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Surgical Draping & Skin Antisepsis

Surgical draping creates a sterile barrier between the operative wound and the surrounding unprepared environment, and is a universal component of aseptic technique.[1] In reconstructive urology and urogynecology it carries specific demands: most procedures need simultaneous abdominal and perineal access, the operative field abuts the genitourinary tract and vagina, and many cases place a prosthesis (artificial urinary sphincter, penile prosthesis, mesh) for which skin-flora contamination is consequential. High-quality evidence specific to draping technique is limited; most guidance extends general surgical-site-infection (SSI) prevention data to the GU context.

Drape Types​

TypeCharacteristics
Reusable wovenLaundered cotton/linen; less effective at resisting bacterial penetration than non-woven materials[2]
Disposable non-wovenSingle-use synthetic (e.g., polypropylene); superior laboratory barrier to bacterial penetration, but meta-analysis shows no significant SSI difference versus woven drapes[2][3]
Plastic adhesive incise drapesApplied to prepped skin; the surgeon incises through drape and skin together. Plain or antimicrobial- (iodine-) impregnated

Evidence and Guidelines​

The WHO 2016 SSI-prevention guideline gives two conditional recommendations on draping:[3]

  1. Either sterile disposable non-woven or sterile reusable woven drapes may be used (conditional, moderate-to-very-low-quality evidence).
  2. Plastic adhesive incise drapes — impregnated or not — should not be used for SSI prevention.

The recommendation against incise drapes is grounded in a Cochrane overview: non-impregnated adhesive drapes were associated with an increased SSI risk versus no drape (RR 1.23; 95% CI 1.02–1.48; high certainty), and iodine-impregnated drapes showed no clear benefit (RR 1.03; 95% CI 0.66–1.60).[1][4] The theoretical rationale — blocking bacterial migration from peri-incisional skin — has not translated into improved clinical outcomes. The disposable-vs-reusable choice may therefore be made on cost, waste, and laundering/re-sterilization infrastructure rather than infection outcomes.[3]

Skin Antisepsis Before Draping​

Antisepsis precedes and conditions effective draping.

  • Abdominal and external genital skin — chlorhexidine-alcohol is the preferred agent (AUA, ACOG, CDC), superior to aqueous povidone-iodine for SSI reduction (OR 0.59; 95% CI 0.42–0.83).[5][6] An iodophor-in-alcohol prep also improves subsequent adhesive-drape adhesion versus a scrub-and-paint technique.[2]
  • Vaginal preparation — for procedures with vaginal access, cleanse with 4% chlorhexidine gluconate or povidone-iodine. Only povidone-iodine is FDA-approved for vaginal antisepsis; 4% CHG (4% alcohol) is widely used off-label and well tolerated. High-concentration alcohol-based chlorhexidine is contraindicated for vaginal preparation.[5][7]
  • Male genitalia / scrotum — the AUS Consensus Conference noted that for scrotal and perineal skin either razors or clippers may be used, departing from the general clipper-only recommendation, because irregular, elastic scrotal skin is poorly suited to clippers and may sustain more skin breaks.[8]
  • Allow the prep to dry fully before draping — both for antiseptic efficacy and for fire safety with alcohol-based agents.[9]

Positioning and Draping Setup for GU Surgery​

Patient position dictates the draping plan.[10]

  • Lithotomy — supine with legs in stirrups gives simultaneous abdominal and perineal access, essential for radical cystectomy with diversion, AUS implantation, sling and prolapse procedures.[8]
  • Robotic procedures — low lithotomy with steep Trendelenburg (25–45°); a laparoscopic-assisted vaginal hysterectomy (LAVH) drape pack accommodates both abdominal port access and perineal exposure. Arms are tucked and padded; a chest strap over foam prevents cephalad sliding.[11]
  • Combined-field draping — a split-sheet or lithotomy drape isolates the legs while exposing both lower abdomen and perineum, with a perineal opening for catheterization, vaginal instrumentation, or perineal incisions.
  • Sequential fields — when abdominal and perineal approaches are used in sequence (e.g., cystectomy with urinary diversion, multi-stage reconstruction), maintain separate sterile fields and instrument sets to limit cross-contamination between the perineal and abdominal fields.

Draping for steep Trendelenburg should not compromise positioning safety — see Positioning & Nerve Injury.

