Contributors of Campbell-Walsh-Wein, 12th edition
Simpa S. Salami, David Mikhail, Simon J. Hall, Manish A. Vira, Christopher J. Hartman, Casey A. Dauw, Stuart J. Wolf, and Melissa R. Kaufman
Preoperative evaluation
History
A “history and physical” should be completed within 30 days of surgery and updated the day of surgery. Significant comorbidities should be elicited, and any poorly controlled comorbidities should be noted for preoperative optimization.
Physical exam
A comprehensive physical exam may reveal signs of poorly compensated systemic disease. Body habitus and previous surgical scars should be noted; careful examination of the abdomen, groin, and perineum may help determine the preferred operative approach. The abdomen should also be specifically assessed for potential stoma sites prior to urinary diversion surgery.
Functional assessment
Preoperative “fitness” is associated with postoperative morbidity and mortality, hospital length of stay, and postoperative return to function. Overall functional status may be assessed through the patient’s ability to perform activities of daily living (ADLs) or independent activities of daily living (IADLs), and brief mobility tests (e.g., The Timed up and go test). Frailty may be assessed with standardized instruments (e.g., Fried frailty score). Detailed cognitive assessment (e.g., mini-cog test) may also be performed for those with cognitive impairment or dementia and for geriatric patients.
Preoperative education
Preoperative education should include discussion regarding the risks, benefits, and alternatives of surgery. Anesthesia type, incision size and location, surgical approach, and postoperative drains or catheters should be addressed. Expectations regarding postoperative recovery, pain management, and anticipated return to activity should be set. Preoperative teaching with a stomal therapist may also benefit patients undergoing urinary diversion.
Risk stratification tools
The American Society of Anesthesiologists (ASA) Physical Status Classification is a commonly used framework to risk stratify patients’ physical status based on preoperative morbidities. This is an independent predictor of perioperative mortality ( Box 2.1 ). Additional surgical risk calculators such as the American College of Surgeons National Surgical Quality Improvement Program calculator (ACS NSQIP, https://riskcalculator.facs.org/RiskCalculator/PatientInfo.jsp ), can also be used to predict a wide range of more individualized postoperative outcomes.
| 1 | ASA class I | Normal healthy patient |
| 2 | ASA class II | Patient with mild systemic disease |
| 3 | ASA class III | Patient with severe systemic disease that limits activity but is not incapacitating |
| 4 | ASA class IV | Patient with incapacitating disease that is a constant threat to life |
| 5 | ASA class V | Moribund patient not expected to survive 24 hours with or without an operation |
| 6 | ASA class VI | A declared brain-dead patient whose organs are being removed for donor purposes |
| 7 | ASA class E | In the event of emergency surgery, an E is added after the Roman numeral (in I through V classes) |
Preoperative tests
Routine preoperative laboratory testing for healthy patients undergoing noncardiac surgeries is not mandatory, as this has been shown to be no more cost-effective or predictive of perioperative outcomes than ASA status. However, for select patients, preoperative tests may help guide perioperative management. This may include a complete blood count, basic metabolic panel, prothrombin time (PT), partial thromboplastin time, and internationalized normalized ratio (INR). Urine pregnancy tests should be performed on the day of surgery for all women of childbearing age. Electrocardiograms should be considered for those with cardiac comorbidities or older than 40 years old. Routine chest radiography is not recommended in the absence of preexisting cardiopulmonary disease. For patients with chronic obstructive pulmonary disease (COPD), pulmonary function tests and spirometry may be considered. However, these are not predictive of postoperative pulmonary complications.
Optimization of preoperative comorbidities
Cardiac
Patients with serious preoperative cardiac disorders (e.g., coronary artery disease, heart failure, symptomatic arrhythmias, orthostatic hypotension, and pacemaker or defibrillator dependency) should be identified preoperatively. The American College of Cardiology and American Heart Association task force (2014) has identified three predictors for major adverse cardiac events: clinical markers, functional capacity, and type of surgical procedure. These determine the need for further cardiac evaluation before nonemergent surgeries ( Fig. 2.1 ). Beta-blockers should be continued perioperatively.
Clinical Markers. Major clinical predictors of cardiovascular risk include recent myocardial infarct (<1 month), unstable angina, cardiac ischemia, decompensated heart failure, significant arrhythmias, and severe valvular disease.
Functional Capacity. Metabolic equivalents of the task (MET) refers to the ability to meet the aerobic demands for a specific activity. A 4-MET equivalent is the ability to climb two flights of stairs; a 4-MET capacity generally indicates no further need for invasive cardiac evaluation. The Duke Activity Status Index ( Table 2.1 ) may be used to assess functional capacity.
