The American Urological Association gratefully acknowledges the assistance of the American Society of Anesthesiologists and Society of Urologic Nurses and Associates in the creation of the white paper.
The purpose of this white paper is to review key components of pre-operative evaluation of the urologic patient and familiarize urologists with existing pre-operative practices in order to identify risk factors that can be modified and allow for more effective counseling of patients prior to surgery. It should be emphasized that a comprehensive pre-operative evaluation requires a team of medical professionals to assess and evaluate the specific patient's needs. Although the urologic practitioner is not primarily responsible for many of the evaluations noted in this document, this white paper is intended to serve as a tool to coordinate care between the operative and supportive pre-operative medical teams. The target audience is urologists, urologic residents, advanced practice providers, and primary care physicians performing pre-operative clearance for urologic patients.
This topic was submitted to the American Urological Association Quality Improvement and Patient Safety Committee and selected as a white paper. A Pre-Operative White Paper Panel comprised of practicing urologists and urologic nurses was assembled. The topic was researched via English language literature search from 1980 through 2018 and focused on pre-operative evaluation and safety. Best practice recommendations were also reviewed from specialty societies, including the American College of Cardiology/American Heart Association, American Society of Anesthesiologists, American Gastroenterological Association, and the European Association of Urology. Recommendations contained in this manuscript reflect expert opinion from the Pre-Operative Panel and are based on review of available evidence and existing best practice statements.
Urologic pre-operative care is defined as medical evaluation or treatment received in preparation prior to a urologic surgery or procedure.
Per the Centers for Medicare & Medicaid Services (CMS) guidelines, a pre-operative history and physical (H+P) must be completed not more than 30 days prior to surgery as set forth in the Conditions of Participation. These are requirements that healthcare organizations must meet in order to begin and continue participating in Medicare and Medicaid programs. It is acceptable to perform the H+P the day of the procedure, but as CMS stipulates, appropriate medical personnel accredited and privileged by the hospital/facility/surgery center to perform the H+P must be present. This may include advanced practice providers per individual state licensing requirements, although the responsible urologist still is required to sign off. However, the patient cannot be under anesthesia, sedation, or in the operating theater when the H+P is performed. CMS and The Joint Commission also note that "an update is required within 24 hours AFTER the patient physically arrives for admission/registration but prior to surgery or a procedure requiring anesthesia services."4 If the H+P is not performed the day of the surgery, but within 30 days, the surgeon should provide an update noting the H+P exam and indicating appropriate changes in the patient's status. This required update also applies to patients who may have been in the hospital longer than 24 hours prior to surgery.
Chief Complaint: The patient's urologic chief complaint to be addressed by the intervention is noted. Laterality, if applicable, is stated in the History of Present Illness.
History of Present Illness: This describes the patient's symptoms and physical signs related to the underlying urologic condition and notes the duration, severity, and location of each. Previous urologic interventions, testing, and imaging relevant to the present condition can be also added in this segment. Additionally, the impact of comorbid conditions on this present illness is also documented here.
Past Medical History/Past Surgical History: Any and all co-morbid conditions are listed, ideally divided into active and resolved issues. Previous surgical intervention is noted with either dates or estimates of when performed. Special attention is usually noted to implantable devices that could affect the planned surgical intervention.
Review of Systems: A multi-system evaluation will help identify any active issues in major organ systems prior to surgery. Urologic issues such as urinary frequency, urgency, incontinence, sexual function, and pain are also helpful to document prior to surgery to establish a baseline.
Allergies: Reactions to medications, foods, supplements, and materials are updated and type of allergic reaction noted. Previous reactions to anesthesia can be noted here.
Medications: An updated medication list includes active medication, dosage, delivery, and frequency. Nutritional supplements are also documented.
Social History: Smoking, alcohol/drug usage, including duration of use, are recorded. A description of the person's job/activities that may impact surgery or recovery are also helpful to describe (e.g., person is not a smoker but worked as a bartender in a bar for 35 years). Marital status can also be noted here.
Assessment/Plan: The procedure, with any laterality, and the assessment that the patient is ready for surgery should be stated. CMS guidelines require that the pre-operative history and physical note that the patient is cleared for surgery in an ambulatory setting.
Frequently, ASA classification determines if a patient can be scheduled in an ambulatory surgery center or in an inpatient hospital facility. Many ambulatory surgery centers require specific clearance for ASA III or above.
