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Preoperative Evaluation

Labs and Adjunct Testing

• UA/UCx: recommended if expected entry into GU tract
• Coags: consider if on active anticoagulation, history coagulopathy, or history operative bleeding
• Pregnancy test: any premenopausal woman who could potentially be pregnant
• Type & screen: any patient undergoing abdominopelvic surgery or percutaneous renal access (increased transfusion risk)
• ECG: questionable benefit, consider for patients > 40yo or with history cardiac disease
• CXR: beneficial if history cardiopulmonary disease
• HbA1c: assess if diabetic, recommend delaying elective surgery if > 6.9

Organ-specific evaluation

• Cardiac: modified risk index helps to stratify risk, ability to complete 4+ METs indicates no need for further cardiac evaluation
• Pulmonary: comorbidities increase risk for complications, assess OSA with Berlin or STOP-BANGquestionnaires
• Hepatobiliary: MELD score may be helpful to predict surgical complications even in absence of liver disease
• ACS NSQIP risk calculator: helpful to assess patient surgical risks based on nationwide patient data, although for larger surgeries may underestimate risk

Specific patient populations

• Age: independently increases morbidity/mortality, increased risk for hospital delirium
• Obesity: increased comorbidities and surgical complications
• Pregnancy: attempt to delay until baby delivered, otherwise attempt to perform surgery during 2nd trimester
• Malnutrition: consider TPN or enteral feeding to decrease surgical wound complications
• Smoking: stop 8+ weeks prior to surgery to achieve risk reduction, otherwise may actually increase complication risks
• Diabetes: discontinue long-acting hypoglycemics (meglitinides, sulfonylureas, SGLT-2i, acarbose) to prevent intraoperative hypoglycemia
• Hyperthyroid: increased risk for thyroid storm (treat with B-blockers, iodine, steroids), difficult airway (from goiter)
• Steroids: HPA suppression seen with 20+mg prednisone taken for 3+weeks, give 50-100mg IV hydrocortisone prior to induction, 25-50mg hydrocortisone q8hr for 24-48hr until baseline steroid use is resumed

Anticoagulation

• Antiplatelet agents: require 7-10 days to reverse (14% normal platelet function restored per day)
• Do not need to discontinue low dose aspirin (ASA 81mg) prior to prostate biopsy, increased risk for minor bleeding
• Can perform ureteroscopy and laser prostate surgeries without stopping anticoagulation
• If on dual-antiplatelet therapy, try to continue aspirin if possible
• Moderate + high risk groups should undergo bridging (not safe to stop)
• Cardiac stents: wait 6-12 weeks for bare metal, 12mo for drug-eluting
• THE KEY: decision often made on individual patient situation, hematology/cardiology consults are recommended if continuing/stopping medications is unclear
• For high risk surgeries (cystectomy, RPLND), recommend preop dose SQH 5KU, discharge home with prophylaxis x4 weeks (recommended by NCCN but not AUA)

Intraoperative management

Avoiding nerve injuries

• 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)

Antibiotic prophylaxis

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
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
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

Other antibiotic recommendations

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

Skin

• 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

Transfusion

• 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

Lasers in urology

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
CO2	10K+nm	Water	0.1mm	Genital warts

Electrocautery complications

• 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

Postoperative management

VTE prophylaxis

Risk	Criteria	Recommendation
Low	Minor surgery + Age < 40yo + No other risk factors	Early ambulation
Moderate	Minor surgery + other risk factors 40-60yo without other risk factors	Heparin 5000U TID Enoxaparin 40mg daily (30mg if CrCL < 30)
High	Age > 60yo 40-60yo with other risk factors
Highest	Multiple risk factors	Enoxaparin 40mg daily (30mg if CrCL < 30) + SCD Heparin 5000U TID + SCD

Non-pharmacologic DVT prophylaxis options

• Compression stockings: decrease DVT risk in low risk patients, need to be proper fit, contraindicated if PVD, pulmonary edema, peripheral neuropathy, leg deformity
• Pneumatic compression: prevent venous stasis and stimulate fibrinolytic activity, reduces risk of DVT by 50%, use at all times unless ambulating, contraindicated if DVT, PVD, pulmonary edema, or leg deformity

Wound care

• Closed incision: keep dressing for 48hr (can change if leakage), consider antimicrobial or negative pressure dressings if wound high risk for breakdown
• Open incision: debride dead tissue, clean with dressing changes, pack wound, consider negative presure dressing
• Ostomy care: empty prior to being full, change pouch first thing in AM (reduces leakage), measure size appropriately (avoid excoriation/breakdown), consider drainage bag for nighttime
• Passive drainage: can use Penrose to assess for bleeding/infection, avoid rapid abscess closure