Type of Surgical Procedure. High-risk procedures include major emergent surgeries and those resulting in long operative times, major fluid shifts, or blood loss. Intermediate-risk procedures include minimally invasive surgeries. Low-risk procedures include endoscopic or superficial surgeries and require no further testing.
Cardiac Risk Calculators. The ACS NSQIP Risk calculator, Gupta Perioperative Risk Myocardial Infarction or Cardiac Arrest Calculator, Goldman’s Risk Indices, and Revised Cardiac Risk Index may all be used to more precisely estimate an individual cardiac risk.
Pulmonary
Risk factors for pulmonary complications include age older than 60 years, chronic lung disease, smoking congestive heart failure, obesity, asthma, and obstructive sleep apnea (OSA). Preoperative bronchodilators for COPD patients and corticosteroid inhalers for asthmatic patients should be continued.
Smoking.
Smokers have a 4-fold higher risk of perioperative morbidity and 10-fold higher mortality rate. Smoking cessation ≥6 months prior to surgery decreases pulmonary morbidity to nonsmoker rates and cessation ≥4 weeks prior to surgery decreases postoperative wound healing and pulmonary complications. Although it was traditionally believed that smoking cessation within 8 weeks of surgery resulted in greater pulmonary complications, more recent literature does not support this.
Obstructive sleep apnea.
OSA may be identified preoperatively using validated screening tools (e.g., Berlin Questionnaire, ASA STOP Questionnaire). Perioperative continuous positive airway pressure therapy should be used for these patients.
Hepatobiliary
The Child-Pugh classification estimates perioperative morbidity and mortality for cirrhotic patients using serum markers (e.g., bilirubin, albumin, PT) and clinical signs (e.g., encephalopathy, ascites). Estimated mortality risk is 0% for Child’s class A, 30% for Child’s class B, and 76%–82% for Child’s class C. The Model for End Stage Liver Disease (MELD) score provides even more accurate estimates of perioperative mortality based on serum laboratories (e.g., creatinine, bilirubin, INR) and dialysis status ( https://mayoclinic.org/meld/mayomodel9.html ). Both provide critical risk assessments for cirrhotic patients.
Endocrine
Careful perioperative management of endocrinopathies are critical to minimize surgical complications.
Diabetes.
Perioperative hyperglycemia is associated with impaired wound healing and higher infection rates. Recommended glucose targets are 140–200 mg/dL, depending on illness severity and patient characteristics. Perioperative management of insulin and hypoglycemic agents is summarized in Table 2.2 .
| AGENT | DAY PRIOR TO ADMISSION | DAY OF SURGERY |
|---|---|---|
| Meglitinides (e.g., repaglinide, nateglinide) | Take as normal | Surgery in am: omit morning dose Surgery in pm: give morning dose if eating |
| Sulphonylurea (e.g., glibenclamide, gliclazide, glipizide) | Take as normal | Surgery in am: omit morning dose Surgery in pm: omit dose |
| SGLT-2 inhibitors (e.g., dapagliflozin, canagliflozin) | No dose change | Surgery in am: ½ usual morning dose; check glucose on admission; leave evening meal dose unchanged Surgery in pm: ½ usual morning dose; check glucose on admission; leave evening meal dose unchanged NB: also omit day after surgery |
| Acarbose | Take as normal | Surgery in am: omit morning dose Surgery in pm: give morning dose if eating |
| DPP-IV inhibitors (e.g., sitagliptin, vildagliptin, saxagliptin, alogliptin, linagliptin) | Take as normal | Take as normal |
| GLP-1 analogues (e.g., exenatide, liraglutide, lixisenatide) | Take as normal | Take as normal |
| Metformin (procedure not requiring use of contrast media) | Take as normal | Take as normal |
| Pioglitazone | Take as normal | Take as normal |
| Basal insulin regimen (e.g., glargine, detemir, NPH) | Take 80% of basal dose | Take 80% of basal dose |
Hypothyroidism.
A euthyroid state should be achieved prior to elective surgery. Thyroid replacement medication and beta-blockers should be continued perioperatively because hypothyroid patients are at risk for thyrotoxicosis. This may manifest as fevers, tachycardia, confusion, or cardiovascular collapse. Thyroid storm may be managed with iodine and steroids.
Chronic steroid use.
Stress-dose steroids should be administered for patients with hypothalamic-pituitary axis suppression from chronic high-dose steroid use (daily intake of >20 mg prednisone or equivalents for >3 weeks during the past year). Typically, 50–100 mg intravenous (IV) cortisone is administered prior to induction of anesthesia followed by 25–50 mg hydrocortisone every 8 hours for 24–48 hours. Without supplementation, patients may exhibit signs of adrenal insufficiency, including nausea, vomiting, hypotension, changes in mental status, hyponatremia, or hyperkalemia.