Studies have shown that many patients may not fully understand the risks, potential complications and benefits of surgery.8 Key components that reflect capacity to make medical decisions include: 1) if the patient is able to indicate his or her treatment choice; 2) whether the patient understands the relevant information communicated by the clinician; 3) if the patient acknowledges his or her medication condition, treatment options and likely outcomes; and 4) whether the patient can engage in a rational discussion about treatment options.9 If a patient is unable to sign surgical consent, a proxy consent can occur through an individual who is provided with the legal right to make decisions on behalf of the patient.
Informational elements of informed consent include the education provided to the patient. Key concepts should include description of the treatment or surgical procedure, including alternatives, complications, and risks, description of the pre-operative and post-operative courses, surgical approach and the desired result. For academic medical centers and teaching facilities, acknowledging care performed by assistants is also encouraged.
In its Statements on Principles, the American College of Surgeons also encourages surgeons to inform patients if the surgeon will be participating in overlapping surgeries.10 An institution or health system may also have specific policies regarding concurrent or overlapping surgeries.
Counseling and education are vital components of pre-operative preparation, care, and the informed consent process. A team approach, including but not limited to the urologist, advance practice providers, and nursing, frequently work together to educate patients throughout the pre-operative assessment. Key components to discuss include type of sedation or anesthesia, incision size and location, surgical approach, drain, device, catheter or stoma care and management, complications and their prevention, pulmonary optimization and toileting, ambulation, venous thromboembolism prophylaxis, pain management, bowel function, side effects, effective coping, recovery timeline, and post-operative limitations, and the need for additional follow up, procedure, or treatments.11 A discussion about the patient's specific cultural norms and values that may impact the pre-operative evaluation is also very helpful to alleviate concerns and to address the patent's potential pre-operative or postoperative needs.
Pre-operatively discussing specific elements of care that will occur while the patient is sedated versus awake is recommended to relieve any fears and reduce the risk of last minute procedure cancellation. Some patients may only consent for certain procedures to be performed while sedated, such as urinary catheterization or ureteral stent removal. Types of care to discuss include catheterization, intravesical instillation, or intravenous catheter placement.
Most patients believe the amount of information offered by their provider is sufficient; however the degree of comprehension of the various components of the informed consent process may not be adequate. Well-designed tools, such as written material, and interactive or audiovisual media, may increase the degree of patients' understanding of the information provided.13 Although there is no consensus on the type or format of any decision aids, making a variety of tools available can help the patient select the format that best suits his/her learning style. Evaluation of understanding is a vital component of patient education. Teach back or repeat back is a tool that allows patients to reiterate in their own words what they understood about content. This has been shown to have a positive effect on patient comprehension.14 Documentation of teaching also helps the surgical team refer back to previous education and address knowledge gaps.
Evaluation and discussion of a patient's preferences and wishes pre-operatively provides clear guidance to the care team. This is especially important during times of post-operative complications, delirium or incapacity to express one's wishes. Studies have shown the majority of elderly pre-operative patients have specific wishes about the types of medical treatment they want but have not discussed with their healthcare providers.15 Shared decision making is encouraged pre-operatively to ensure all are in agreement with the patient's wishes. Shared decision making is associated with increased patient knowledge and satisfaction, and more realistic expectations, as well as higher patient engagement through rational discussion between the patient and provider about treatment options that coincide with the patient's wishes and goals.16 Discussion of one's goals, as applicable to treatment options and quality of life, presents an excellent opportunity for advance care planning. The patient's expectations should be explored, and the provider should clarify or correct unrealistic expectations to ensure appropriate understanding.
Patients and providers should discuss advance care planning during the informed consent process. Pre-operative discussion and agreement on one's wishes, goals of care, and treatments helps the care team to understand what measures to pursue. The patient should appoint a healthcare proxy who actively participates in the informed consent process and clearly understands the patient's goals and wishes.17 Conversation should include discussion of the patient's wishes if complications arise or if intra-operative findings prompt an alternative treatment approach.
