevil K.
      • Giles D.L.
      Preemptive analgesia in minimally invasive gynecologic surgery.
      ,
      • Jones C.L.
      • Gruber D.D.
      • Fischer J.R.
      • Leonard K.
      • Hernandez S.L.
      Liposomal bupivacaine efficacy for postoperative pain following posterior vaginal surgery: a randomized, double-blind, placebo-controlled trial.
      Postoperatively, patients should receive scheduled oral acetaminophen and ibuprofen, oral opioids as needed, and IV opioids for breakthrough pain. Given the rarity of severe pain in this population, patients with breakthrough pain should be carefully examined for infections, wound breakdown, or other complications. Patients who do not require opioids in hospital will not require home-going opioid prescriptions and should be counseled to continue scheduled ibuprofen and acetaminophen. For patients requiring home-going opioids, we recommend a prescription for the minimum duration, for example, 10 tablets of oxycodone 5 mg to minimize the risk of opioid dependence and diversion.
      • Glaser G.E.
      • Kalogera E.
      • Kumar A.
      • et al.
      Outcomes and patient perspectives following implementation of tiered opioid prescription guidelines in gynecologic surgery.

      Recommendation

      A multimodal postoperative analgesic protocol should be used routinely, and home-going opioid prescriptions should be minimized (High).

      Preoperative and postoperative nutrition

      Historically, surgical patients have been subjected to the “nothing per orem after midnight” rule preoperatively with no supporting evidence. In fact, adoption of modern fasting rules whereby a patient is allowed to have a light snack up until 6 hours and clear fluids (including oral carbohydrate drinks) up until 2 hours before surgery has been shown to be safe.
      • Brady M.
      • Kinn S.
      • Stuart P.
      Preoperative fasting for adults to prevent perioperative complications.
      Furthermore, administration of oral carbohydrates preoperatively is associated with improved preoperative well-being and reduced postoperative insulin resistance.
      • Nygren J.
      • Thorell A.
      • Ljungqvist O.
      Preoperative oral carbohydrate therapy.
      There remain no specific trials in vulvar or vaginal surgery, but the underlying principles from laparotomy can be broadly adopted here until further research is completed.
      Similarly, in the past, it was common practice to withhold food from postoperative patients until passage of flatus. Early feeding, whereby nutrition is introduced within 24 hours after gynecologic surgery, has been shown to be safe without increased gastrointestinal concern or postoperative complications.
      • Charoenkwan K.
      • Matovinovic E.
      Early versus delayed oral fluids and food for reducing complications after major abdominal gynaecologic surgery.
      This approach is associated with earlier return of bowel function, shorter length of hospital stay, and improved patient satisfaction. A number of studies have now successfully and safely incorporated these perioperative nutritional practices into their urogynecologic ERAS protocols. Finally, there is little concern for ileus in patients undergoing vulvar or vaginal surgery,
      • Kalogera E.
      • Bakkum-Gamez J.N.
      • Jankowski C.J.
      • et al.
      Enhanced recovery in gynecologic surgery.
      ,
      • Carter-Brooks C.M.
      • Du A.L.
      • Ruppert K.M.
      • Romanova A.L.
      • Zyczynski H.M.
      Implementation of a urogynecology-specific enhanced recovery after surgery (ERAS) pathway.
      which further strengthens an early refeeding approach.

      Recommendation

      Patients should be encouraged to eat a light snack up until 6 hours and clear fluids (including oral carbohydrate drinks) up until 2 hours before the initiation of anesthesia (High). A regular diet within the first 24 hours after vaginal or vulvar surgery is recommended on the basis of extrapolation from larger more invasive procedures (Moderate by indirectness).

