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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)