Assessing a patient's social needs and support pre-operatively helps to identify any essential needs that may be unmet. As with other pre-operative education, pre-operative teams can utilize a team approach to complete the assessment. Key domains to inquire about include food insecurity, housing instability, utility needs, financial resource strain, transportation, exposure to violence, and socioeconomic status.18 A lack of resources may have a detrimental impact on a patient's recovery. One's healthcare insurance plan should be reviewed and considerations given for co-payment costs, deductible costs, and the ability to purchase any costly medical supplies or medications. A patient's support system should be evaluated to identify from whom the patient may receive assistance before and after surgery. Identification of any needs pre-operatively may allow additional resources to be allocated, a social work professional may be engaged, and concerns that affect a patient's coping and recovery be addressed, thereby preventing potential post-operative discontinuities.
In the last 12 months, did you ever eat less than you felt you should because there was not enough money for food?
Are you worried or concerned that in the next two months you may not have stable housing that you own, rent, or stay in as a part of a household?
In the past year, has the utility company shut off your service for not paying your bills?
In the last 12 months, was there a time when you needed to see a doctor but could not because of cost?
In the last six months, have you ever had to go without healthcare because you did not have a way to get there?
Are you afraid you might be hurt in your apartment building or house?
Do problems getting childcare make it difficult for you to work or study?
Do you ever need help reading hospital materials?
The patient's identified support person or health coach is advised to accompany the patient to appointments, especially during explanation of treatment options and surgical procedure, counseling, informed consent, shared decision making, or identification of preferences and wishes. Expected duties of the health coach should be verbalized, such as driving the patient to the hospital, staying with the patient following surgery, assisting with activities of daily living or assisting with care of medical devices post-operatively. Clear understanding of the duties of the health coach and agreement by the patient and health coach to fulfill these needs will reduce any confusion post-operatively.
Identification of unmet needs pre-operatively may allow opportunity for a patient to arrange support to correct any deficits or refine a discharge plan to a rehabilitation center, skilled nursing facility or home with visiting nurse services. If a patient's unmet needs are not addressed pre-operatively, negative outcomes may ensue post-operatively to include elongated length of stay, readmission, reoperation or mortality.
In addition to the standard pre-operative assessment by organ system, a more global and holistic assessment of an individual's "surgical fitness" is important, particularly among older adults. Pre-operative assessment of "surgical fitness" includes evaluation of functional status and frailty, both of which are known to be associated with increased risk of post-operative morbidity and mortality, prolonged hospitalization, prolonged intensive care lengths of stay, deleterious effects on health-related quality of life, and loss of independence.19,20 Risk assessment tools also exist that incorporate functional status, frailty, and other factors. Collectively, these assessments serve to help counsel, risk stratify, and potentially risk modify patients in the pre-operative setting.
Can you get out of bed or chair with yourself?
†If NO to any of the above, more in-depth evaluation should be performed, including full screening of ADLs and IADLs.
†NOTE: Patient's responses may not be reliable in the presence of cognitive impairment of dementia.
2. Document deficits in vision, hearing, or swallowing.
3. Inquire about history of falls ("Have you fallen in the past year?").
4. Evaluate the patient for limitations in gait and mobility [using the Time Up and Go Test (TUGT)] and determine risk for falls.
2. Exhaustion Self-reported exhaustion and endurance measured by 10-item Center for Epidemiological Studies - Depression scale.
3. Weakness Decreased grip strength measured by a dynamometer adjusted for gender and body mass index.
Scoring: Patient receives 1 point for each criteria met. 0-1, not frail; 2-3, intermediate frail (pre-frail); 4-5, frail.
Obtain a detailed history and cognitive assessment, such as the Mini-Cog (Table 3) for any older patient without a known history of cognitive impairment or dementia.
If possible, interview a knowledgeable informant (i.e., spouse or family member) about the evolution of any cognitive or functional decline in the patient.
An identified decline in cognitive function should prompt referral to a primary care physician, geriatrician, or mental health specialist for further evaluation.
Carefully document pre-operative cognitive status because post-operative cognitive dysfunction is common but difficult to quantify without a baseline.
It is recommended that cognitive assessment be performed early in the evaluation since evidence of impairment or dementia may indicate that subsequent assessment of functional status and/or medication use may be unreliable.
"I am going to say three words that I want you to remember now and later. The words are banana, sunrise, chair. Please say them now."
Give the patient three tries to repeat the words. If unable after three tries, go to the next item.
"Please draw a clock in the space below. Start by drawing a large circle. Put all the numbers in the circle and set the hands to show 11:10 (10 past 11).
If subject has not finished clock drawing in three minutes, discontinue and ask for recall items.
All numbers 1-12, each only once, are present in the correct order and direction (clockwise) in the circle.
