What preoperative work‑up and investigations should be performed before a vaginal hysterectomy with anterior and posterior repair for pelvic organ prolapse and a moderate cystorectocele?

Preoperative Work-Up for Vaginal Hysterectomy with Anterior and Posterior Repair

For vaginal hysterectomy with anterior and posterior repair for pelvic organ prolapse and moderate cystorectocele, perform a focused clinical examination with POP-Q staging, assess for urinary symptoms requiring urodynamic evaluation, obtain routine preoperative labs, and reserve imaging (transperineal ultrasound or MR defecography) only for complex cases with multicompartment involvement or when clinical examination is inadequate. 1, 2

Essential Clinical Assessment

History and Symptom Evaluation

• Document specific prolapse symptoms: sensation of vaginal bulging or protrusion, pelvic pressure, difficulty with bladder emptying, need for digital splinting to void, urinary frequency, urgency, or incomplete voiding 2
• Assess for urinary incontinence: differentiate between stress incontinence and urgency symptoms, as concurrent stress urinary incontinence may require additional surgical planning 2, 3
• Evaluate bowel function: constipation, fecal incontinence, or need for splinting during defecation 3
• Review risk factors: parity, prior pelvic surgeries, chronic cough, obesity, heavy lifting history 3

Physical Examination with POP-Q Staging

• Perform systematic pelvic examination with POP-Q staging: this is the cornerstone of diagnosis and adequate for most straightforward cases 1, 2
• Assess all three compartments: anterior (cystocele), posterior (rectocele), and apical (uterine descent) to identify multicompartment involvement 1, 3
• Document POP-Q stage: this affects treatment planning and surgical approach 2, 4
• Evaluate for occult stress incontinence: perform cough stress test with prolapse reduced, as this may unmask latent incontinence requiring concurrent anti-incontinence procedure 3

Imaging Studies (Selective Use)

When Imaging Is NOT Needed

• Clinical examination is adequate for most cases: imaging should only be ordered when clinical evaluation is difficult or inadequate 1, 2
• Straightforward single-compartment prolapse: does not require routine imaging 2

When to Consider Imaging

• Transperineal ultrasound (first-line imaging): non-invasive, less expensive, provides real-time dynamic assessment, and can detect levator muscle avulsion which predicts recurrence 2

  • Indicated when clinical examination is difficult or inadequate 1, 2
  • Has 59.6% prediction rate for anterior compartment prolapse 2
  • Can identify levator muscle defects that increase recurrence risk 2

• MR defecography (for complex cases): provides comprehensive multicompartment evaluation with 85% agreement with physical examination for anterior compartment prolapse 2

  • Reserve for suspected multicompartment involvement requiring detailed surgical planning 2
  • Optimal when multiple compartments are involved and comprehensive pelvic floor assessment is needed 2
  • Can detect associated pelvic floor abnormalities not apparent on examination 1

• Avoid routine fluoroscopy cystocolpoproctography: while it has 96% sensitivity for cystoceles, it requires contrast installation in bladder, vagina, and oral contrast, involves radiation exposure, and is primarily useful for posterior compartment evaluation 1, 2

• Voiding cystourethrography has limited utility: focuses only on anterior compartment with lower detection rates compared to MR defecography 2

Preoperative Laboratory and Medical Optimization

Standard Preoperative Testing

• Routine preoperative labs: complete blood count, basic metabolic panel, type and screen (based on institutional protocols and patient comorbidities) 1
• Urinalysis: to rule out urinary tract infection before surgery 1

Urodynamic Studies (Selective)

• Consider urodynamics if: significant urinary symptoms present, occult stress incontinence suspected with prolapse reduction, or planning concurrent anti-incontinence procedure 3
• Not routinely required: for uncomplicated prolapse repair without significant urinary symptoms 3

Gynecologic-Specific Preoperative Evaluation

Cervical Cancer Screening

• Review cervical cancer screening history: ensure up-to-date Pap smear and HPV testing per guidelines before proceeding with hysterectomy 5
• Address abnormal screening: any abnormal results require appropriate follow-up or colposcopy before elective hysterectomy 5

Endometrial Assessment

• Evaluate for uterine malignancy risk factors: postmenopausal bleeding, abnormal uterine bleeding, obesity, diabetes, unopposed estrogen exposure 5
• Obtain endometrial sampling if indicated: any abnormal bleeding warrants endometrial biopsy or ultrasound before hysterectomy 5

Adnexal Evaluation

• Discuss prophylactic salpingo-oophorectomy: review patient age, family history of ovarian/breast cancer, and patient preferences regarding ovarian conservation 5
• Pelvic ultrasound if indicated: for palpable adnexal masses or concerning findings on examination 5

Perioperative Protocols

Bowel Preparation

• Mechanical bowel preparation is NOT recommended: meta-analysis of 21,568 patients showed no benefit in anastomotic leak rates, surgical site infection, or hospital length of stay 1
• Enemas may be considered: to reduce stool burden without adverse effects on recovery, though not required 1

Preoperative Fasting

• Allow light snack until 6 hours before surgery: clear fluids (including oral carbohydrate drinks) until 2 hours before anesthesia initiation 1
• Oral carbohydrate loading: associated with improved preoperative well-being and reduced postoperative insulin resistance 1

Antibiotic Prophylaxis

• Administer IV antibiotics within 60 minutes before incision: single-dose antimicrobial prophylaxis is mandatory for vaginal hysterectomy 1
• Recommended regimen: second- or third-generation cephalosporin (provides adequate coverage for vaginal flora) 1
• For anterior/posterior colporrhaphy without hysterectomy: evidence is less clear, but consider prophylaxis given clean-contaminated classification 1

VTE Prophylaxis

• Dual mechanical and chemical prophylaxis: for procedures lasting >30 minutes, use sequential compression devices plus low-molecular-weight heparin or unfractionated heparin 1
• Initiate preoperatively: continue throughout hospital stay 1
• Note: VTE rates are very low (<1%) in benign vaginal surgery, with vaginal approach having lowest rate (0.17%), but prophylaxis should still be considered 1

Critical Pitfalls to Avoid

• Do not routinely order imaging: clinical examination is adequate for most cases; imaging adds cost without improving outcomes in straightforward prolapse 1, 2
• Do not skip assessment for occult stress incontinence: failure to identify this preoperatively leads to postoperative patient dissatisfaction when incontinence becomes apparent after prolapse reduction 3
• Do not perform mechanical bowel preparation: no evidence of benefit and may worsen patient experience 1
• Do not forget cervical cancer screening: proceeding with hysterectomy without current screening is a medicolegal risk 5
• Recognize advanced preoperative stage as recurrence risk factor: stage 3-4 prolapse has 5-fold increased odds of recurrence (OR 5.337,95% CI 2.58-11.036) compared to stage 1-2, which should inform surgical planning and patient counseling 4