Draping Within the SSI-Prevention Bundle​

Draping is one element of a broader aseptic strategy, and bundle-level interventions outperform any single component. A single-center study of major urologic surgery (cystectomy, nephrectomy, prostatectomy) found that a simple OR bundle — allowing the skin prep to dry, changing gloves before closure, irrigating the wound before closure, and using a separate sterile closing instrument set — reduced superficial SSI from 3.57% to 1.37% (p = 0.023).[12]

The AUA Best Practice Statement on antimicrobial prophylaxis notes that groin and perineal incisions carry increased SSI risk and warrant single-dose prophylaxis, and that prosthetic implantation (AUS, penile prosthesis) requires coverage of skin flora including coagulase-negative staphylococci and gram-negative bacilli.[13] See Perioperative Antibiotic Prophylaxis and Prosthetic Infection & Biofilm Protocols.

Practical Summary​

  • Disposable non-woven and reusable woven drapes are equivalent for SSI outcomes — choose on cost and logistics.
  • Avoid plastic adhesive incise drapes for SSI prevention; non-impregnated versions may worsen SSI risk.
  • Prep abdominal and external genital skin with chlorhexidine-alcohol; use aqueous povidone-iodine or 4% CHG for the vagina, never high-concentration alcoholic CHG.
  • Let the prep dry fully before draping.
  • Plan the drape around the position: a combined abdominal-perineal field needs a split-sheet/lithotomy drape; sequential fields need separate sterile setups.
  • Treat draping as one component of an SSI-prevention bundle, not a standalone safeguard.

See Also​

References​

1. Webster J, Alghamdi A. "Use of plastic adhesive drapes during surgery for preventing surgical site infection." Cochrane Database Syst Rev. 2015;(4):CD006353. doi:10.1002/14651858.CD006353.pub4

2. Markatos K, Kaseta M, Nikolaou VS. "Perioperative skin preparation and draping in modern total joint arthroplasty: current evidence." Surg Infect (Larchmt). 2015;16(3):221-225. doi:10.1089/sur.2014.097

3. Allegranzi B, Zayed B, Bischoff P, et al. "New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective." Lancet Infect Dis. 2016;16(12):e288-e303. doi:10.1016/S1473-3099(16)30402-9

4. Liu Z, Dumville JC, Norman G, et al. "Intraoperative interventions for preventing surgical site infection: an overview of Cochrane reviews." Cochrane Database Syst Rev. 2018;2:CD012653. doi:10.1002/14651858.CD012653.pub2

5. Committee on Practice Bulletins—Gynecology. "ACOG Practice Bulletin No. 195: prevention of infection after gynecologic procedures." Obstet Gynecol. 2018;131(6):e172-e189. doi:10.1097/AOG.0000000000002670

6. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. "Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017." JAMA Surg. 2017;152(8):784-791. doi:10.1001/jamasurg.2017.0904

7. Committee on Gynecologic Practice. "ACOG Committee Opinion No. 750: perioperative pathways: enhanced recovery after surgery." Obstet Gynecol. 2018;132(3):e120-e130. doi:10.1097/AOG.0000000000002818

8. Biardeau X, Aharony S, AUS Consensus Group, Campeau L, Corcos J. "Artificial urinary sphincter: report of the 2015 Consensus Conference." Neurourol Urodyn. 2016;35(Suppl 2):S8-S24. doi:10.1002/nau.22989

9. Kapadia BH, Berg RA, Daley JA, et al. "Periprosthetic joint infection." Lancet. 2016;387(10016):386-394. doi:10.1016/S0140-6736(14)61798-0

10. Bjøro B, Mykkeltveit I, Rustøen T, et al. "Intraoperative peripheral nerve injury related to lithotomy positioning with steep Trendelenburg in patients undergoing robotic-assisted laparoscopic surgery — a systematic review." J Adv Nurs. 2020;76(2):490-503. doi:10.1111/jan.14271

11. Kurpad R, Woods M. "Robot-assisted radical cystectomy." J Surg Oncol. 2015;112(7):728-735. doi:10.1002/jso.24009

12. Vij SC, Kartha G, Krishnamurthi V, Ponziano M, Goldman HB. "Simple operating room bundle reduces superficial surgical site infections after major urologic surgery." Urology. 2018;112:66-68. doi:10.1016/j.urology.2017.10.028

13. Lightner DJ, Wymer K, Sanchez J, Kavoussi L. "Best practice statement on urologic procedures and antimicrobial prophylaxis." J Urol. 2020;203(2):351-356. doi:10.1097/JU.0000000000000509