Two hands are present, one pointing to 11 and one pointing to 2.
ANY CLOCK MISSING ANY OF THESE ELEMENTS IS SCORED ABNORMAL. REFUSAL TO DRAW A CLOCK IS SCORED ABNORMAL.
The patient can clearly indicate his or her treatment choice.
The patient understands the relevant information communicated by the physician.
The patient acknowledges his or her medical condition, treatment options, and the likely outcomes.
The patient can engage in a rational discussion about the treatment options.
Post-operative pulmonary complications are a significant source of morbidity and mortality in surgical patients, and occur in up to six percent of patients undergoing major abdominal surgery with up to 25 percent of patients dying as a result of post-operative respiratory failure.67,68 Pulmonary complications increase patient length of stay, and are a common cause of readmission and cost associated with radical cystectomy.69,70 Identifying patient and procedure related risk is paramount in hopes of minimizing pulmonary complications following surgery.
The provider evaluating the urologic surgical patient needs to assess the risk for intra-operative pulmonary complications, determine whether pre-operative medical tests will clarify this risk, and attempt to mitigate the risks of pulmonary complication.
Again, the use of a risk calculator (as previously discussed, ASC NSQUIP calculator) allows clinicians to estimate the risk of post-operative respiratory failure. It is an important tool in the informed consent process and patient centered decision making prior to urologic surgery, and will allow for pre-operative optimization for at risk patients.
In patients with known OSA, consistent use of continuous positive airway pressure (CPAP) pre-operatively and continuing post-operatively is the most effective means of reducing intra-operative and post-operative complications.75,76 Identifying urologic surgical patients with a suspicion of OSA is of high importance due to the potentially significant morbidity associated with unrecognized and untreated OSA.77 An algorithm to screen patients suspected of having OSA involves a detailed H+P, a screening questionnaire, and sleep study if necessary (Figure 1). Patients should be advised to bring their own CPAP or similar machine at time of surgery for inpatient, postoperative use.
*Reproduced with permission from the ©ERS 2018.
Patients with severe nutritional deficiency are likely to be at risk for a variety of post-operative complications. Serum albumin (<30 g/L) is an independent risk factor for the development of post-operative pulmonary complications as well as early post-operative morbidity and mortality in urologic oncology patients.85,86 In nutritionally replete patients, there may be value for pre-operative nutritional supplementation prior to elective urologic surgery. Prehabilitation will be discussed in a subsequent section.
Many patients undergoing urologic surgery are at risk for a cardiovascular event. A recent study found that patients undergoing non-cardiac surgery have a three percent risk of major cardiovascular and cerebrovascular events (in-hospital, all-cause death, acute myocardial infarction, or acute ischemic stroke).87 The risks associated with development of a cardiovascular event are due to both patient and procedure specific factors. While the risks associated with various urologic procedures vary widely, identification of patient and procedure specific risk factors will help the urologist balance the risk-benefit ratio for patients and potentially identify interventions that may reduce the risk for a particular procedure or potentially identify cardiovascular conditions that require long-term management.
All patients undergoing urologic surgery should have an assessment of their cardiovascular risk prior to surgery, and the scope of this assessment will vary depending on the presence of risk factors and complexity of the surgical procedure. This assessment may reveal an undiagnosed condition, help the patient and urologist better understand the risks and benefits of surgery, and may influence the optimal timing of surgery. The patient's perspective in understanding their cardiovascular risk is an important factor in surgical decision making.
As part of the pre-operative evaluation, clinicians should inquire about the patient's history of hypertension, diabetes, heart disease, chest pain, dyspnea, palpitations, valvular heart disease, erectile dysfunction cerebrovascular and peripheral vascular disease, and chronic kidney disease. Erectile dysfunction often precedes cardiovascular disease, and may be a marker of cardiovascular disease.88 The patient's prior cardiac testing should be obtained.
As part of the patient history, the cardiac functional status should be determined as this impacts whether further cardiac testing is recommended prior to surgery. Functional status can be expressed in metabolic equivalents (1 MET is defined as 3.5 mL O2 uptake/kg/min, which is the resting oxygen uptake in a sitting position).
For patients with a low risk of intra-operative MACE, further testing is not recommended prior to surgical intervention.
In patients at high risk of MACE, referral to a cardiologist may be considered, and determination of cardiac functional status should be performed (as discussed above).