Neurologic
Risk factors for perioperative cerebrovascular accidents include hypertension, diabetes, heart disease, smoking, obesity, age, gender, prior transient ischemic events, brain aneurysms, or arteriovenous malformations. Prior to elective surgery, carotid artery stenting or endarterectomy is indicated for symptomatic, high-grade (>70%) stenosis and should also be considered for asymptomatic patients with >60% stenosis.
Perioperative considerations
Antithrombotic therapy
Management of antithrombotic therapy requires a careful balance of thrombotic risk and perioperative bleeding risk. The 2014 AUA/International Consultation on Urological Disease (ICUD) White paper provides perioperative recommendations for the management of antiplatelet and anticoagulant agents for commonly performed urologic procedures.
Antiplatelet agents.
Antiplatelet agents (e.g., aspirin, clopidogrel) irreversibly inhibit platelet function and must be stopped 7–10 days before surgery. Dual antiplatelet therapy should be continued for at least 6 weeks following placement of bare-metal cardiac stents and 12 months after drug-eluting stents; elective surgery should be deferred until one or both agents may be stopped. Patients taking antiplatelets for secondary stroke prevention should continue aspirin perioperatively. Low-dose aspirin may be continued perioperatively if significant cardiac risk factors exist. A summary of antiplatelet management is illustrated in Fig. 2.2 .
Anticoagulants.
Warfarin should be discontinued 5 days preoperatively (goal INR <1.5). Novel oral anticoagulants require shorter periods of cessation ( Table 2.3 ). Perioperative bridging with therapeutic dose low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) is recommended for moderate- and high-risk patients ( Table 2.4 ). Anticoagulation should be resumed postoperatively within 12–24 hours if the bleeding risk is acceptable.
| ANTICOAGULANT | TIME TO MAXIMUM EFFECT | LOW BLEEDING RISK SURGERY | HIGH BLEEDING RISK SURGERY |
|---|---|---|---|
| Dabigatran | 1.25–3 hours | Last dose 2 days before surgery (skip two doses) | Last dose 3 days before surgery (skip four doses) |
| Rivaroxaban | 2–4 hours | Last dose 2 days before surgery (skip one dose) | Last dose 3 days before surgery (skip two doses) |
| Apixaban | 1–3 hours | Last dose 2 days before surgery (skip two doses) | Last dose 3 days before surgery (skip four doses) |
| INDICATIONS FOR ANTICOAGULANT THERAPY | |||
|---|---|---|---|
| RISK STRATUM | MECHANICAL HEART VALVE | ATRIAL FIBRILLATION | VTE |
| Low | Bileaflet aortic valve prosthesis without atrial fibrillation and no other risk factors for stroke | CHADS2 score of 0–2 (and no prior stroke or transient ischemic attack) | Single VTE occurred >12 months ago and no other risk factors |
| Moderate | Bileaflet aortic valve prosthesis plus one or more of the following: atrial fibrillation, prior stroke or transient ischemic attack, hypertension, diabetes, congestive heart failure, age older than 75 years | CHADS2 score of 3–4 | VTE within the past 3–12 months Nonsevere thrombophilic conditions (e.g., heterozygous factor V Leiden mutation, heterozygous factor II mutation) Recurrent VTE Active cancer (treated within 6 months or palliative) |
| High | Any mitral valve prosthesis Any caged-ball or tilting disc aortic valve prosthesis Recent (within 6 months) stroke or transient ischemic attack | CHADS2 score of 5–6 Recent (within 3 months) stroke or transient ischemic attack Rheumatic valvular heart disease | Recent (within 3 months) VTE Severe thrombophilia (e.g., deficiency of protein C, protein S, or antithrombin; presence of antiphospholipid antibodies; multiple abnormalities |
Nutrition
Adequate nutrition is critical for wound healing, immune response, return of bowel function, and maintenance of end organ function. Nutritional assessment may include laboratory testing (e.g., lymphocyte count, serum albumin) and validated assessment tools (e.g., Subjective Global Assessment, http://subjectiveglobalassessment.com ). Protein supplements and “immunonutrition” decrease rates of postoperative infection, decrease complications, and length of hospital stay. Malnourished patients may further benefit from preoperative enteral or total parenteral nutrition (TPN) nutrition; enteral nutrition is preferred because it helps maintain the intestinal mucosal barrier. Prior to surgery, solid food, nonhuman milk, and light meals may be consumed up to 6 hours before induction of general anesthesia. Breast milk may be consumed up to 4 hours prior to and clear liquids up to 2 hours prior to surgery.
Bowel prep
Extrapolating from the general surgery literature, mechanical and oral antibiotic bowel preparations (e.g., neomycin + erythromycin or metronidazole) have traditionally been used prior to major urologic surgery. However, recent meta-analyses have not demonstrated reduced rates of anastomotic leak, wound infection, intra-abdominal abscess, or mortality with the use of mechanical bowel prep. The benefit of antibiotic bowel prep has not been well-studied for urologic surgeries.