      Postoperative dressing care

      Vaginal packing is thought to decrease postoperative vaginal and vault hematoma formation and consequently decrease infection rates in prolapse surgery. However, it has been suggested that packing also increases pain, prolongs hospitalization, and can lead to leaving packing accidentally in place, resulting in retained “foreign objects.” Recent trends have been to use vaginal packing for 24 hours postoperatively,
      • Baggish M.S.
      • Karram M.M.
      Atlas of pelvic anatomy and gynecologic surgery.
      which requires indwelling catheterization. One RCT involving 190 women examined outcomes at 24 hours postoperatively for patients packed with proflavine-soaked cotton gauze vs no packing and found no difference in pain scores, infectious morbidity, or hematoma formation (7.3% in pack group vs 14.8% in no pack group; P=.204).
      • Thiagamoorthy G.
      • Khalil A.
      • Cardozo L.
      • Srikrishna S.
      • Leslie G.
      • Robinson D.
      The value of vaginal packing in pelvic floor surgery: a randomised double-blind study.
      A second small RCT showed similar pain on a visual analog scale but less use of ketorolac in the first 24 hours and nursing-reported pain in the packing group.
      • Westermann L.B.
      • Crisp C.C.
      • Oakley S.H.
      • et al.
      To pack or not to pack? A randomized trial of vaginal packing after vaginal reconstructive surgery.
      Two RCTs investigated the length of time for packing and found no difference between 3 hours and 24 hours; there was no difference in febrile morbidity and complications, but shorter packing was associated with nonsignificantly higher urinary retention rates.
      • Glavind K.
      • Mørup L.
      • Madsen H.
      • Glavind J.
      A prospective, randomised, controlled trial comparing 3 hour and 24 hour postoperative removal of bladder catheter and vaginal pack following vaginal prolapse surgery.
      ,
      • Rajan P.
      • Soundara Raghavan S.
      • Sharma D.
      Study comparing 3 hour and 24 hour post-operative removal of bladder catheter and vaginal pack following vaginal surgery: a randomised controlled trial.
      Although no specific research has been conducted for patients undergoing laser treatment of the vulva, several studies have examined the role of occlusive dressings after laser skin resurfacing. A small retrospective study of open wound care compared with perforated silicone occlusive dressing found a decrease in the rate of erythema, swelling, and crusting.
      • Batra R.S.
      • Ort R.J.
      • Jacob C.
      • Hobbs L.
      • Arndt K.A.
      • Dover J.S.
      Evaluation of a silicone occlusive dressing after laser skin resurfacing.
      Occlusive dressings may promote reepithelialization and improve wound healing by creating a moist environment.
      • Newman J.P.
      • Fitzgerald P.
      • Koch R.J.
      Review of closed dressings after laser resurfacing.
      • Collawn S.S.
      Occlusion following laser resurfacing promotes reepithelialization and wound healing.
      • Altman A.D.
      • Robinson C.
      Vulvar postoperative care, gestalt or evidence based medicine? A comprehensive systematic review.
      Vacuum-assisted closure (VAC) dressings have also occasionally been used for the closure of radically excised perineal and vulvar wounds.
      • Altman A.D.
      • Robinson C.
      Vulvar postoperative care, gestalt or evidence based medicine? A comprehensive systematic review.
      • Dhar R.
      • Copson D.
      • Williamson K.
      • Nunns D.
      Use of topical negative pressure to close a large MRSA-infected groin wound following vulvectomy.
      • Shvartsman H.S.
      • Langstein H.
      • Worley C.
      • Malpica A.
      • Ramondetta L.M.
      Use of a vacuum-assisted closure device in the treatment of recurrent Paget’s disease of the vulva.