Emergency: The procedure usually occurs in <6 hours as life or limb is threatened if not in the operating room.
Urgent: Life or limb is threatened if not in the operating room between 6-24 hours. A limited cardiovascular assessment may be made.
Time sensitive: A delay in surgery more than one to six weeks will negatively affect outcomes.
Elective: The procedure can be delayed for up to one year.
While individual institutions may have slightly different definitions of urgency and risk, a general framework is helpful to both providers and patients when evaluating patient and procedure risk and the necessary cardiovascular workup prior to surgery.
If the patient has stable coronary artery disease (CAD) and is low risk (MACE less than one percent), then the patient may proceed to surgery without further testing.
If the patient has moderate, good or excellent cardiac functional capacity (METs ≥4), then the patient may proceed to surgery without further cardiac testing.
If the patient has poor (<4 METs) or unknown cardiac functional capacity, then the patient, surgeon, and intra-operative team should evaluate whether further testing will impact the surgical decision making or intra-operative care. Cardiology referral and management of pharmacologic stress testing is appropriate if the results of testing will impact the decision to proceed with surgery (Figure 2).
Fleisher LA, Fleischmann KE, Auerbach AD, et al: 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 130:2215-2245, 2014.
Elective urologic surgery should be delayed for 14 days after coronary balloon angioplasty, 30 days after bare metal stent (BMS) implantation, and one year after drug-eluting (DES) implantation.89 Elective urologic surgery may be considered after 180 days in patients with DES implantation if the risk of surgical delay is greater than the risk of cardiac ischemia and stent thrombosis. However, dual antiplatelet (AP) therapy should not be discontinued for elective urologic surgery in patients who had a BMS within 30 days or DES within one year.89 As newer DES and antiplatelet agents are developed and the optimal time between stent placement and elective surgery changes, consultation with internal medicine or cardiology is important.
In 2014, the AUA and the International Consultation on Urological Diseases published a white paper100 on anticoagulation/antiplatelet (AC/AP) therapy in urological practice.100 A systematic literature review was performed, and urologic procedure specific recommendations were made based on numerous observational studies. Having a patient-centered conversation about the risks of procedural bleeding with thrombosis is critical when making decisions about AC medication strategies. For the purposes of the pre-operative evaluation of the urologic patient, a summary of the findings is provided.
For patients on clopidogrel or aspirin for secondary stroke prevention, especially for recent events, it is recommended to continue aspirin through the perioperative period.
Withdrawal of dual AP therapy (DAPT) should NOT occur prior to urologic procedures within 12 months of DES placement or within three months of BMS placement, due to the high risk of major adverse cardiac and cerebrovascular events.
Patients with mechanical heart valves are at high risk for thrombotic complications and should be bridged as appropriate.
For those patients with cardiac risk factors on low-dose aspirin alone, this can be continued in the perioperative period without increased risk of major bleeding.
Patients taking low-dose aspirin without specific medical indications may be scheduled electively, and discontinuing the antiplatelet drug (antiplatelet medications: inclusive of aspirin, clopidogrel, ticagrelor, ticlopine, dipyridamole) until directed by the surgical team.
For procedures with only a minor risk of bleeding, NOAC use does not have to be modified, similar to the management with warfarin or low molecular weight heparin.
For urgent procedures: a delay of the procedure, if medically appropriate for 24 to 36 hours, allowing for expert consultation with cardiology/hematology/ thrombosis services.
For emergent procedures: if there is an increased risk of bleeding associated with this procedure, consultation with experts is strongly advised. Spinal/epidural anesthetics are contraindicated.
Renal reduction procedures will require assessment of renal function post-procedure in order to determine the safety and dosing of NOAC.
Perioperative management of atrial fibrillation in high risk surgical procedures requires that warfarin would be stopped five days before the surgical procedure and should be restarted 12 to 24 hours after surgery if the bleeding risk is acceptable.
Perioperative management of prosthetic valves should follow the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions 2011 percutaneous coronary intervention Guidelines 23 for the management in patients with valvular heart disease.
In patients at high risk of thrombosis (defined as those with any mechanical mitral valve replacement or a mechanical aortic valve with any risk factor) bridging should be started when the international normalized ration falls below 2.0 (typically 48 hours before surgery), and the dose adjusted to achieve an activated partial thromboplastin time two to three times the control.
