Comment on “Evaluating a Novel Postoperative Recovery Protocol: A Randomized Controlled Trial”

Pelvic organ prolapse (POP) and urinary incontinence affect many women over their lifetimes, with an estimated 1 in 5 undergoing at least one procedure for these conditions before the age of 80. As many as a quarter of patients who have procedures for POP or incontinence need a second procedure. Restrictions for activity after a procedure are commonplace, but recent research has provided evidence that postoperative activity restrictions that are more lenient are safe, do not contribute to adverse outcomes, and may benefit overall recovery. This study was designed to build on recent evidence by assessing an active recovery and its association with pelvic floor symptoms after urogynecologic surgery. This was a randomized controlled trial that compared routine restrictions to active recovery, with a primary outcome of the change in Pelvic Floor Distress Inventory-20 (PFDI-20) scores at 12 weeks post surgery. Secondary outcomes included quality of life and mental health measures from baseline to 12 weeks and immediate effects on patients’ impression of improvement and time to return to function. Inclusion criteria were patients undergoing minimally invasive apical prolapse reconstructive procedures at a single center in Portland, Oregon, between August 2023 and December 2024, aged between 18 and 89 years, fluent in English, and a reliable email address. Exclusion criteria were planned concurrent nonurogynecologic surgery, daily or long-term opioid use, significant mobility restrictions at baseline, and inability to sustain 30 minutes of walking or moderate activity at baseline. The active recovery intervention consisted of prescribed activity, core strength exercises, and pelvic floor exercises that focused on urinary and bowel symptoms. The regimen included at least 30 minutes of walking a day for 5 days a week after surgery, beginning on postoperative day 1. Final analysis included 57 patients, with no significant differences at baseline. No significant differences were reported in the change of total or subscale PFDI scores between groups. Notably, however, the total PFDI-20 score and the urinary subscale score for the active recovery group 12 weeks postoperatively were significantly lower, indicating better function ( P = 0.007). Adherence for active recovery was 92.6% for 3 days a week or greater and 59.3% for 5 days a week or greater. Excluding patients who completed the exercises fewer than 3 days a week did not change the results. No significant differences were observed in physical functioning or pain subscales of the Short Form Health Survey (SF-36), in the Patient Health Questionnaire (PHQ-9), the Patient Global Impression of Improvement (PGI-I), or on postoperative physical exam. Average time to discontinue opioid medications was also similar between groups, as well as the occurrence of adverse events. These results indicate that an active recovery protocol did not substantially change the course of recovery after minimally invasive urogynecologic surgery and provided benefit in terms of pelvic floor symptom improvement. In addition, there were no significant anatomic differences or differences in adverse events. This contributes to recent evidence showing that postoperative activity restrictions are unnecessary and that more lenient restrictions are safe. Future studies should focus on longer-term follow-up, increasing sample size, and long-term anatomic outcomes. (Summarized from Carbonell R, Ward L, Gregory WT, et al. Evaluating a novel postoperative recovery protocol: a randomized control trial. Urogynecology . 2026;32(3):296–304. doi: 10.1097/SPV.0000000000001805)