      • Piovano E.
      • Ferrero A.
      • Ravarino N.
      • Martra F.
      • Modaffari P.
      • Zola P.
      Syringoid eccrine carcinoma: case report of a rare tumor occasionally detected in the vulva.
      • Schimp V.L.
      • Worley C.
      • Brunello S.
      • et al.
      Vacuum-assisted closure in the treatment of gynecologic oncology wound failures.
      • Riebe E.
      • Ohlinger R.
      • Thele F.
      • Köhler G.
      Polypropylene mesh implantation in combination with vacuum-assisted closure in the management of metastatic or locally recurrent vulvar cancer: case report and review of literature.
      • Dainty L.A.
      • Bosco J.J.
      • McBroom J.W.
      • Winter 3rd, W.E.
      • Rose G.S.
      • Elkas J.C.
      Novel techniques to improve split-thickness skin graft viability during vulvo-vaginal reconstruction.
      • Narducci F.
      • Samouelian V.
      • Marchaudon V.
      • et al.
      Vacuum-assisted closure therapy in the management of patients undergoing vulvectomy.
      One investigation retrospectively examined 54 patients with VAC compared with standard postoperative care in patients after radical excisions and found a decrease in time to complete healing (44.4 vs 60.2 days; P=.0175).
      • Narducci F.
      • Samouelian V.
      • Marchaudon V.
      • et al.
      Vacuum-assisted closure therapy in the management of patients undergoing vulvectomy.
      Another group retrospectively assessed 24 patients with penile or urethral cancer requiring inguinofemoral lymph node dissections and found decreased rates of hospitalization, lymphocele, persistent lymphorrhea, and lymphedema with the use of VAC.
      • Tauber R.
      • Schmid S.
      • Horn T.
      • et al.
      Inguinal lymph node dissection: epidermal vacuum therapy for prevention of wound complications.
      Contamination with stool and urine must be avoided when VAC dressings are applied to the vulva and perineum; immediate treatment solutions have included the use of Foley catheters, antimotility agents (eg, Imodium and codeine), rectal tubes, and waterproof dressings (eg, DuoDERM).
      • Shvartsman H.S.
      • Langstein H.
      • Worley C.
      • Malpica A.
      • Ramondetta L.M.
      Use of a vacuum-assisted closure device in the treatment of recurrent Paget’s disease of the vulva.
      ,
      • Schimp V.L.
      • Worley C.
      • Brunello S.
      • et al.
      Vacuum-assisted closure in the treatment of gynecologic oncology wound failures.
      VAC dressings have also been used in complicated inguinal incisions.
      • Altman A.D.
      • Robinson C.
      Vulvar postoperative care, gestalt or evidence based medicine? A comprehensive systematic review.
      ,
      • Riebe E.
      • Ohlinger R.
      • Thele F.
      • Köhler G.
      Polypropylene mesh implantation in combination with vacuum-assisted closure in the management of metastatic or locally recurrent vulvar cancer: case report and review of literature.
      ,
      • Stanirowski P.J.
      • Wnuk A.
      • Cendrowski K.
      • Sawicki W.
      Growth factors, silver dressings and negative pressure wound therapy in the management of hard-to-heal postoperative wounds in obstetrics and gynecology: a review.
      • Altman A.D.
      • Nelson G.
      • Nation J.
      • Chu P.
      • Ghatage P.
      Vacuum assisted wound closures in gynaecologic surgery.
      • Denzinger S.
      • Lübke L.
      • Roessler W.
      • Wieland W.F.
      • Kessler S.
      • Burger M.
      Vacuum-assisted closure versus conventional wound care in the treatment of wound failures following inguinal lymphadenectomy for penile cancer: a retrospective study.
      Although it continues to be common practice, there are no high-quality studies examining the utility of silver sulfadiazine cream after the laser vaporization of the vulva.