A high-dose (therapeutic-dose) heparin bridging (e.g., low molecular weight heparin such as enoxaparin 1 mg/kg bid or 1.5 mg/kg daily, dalteparin 100 IU/kg bid or 200 IU/kg daily, tinzaparin 175 IU/kg daily, or i.v. unfractionated heparin to attain an activated partial thromboplastin time [aPTT] 1.5 to 2 times the control aPTT).
A low-dose (prophylactic-dose) heparin regimen (e.g., enoxaparin 30 mg bid or 40 mg daily, dalteparin 5,000 IU daily, unfractionated heparin 5,000-7,500 IU bid).
An intermediate-dose regimen (e.g., enoxaparin 40 mg bid).
AC (anticoagulant/anticoagulation medications: inclusive of coumarins, heparin, NOAC)/AP (anti-platelet) agents should be discontinued and/or reversed prior to shock wave lithotripsy.
Ureteroscopy can be performed with continuing oral AC/AP therapy.
Oral AC/AP medications should be discontinued prior to percutaneous nephrostolithotomy and patients bridged where deemed necessary.
In appropriately selected patients, laser prostate surgery can be safely accomplished for the patient with a therapeutic international normalized ratio who has a significant risk of thrombosis without the discontinuation of oral AC/AP.
AC/AP in patients undergoing transurethral resection of the prostate is associated with an increased risk of bleeding complications which may continue throughout the perioperative period.
Prostate biopsy can be performed safely for the patient on low dose aspirin with a risk of minor bleeding approximately one third higher than controls.
Higher risk urologic procedures, such as radical prostatectomy and partial nephrectomy, have been safely performed with bridging therapy in those with a higher risk of thromboembolic complications, albeit with an increased risk of bleeding.
In general, the perioperative continuation of aspirin may be associated with a minor risk of increased bleeding, but the transfusion rate is not increased and the consequences of that bleeding are minor with the probable exception of transurethral resection of the prostate.
Patients with symptomatic, high-grade carotid artery stenosis (>70 percent stenosis) should have carotid artery stenting or endarterectomy prior to elective urologic surgery. Symptomatic carotid stenosis is commonly defined as stenosis in the internal carotid artery, either intracranial or extracranial, leading to symptoms of amaurosis fugax, transient ischemic attacks, or ischemic stroke ipsilateral to the lesion.116 Management of the asymptomatic patient with more than 60 percent stenosis also has improved outcomes with endarterectomy. Although the pre-operative implications of these findings have not been addressed in the literature, patients with significant carotid stenosis should be evaluated by vascular medicine/surgery pre-operatively to determine their risk of stroke and possible benefit of revascularization prior to elective urologic surgery.
Patients on antiarrhythmic or rate controlling agents should continue these medications for the intra-operative period.
aAlso omit the day after surgery.
bIf contrast medium is to be used or the estimated glomerular filtration rate is under 60 mL/min per 1.73 m2, metformin should be omitted on the day of the procedure and for the following 48 h. SGLT‐2, sodium‐glucose co‐transporter‐2; DPP‐IV, dipeptidyl peptidase‐IV; GLP‐1, glucagon‐like peptide‐1.
Barker P, Creasey E, Dhatariya K, et al: Peri-operative Management of the Surgical Patient with Diabetes 2015. Anaesthesia 70:1427, 2015.
Duncan, A: Hyperglycemia and Perioperative Glucose Management. Curr Pharm Des 18:6195-6203.
Patients taking chronic steroid medication should be identified prior to surgery. Not all patients on chronic steroid medications require changes in steroid dosing before surgery. Patients should be educated not to arbitrarily stop steroids without discussion with the pre-operative team since patients taking prednisone 20mg daily for at least three weeks may experience some suppression of the hypothalamus/pituitary/adrenal axis if steroid supplementation is suddenly stopped.124 Some patients on long-term steroids for greater than three weeks may need to have steroid doses adjusted prior to surgery to address potential gastrointestinal bleeding risk or reactive airway issues during surgery. In general, most patients should continue current steroid dosing up to scheduled surgery and take the medication the night before surgery.
The ASA published recommendations in 2016 regarding recommendations for pre-operative pregnancy testing. The group recommended performing testing in patients at risk for fetal harm during or subsequent to the surgical procedure. Such procedures include those that could disrupt or affect uterine cavity or blood flow to the uterus.125 The ASA previously published a report stating that the risk of anesthesia on early pregnancy is not completely known and suggested that pre-operative testing be performed if knowledge of a positive test would change decision making.80 There is no standard pre-operative pregnancy testing recommendation regarding timing or method of testing, and recommendations may differ between practice sites.
