Intraop Care

Intraoperative Care

Arm position: avoid brachial plexus injury by abducting arms < 90 degrees, avoid shoulder stretch
Axillary roll: use when in flank position, place caudal to axilla to avoid compression of brachial plexus
Lithotomy: position legs simultaneously, flex hips 80-100 degrees with 30-45 degree abduction
Prone position: ensure careful padding
Trendelenberg: avoid shoulder braces (cause brachial neuropathy)

Procedure	First Choice Antibiotic	Alternate Antibiotics	Indicated
Catheter removal	Fluoroquinolone TMP/SMX	Aminoglycoside +/- Ampicillin 1st/2nd gen Cephalosporin Amoxicillin/Clavulanate	If risk factors
Cystoscopy Urodynamics Cystography			If risk factors
Cystoscopy + manipulation			Always
Transperineal prostate procedure (Brachytherapy/Cryotherapy)	1st gen Cephalosporin	Clindamycin
Transrectal prostate biopsy	Fluoroquinolon 2nd/3rd gen Cephalosporin	Aminoglycoside + Metronidazole or Clindamycin
Shock Wave Lithotripsy	Fluoroquinolone TMP/SMX	Aminoglycoside +/- Ampicillin 1st/2nd gen Cephalosporin Augmentin
Ureteroscopy	Fluoroquinolone TMP/SMX
Percutaneous renal surgery	1st/2nd gen Cephalosporin Aminoglycoside + Metranidazole or Clindamycin	Ampicillin/Sulbactam Fluoroquinolone
Vaginal surgery
Entry into GU tract
Intestinal surgery	2nd/3rd gen Cephalosporin Aminoglycoside + Metranidazole or Clindamycin	Ampicillin/Sulbactam Ticarcillin/Clavulanate Piperacillin/Tazobactam Fluoroquinolone
Prosthesis implant	Aminoglycoside + 1st/2nd gen Cephalosporin or Vancomycin	Ampicillin/Sulbactam Ticarcillin/Clavulanate Piperacillin/Tazobactam
Abdominopelvic surgery without GU entry	1st gen Cephalosporin	Clindamycin	If risk factors

Joint replacement: fluoroquinolone or amp + gent perioperatively
Endocarditis prevention: no specific recommendations
Catheter removal: can give peri-catheter pull antibiotics but no strong guidelines

Hair removal: should be performed immediately prior (not at home) to surgery with clippers (not shaving), only shave surgical site
Skin prep: no difference between chlorhexidine and betadyne

pRBC indications: hematocrit < 21, hematocrit < 24 + cardiac history, never for > 30
FFP indications: immediate reversal of warfarin, replacement of clotting factor deficiencies, bleeding + INR > 1.5, after 1U RBC during massive transfusion protocol
Risk of HIV/HCV 1/2mil, HBC 1/200K

Laser	Wavelength	Absorbed by:	Penetration	Uses
KTP	532nm	Hgb	0.8mm	Prostate vaporization
Ho:YAG	2140nm	Water/target	0.4mm	Stones Prostate enucleation Strictures Tumor fulguration
Thulium	2013nm	Water	0.2mm	Stones Prostate enucleation Strictures Tumor fulguration
CO₂	10K+nm	Water	0.1mm	Genital warts

Direct coupling: unintended contact with another instrument, can happen outside field of view
Residual heat injury: device not cooled when contacting new tissue
Insulation failure: current escapes via laparoscopic instrument shaft
Capacitative Coupling: charge cannot dissipate via abdominal wall and instead travels through nearby tissues
Overuse: accidental tissue charring, inadequate pathology specimen
Poor grounding contact: can increase charge through pad if inadequately attached, leading to skin burns

AUA Core Curriculum
Chrouser, Kristin, et al. "Optimizing Outcomes in Urologic Surgery: Intraoperative Environmental, Behavioral, and Performance Considerations." Urology Practice 7.5 (2020): 405-412.
Culkin, Daniel J., et al. "Anticoagulation and antiplatelet therapy in urological practice: ICUD/AUA review paper." The Journal of urology 192.4 (2014): 1026-1034.
Naik, Rishi, et al. "The role of extended venous thromboembolism prophylaxis for major urological cancer operations." BJU international 124.6 (2019): 935-944.
Salami, S. "Principles of Urologic Surgery: Perioperative Care." Campbell-Walsh Urology 12 (2020).
Violette, Philippe D., et al. "Guideline of guidelines: thromboprophylaxis for urological surgery." BJU international 118.3 (2016): 351-358.
Wieder JA: Pocket Guide to Urology. Sixth Edition. J.Wieder Medical: Oakland, CA, 2021.