      Recommendation

      Vaginal packing does not seem to decrease postoperative bleeding and hematoma formation or increase postoperative pain (High). Vaginal packing may result in an increase in postoperative infection rates when left for longer than 24 hours (Low) and longer use of packing results in longer catheterization and thus higher rates of UTI. Occlusive dressings may be used after laser treatment to promote healing (Low).

      Postoperative drains and adjuvant therapies

      Postoperative drains after systematic inguinofemoral lymph node (IFLN) dissection are used routinely and often left in situ until producing <20 to 50 mL per 24 hours,
      • Spiess P.E.
      • Hernandez M.S.
      • Pettaway C.A.
      Contemporary inguinal lymph node dissection: minimizing complications.
      • Walker K.F.
      • Day H.
      • Abu J.
      • Nunns D.
      • Williamson K.
      • Duncan T.
      Do surgical techniques used in groin lymphadenectomy for vulval cancer affect morbidity rates?.
      • Dardarian T.S.
      • Gray H.J.
      • Morgan M.A.
      • Rubin S.C.
      • Randall T.C.
      Saphenous vein sparing during inguinal lymphadenectomy to reduce morbidity in patients with vulvar carcinoma.
      • Gould N.
      • Kamelle S.
      • Tillmanns T.
      • et al.
      Predictors of complications after inguinal lymphadenectomy.
      • Reedy M.B.
      • Capen C.V.
      • Baker D.P.
      • Petersen W.G.
      • Kuehl T.J.
      Hyperbaric oxygen therapy following radical vulvectomy: an adjunctive therapy to improve wound healing.
      with some recommendations to leave the drains in place at least 5 to 7 days postoperatively.
      • Altman A.D.
      • Robinson C.
      Vulvar postoperative care, gestalt or evidence based medicine? A comprehensive systematic review.
      ,
      • Gaarenstroom K.N.
      • Kenter G.G.
      • Trimbos J.B.
      • et al.
      Postoperative complications after vulvectomy and inguinofemoral lymphadenectomy using separate groin incisions.
      ,
      • Hinten F.
      • van den Einden L.C.
      • Hendriks J.C.
      • et al.
      Risk factors for short- and long-term complications after groin surgery in vulvar cancer.
      This is thought to decrease lymphocyst formation by allowing the overlying skin flaps to adhere to the underlying connective tissue.
      • Spiess P.E.
      • Hernandez M.S.
      • Pettaway C.A.
      Contemporary inguinal lymph node dissection: minimizing complications.
      Separate vulvar drainage has been abandoned by most.
      • Leminen A.
      • Forss M.
      • Paavonen J.
      Wound complications in patients with carcinoma of the vulva. Comparison between radical and modified vulvectomies.
      Adjuvant products such as fibrin sealant and albumin-glutaraldehyde adhesive have not been proven to decrease morbidity.
      • Altman A.D.
      • Robinson C.
      Vulvar postoperative care, gestalt or evidence based medicine? A comprehensive systematic review.
      ,
      • Mortenson M.M.
      • Xing Y.
      • Weaver S.
      • et al.
      Fibrin sealant does not decrease seroma output or time to drain removal following inguino-femoral lymph node dissection in melanoma patients: a randomized controlled trial (NCT00506311).
      • Bouchot O.
      • Rigaud J.
      • Maillet F.
      • Hetet J.F.
      • Karam G.
      Morbidity of inguinal lymphadenectomy for invasive penile carcinoma.
      • Buda A.
      • Ghelardi A.
      • Fruscio R.
      • et al.
      The contribution of a collagen-fibrin patch (Tachosil) to prevent the postoperative lymphatic complications after groin lymphadenectomy: a double institution observational study.
      The preservation of the saphenous vein seems to reduce the rate of lymphedema, cellulitis, and dehiscence.
      • Tranoulis A.
      • Laios A.
      • Theophilou G.
      • Bramis K.
      • Kehoe S.
      The impact of saphenous vein sparing during inguinal lymphadenectomy on postoperative morbidity in women with vulval cancer: an updated per-groin meta-analysis of short-term outcomes.
      Multiple retrospective studies have investigated time-based or volume-based IFLN drainage to guide drain removal, with no definitive conclusions. Overall, short duration of use (<3 days) was associated with higher rates of wound breakdown, whereas longer duration of use (>7 days) was associated with higher rates of lymphedema.
      • Walker K.F.
      • Day H.
      • Abu J.
      • Nunns D.
      • Williamson K.
      • Duncan T.
      Do surgical techniques used in groin lymphadenectomy for vulval cancer affect morbidity rates?.
      Drain use has also been shown to be associated with higher rates of cellulitis.
      • Pontre J.
      • Harding J.
      • Chivers P.
      • et al.
      Do groin drains reduce postoperative morbidity in women undergoing inguinofemoral lymphadenectomy for vulvar cancer?.
      Another investigation showed that higher drain output on the final day before removal was a risk factor for complications, including lymphocele formation.
      • Hinten F.
      • van den Einden L.C.
      • Hendriks J.C.
      • et al.
      Risk factors for short- and long-term complications after groin surgery in vulvar cancer.
      Two prospective studies demonstrated that removal once the output had decreased to <30 to 50 cc per day resulted in lower rates of lymphocele formation and other complications. No prospective studies have evaluated drainage after inguinal sentinel lymph node biopsy in women with vulvar cancer.
      There were no studies examining the role of surgical drains for vaginal or prolapse surgery.