Patients with other gastrointestinal conditions requiring active management, such as inflammatory bowel disease, can be referred to gastroenterology prior to surgery for assessment and potential adjustment of immunosuppressive medications prior to any scheduled surgery.
There are more data suggesting that an oral antibiotic prep may have efficacy in reducing surgical site infections during colonic surgery. Most oral antibiotic bowel preps utilize non-absorbable antibiotics, including aminoglycosides, macrolides, and/or polymixins. Bellows et al. performed at meta-analysis in 2011 demonstrating that oral and intravenous antibiotics were superior in reducing surgical site infections during colon surgery compared to intravenous antibiotics alone. However, there was no change in rate of other complications.132 The benefits of oral antibiotic prep have not been well studied in urologic surgeries such as enterocystoplasty or continent diversion.
Patients with end stage renal disease (ESRD) could potentially have increased risk of morbidity and mortality after surgery due to electrolyte imbalances. To address these concerns, ESRD patients can be evaluated prior to surgery for hyperkalemia (>5.5 mmol/L), altered acid base status, prolonged bleeding times, and anemia. ESRD disease patients can also potentially be at risk for cardiovascular events. Cardiac evaluation (see above) can also be considered for selected ESRD patients prior to surgery.
Patients undergoing urologic procedures may also have indwelling catheters, urostomies, or other tubes that drain the urinary tract. As part of the pre-operative assessment, it is important to identify which of these patients could be at risk for intra-operative or post-operative urinary tract infections.
Patients need both aerobic reserve to compensate for surgical stressors and the strength to participate in critical aspects of the post-operative recovery program (e.g., incentive spirometry, early ambulation). Prehabilitation is the process of improving a patient's fitness prior to surgery, often involving cardiovascular and strength conditioning.
Hospital readmission after major urologic surgery is one of the most pressing issues in the urologic patient population. Ninety-day hospital readmission rates for cystectomy patients, for instance, have been reported to be as high as 40 percent.149 This readmission rate has been corroborated by other studies, with readmission being linked to patient gender, age and comorbidities.150,151 Those patients readmitted also had a significantly higher rate of death within two years of surgery. The circumstances that lead to readmission not only delay patient recovery but also significantly increase healthcare costs.
Although prehabilitation is not yet a common component of the urologic patient's pre-operative pathway, there is mounting evidence that strength and endurance conditioning prior to major surgery can reduce post-operative complications, shorten length of hospital stay, and result in durable improvements in physical capacity. Further work is necessary to establish soundly the functional and quality of life benefit of prehabilitation in urological patients. The optimal length and intensity of a prehabilitation intervention still needs to be established. Proving improved patient outcomes and cost savings is still necessary to sway payers to support making supervised prehabilitation a routine component of pre-operative care. For now, a simple intervention such as an at-home, graduated patient walking program is safe, inexpensive and likely will help improve patient outcomes after major urologic surgery.
Surgery increases a patient's metabolic requirements. An optimized baseline nutritional status plus adequate nutritional support during convalescence will meet these metabolic demands. Unfortunately, many urological patients are malnourished, and too often, this malnourished state goes unrecognized. This places patients at risk for complications and prolonged recovery.
The doctor/patient interaction before an operative procedure provides an opportunity for urologists to positively impact a patient's overall health. A significant amount of information and education is transferred in the patient encounters leading up to the surgical date; time constraints can cause opportunities for intervention to be overlooked.
Tobacco dependence is a chronic disease; nicotine is one of the most addictive substances known, behind only cocaine and heroin.166 As many as 44 percent of the 45 million American smokers attempt to quit every year, but only as few as four to seven percent are successful.167 The most successful smoking interventions combine both counseling and medications, including nicotine replacements (e.g., gum, patches, lozenges, inhalers, nasal spray), Bupropion SR (Zyban), and Varenicline (Chantix). Patients who attempt to quit smoking require ongoing support. Institutional or community smoking cessation programs can assist patients to better assure success. The crucial first step is for a medical provider to identify those patients who use tobacco products, encourage them to quit, and provide them with resources to better assure success. The pre-operative encounter presents such an opportunity.