      Novel postoperative therapies

      Routine postoperative vulvar care for radical vulvar excisions often consists of irrigation and perineal drying with either a hair dryer or vulvar blower or fan.
      • Altman A.D.
      • Robinson C.
      Vulvar postoperative care, gestalt or evidence based medicine? A comprehensive systematic review.
      ,
      • Narducci F.
      • Samouelian V.
      • Marchaudon V.
      • et al.
      Vacuum-assisted closure therapy in the management of patients undergoing vulvectomy.
      However, no studies have been identified showing efficacy for this practice.
      A small RCT was performed on granulocyte colony-stimulating factor (G-CSF) vs placebo in 40 patients undergoing vulvar cancer resection based on an earlier retrospective study.
      • Uyl-De Groot C.A.
      • Hartog J.G.
      • Derksen J.G.
      • et al.
      Cost-effectiveness and quality of life of granulocyte-colony stimulating factor (filgrastim) after radical vulvectomy and bilateral inguino-femoral lymphadenectomy: results of a randomized clinical trial.
      The authors found no difference in rates of wound infection between the groups, with increased cost associated with G-CSF. Adjuvant platelet gel has been studied in a retrospective study
      • Morelli M.
      • Rocca M.L.
      • Venturella R.
      • et al.
      Adjuvant use of platelet gel for wound breakdown prevention in advanced vulvar cancer surgery: a retrospective study.
      applied to the vaginal resection portion of the radical vulvectomy; the platelet gel group had significantly fewer wound complications; no prospective or randomized trials have been performed.
      Hyperbaric oxygen (HBO) has been used to improve tissue oxygenation, thereby stimulating healing and angiogenesis. Investigation of HBO in patients undergoing radical vulvectomy showed significantly less wound breakdown compared with historical controls (P=.0105).
      • Reedy M.B.
      • Capen C.V.
      • Baker D.P.
      • Petersen W.G.
      • Kuehl T.J.
      Hyperbaric oxygen therapy following radical vulvectomy: an adjunctive therapy to improve wound healing.
      ,
      • Wills A.
      • Obermair A.
      A review of complications associated with the surgical treatment of vulvar cancer.
      Although HBO is a very promising treatment that is commonly used, further trials must be performed to demonstrate efficacy of this expensive therapy.
      Zinc has been shown to be necessary for the early stages of repair, and oral supplementation is thought to restore subclinically low levels. A pilot study investigated the dosage of zinc sulfate 220 mg orally 3 times daily for 7 days preoperatively in patients undergoing radical vulvectomy and lymphadenectomy. The authors showed a decreased rate of wound dehiscence and a reduced hospital stay from 37 to 18 days.
      • Altman A.D.
      • Robinson C.
      Vulvar postoperative care, gestalt or evidence based medicine? A comprehensive systematic review.

      Recommendation

      The drainage of inguinal lymph node dissection should continue until <30 to 50 cc per day of drainage (Moderate). Saphenous vein preservation should be considered in IFLN dissection (Moderate).

      Comment

      This guideline summarizes current evidence examined by the ERAS Society Gynecology Chapter on recommendations for the elements of pre-, intra-, and postoperative care in vulvar and vaginal surgeries. In several instances, where good quality data were not available, recommendations were made on the basis of other surgical disciplines and the original ERAS gynecologic oncology guidelines. The guideline committee decided to combine vulvar and vaginal surgeries because these surgeries are common approaches in practice for general gynecology and subspecialties, including urogynecology and gynecologic oncology. The authors believed that the perioperative care for both was similar, and the differences have been highlighted in the aforementioned sections. As ERAS guidelines are created by reviewing all the current and updated literature, including systematic reviews, meta-analyses, RCTs, retrospective studies, and studies in similar disciplines, it does not follow the same process as a systematic review of looking at only specialty-specific randomized trials. The advantages of this process include using any relevant information that is currently available, which is then reviewed by an international panel of experts. The disadvantages are that some of the recommendations are based on expert opinion and low levels of evidence.
      This guideline summarizes the best evidence in common practices for vulvar and vaginal surgeries but recognizes the paucity of evidence specific to this area in topics such as ileus prevention, postoperative diet, and mobilization. We hope that these guidelines will help expand ERAS protocols into gynecologic surgeries outside of the realm of laparotomy or laparoscopy, helping improve patient outcome, optimize hospital stay, and reduce systemic costs.

      Supplemental Appendix

      • Supplement 1

        Reference list of all articles examined for the review of the ERAS guideline

        ERAS, Enhanced Recovery After Surgery.

        Altman. Enhanced Recovery After Surgery Society recommendations for vulvar and vaginal surgeries. Am J Obstet Gynecol 2020.

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        Enhanced recovery after surgery: a review.
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        • Nelson G.
        ERAS-value based surgery.
        J Surg Oncol. 2017; 116: 608-612
        • Nelson G.
        • Altman A.D.
        • Nick A.
        • et al.
        Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations—part I.
        Gynecol Oncol. 2016; 140: 313-322
        • Nelson G.
        • Altman A.D.
        • Nick A.
        • et al.
        Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations—part II.
        Gynecol Oncol. 2016; 140: 323-332
        • Nelson G.
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