Surgery, no matter how minor, is a stressful event for a patient. Much of this anxiety comes from fear of the unknown; not knowing what to expect in the days leading up to a surgical procedure, the day of surgery, and post-operatively during recovery. Specific patient concerns that can be particularly anxiety provoking are surgical outcomes (i.e., the success rate of the surgery), recovery period (e.g., how long they can expect to be away from work and their usual activities), and pain management. Patients with higher anxiety levels can have delayed recovery from general anesthesia and require more pain medication after surgery.171 Pre-operative anxiety has been linked to post-operative wound complications, longer post-operative stay, risk for readmission and can even predict patient mortality.172,173 Education and managing patient expectations is a crucial and often overlooked component of the surgical encounter.
Thorough, realistic counseling and expectation management improves urologic patient outcomes and procedure success.174 Patient education can come is several forms. The simplest and most direct is discussion with the surgeon. It can come in other forms as well, such as pamphlets or handouts provided by the surgeon's office, pre-operative seminars, support groups, contact with past patients and vetted, reliable internet content or blogs. The more information a patient has about the pre- and post-operative period, the more at ease they will be leading up to the day of surgery.
There are several relaxation therapy techniques that can help manage patient anxiety. Music therapy can reduce patient anxiety, pain, and need for sedative medications. This has been shown to be true when patients listened to music when sedated for outpatient urological procedures175 but can apply to the gamut of urologic procedures as well. Other relaxation methods that can help manage intra-operative stress include exercise, yoga, meditation, massage, and aromatherapy. A healthier and more relaxed patient psychological state will improve surgical outcomes and patient satisfaction.
A thorough pre-operative evaluation and assessment is important for urologic patients scheduled to undergo a surgical or procedural intervention. The pre-operative process can involve multiple different steps, based on an individual patient's needs, and a "team approach" can be beneficial to maximizing a patient's readiness for surgery.
Jeong YM, Lee E, Kim KI, et al. Association of pre-operative medication use with post-operative delirium in surgical oncology patients receiving comprehensive geriatric assessment. BMC Geriatr 2016; 16: 134.
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The AUA appreciates the assistance of the persons and organizations listed below who contributed to the white paper by providing comments during the peer review process. Their reviews do not necessarily imply endorsement.
This document was written by the Optimizing Surgical Outcomes: Pre-operative Care for the Patient Undergoing Urologic Surgery or Procedure workgroup of the American Urological Association Education and Research, Inc., which was created in 2017. The Quality Improvement and Patient Safety (QIPS) Committee of the AUA selected the workgroup chair, and workgroup members were then selected by the chair. Membership of the workgroup included specialists in urology, anesthesiology, and nursing with extensive experience in pre-operative care for urologic surgery. The mission of the workgroup was to develop a comprehensive qualitative assessment of care for patients undergoing preoperative surgery using existing literature and expert opinion where literature is not available.
Funding of the workgroup was provided by the AUA. Workgroup members received no remuneration for their work. Each member of the Workgroup provides an ongoing conflict of interest disclosure to the AUA.
While the white paper does not necessarily establish the standard of care, AUA seeks to recommend and encourage compliance by practitioners with current best practices related to the subject addressed by the paper. As medical knowledge expands and technology advances, the white paper will be reviewed to ensure its continued accuracy and relevance. White papers do not represent absolute mandates but are provisional proposals for treatment under the specific conditions described in each document. For all these reasons, the white papers do not pre-empt physician judgment in individual cases.
Treating physicians must take into account variations in resources, and patient tolerances, needs, and preferences. Adherence to any white paper does not guarantee a successful outcome. The white paper text may include information or recommendations about certain drug uses ('off label') that are not approved by the Food and Drug Administration (FDA), or about medications or substances not subject to the FDA approval process. AUA urges strict compliance with all government regulations and protocols for prescription and use of these substances. The physician is encouraged to carefully follow all available prescribing information about indications, contraindications, precautions and warnings. White papers are not intended to provide legal advice about use and misuse of these substances.
Although white papers are intended to encourage best practices and potentially encompass available technologies with sufficient data as of close of the literature review, they are necessarily time-limited. White papers cannot include evaluation of all data on emerging technologies or management, including those that are FDA-approved, which may immediately come to represent accepted clinical practices.
For this reason, the AUA does not regard technologies or management which are too new to be addressed by this white paper as necessarily experimental or investigational.