Intraoperative considerations
Antibiotic prophylaxis
Level 1 evidence supports the use of antibiotic prophylaxis to prevent surgical-site infections (SSIs). The most appropriate antibiotic agent is determined by patient susceptibility ( Box 2.2 ) and wound class ( Box 2.3 ). The most recent 2019 AUA recommendations for procedure-specific prophylaxis regimens are summarized in Table 2.5 and should be considered in conjunction with local antibiograms. Antimicrobial prophylaxis should be administered 1 hour before incision and continued for <24 hours perioperatively; prolonged use increases the risk of Clostridium difficile colitis and antibiotic resistance and increases cost.
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Advanced age
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Anatomic anomalies
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Poor nutritional status
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Smoking
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Chronic corticosteroid use
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Immunodeficiency
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Chronic indwelling hardware
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Infected endogenous or exogenous material
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Distant coexistent infection
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Prolonged hospitalization
Clean
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Uninfected wound without inflammation or entry into the genital, urinary, or alimentary tract
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Primary wound closure, closed drainage
Clean contaminated
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Uninfected wound with controlled entry into the genital, urinary, or alimentary tract
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Primary wound closure, closed drainage
Contaminated
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Uninfected wound with major break in sterile technique (gross spillage from gastrointestinal tract or nonpurulent inflammation)
- •
Open fresh accidental wounds
Dirty infected
- •
Wound with preexisting clinical infection or perforated viscera
- •
Old traumatic wounds with devitalized tissue
| PROCEDURE | LIKELY ORGANISMS | WOUND CLASS | ANTIMICROBIAL(S) OF CHOICE | ALTERNATIVE ANTIMICROBIALS |
|---|---|---|---|---|
| Cystourethroscopy with minor manipulation (e.g., break in mucosal barriers, biopsy, fulguration, etc.) | GNR, rarely enterococci | Clean-contaminated | TMP-SMX, amoxicillin–clavulanate | First- or second- generation cephalosporin + aminoglycoside a ± ampicillin |
| Transurethral cases(e.g., TURP, TURBT, laser enucleation, laser ablation, etc) | GNR, rarely enterococci | Clean-contaminated | Cefazolin, TMP-SMX | Amoxicillin–clavulanate, aminoglycoside a ± ampicillin |
| Prostate brachytherapy, cryotherapy | Staphlyococcus aureus , coagulase-negative staphylococci, group A streptococci , | Clean-contaminated | Cefazolin | Clindamycin |
| Transrectal prostate biopsy | GNR, anaerobes; consider MDR coverage if recent systemic antibiotics (<6 months), international travel, healthcare worker | Contaminated | Fluoroquinolone, first-, second-, or third-generation cephalosporin (ceftriaxone commonly used) + aminoglycoside a | Aztreonam May consider infectious disease consultation |
| Percutaneous renal surgery (e.g., PCNL) | GNR, rarely enterococci, coagulase-negative staphylococci, group A streptococci , S. aureus | Clean-contaminated | First- or second-generation cephalosporin, aminoglycoside a + metronidazole, or clindamycin | Ampicillin–sulbactam |
| Ureteroscopy | GNR, rarely enterococci | Clean-contaminated | TMP-SMX, first- or second-generation cephalosporin | Aminoglycoside a ± ampicillin, first- or second- generation cephalosporin, amoxicillin–clavulanate |
| Open, laparoscopic, or robotic surgery without entering urinary tract (e.g., adrenalectomy, pelvic or retroperitoneal lymphadenectomy) | S. aureus, coagulase-negative staphylococci, group A streptococci | Clean | Cefazolin | Clindamycin |
| Penile surgery (e.g., circumcision, penile biopsy) | S. aureus | Clean-contaminated | N/A | N/A |
| Urethroplasty (e.g., anterior urethral reconstruction, stricture repair including urethrectomy, controlled entry into urinary tract) | GNR, rarely enterococci, S. aureus | Clean, contaminated | Cefazolin | Cefoxitin, cefotetan, ampicillin–sulbactam |
| Involving controlled entry into the urinary tract (e.g., renal surgery, partial or radical nephrectomy, ureterectomy, pyeloplasty, radical prostatectomy, partial cystectomy) | GNR ( Escherichia coli ), rarely enterococci | Clean-contaminated | Cefazolin, TMP-SMX | Ampicillin–sulbactam, aminoglycoside a + metronidazole, or clindamycin |
| Involving small bowel (e.g., urinary diversion) cystectomy with small bowel conduit, ureteropelvic junction repair, partial cystectomy | S. aureus, coagulase-negative staphylococci, group A streptococci, GNR, rarely enterococci | Clean-contaminated | Cefazolin | Clindamycin + aminoglycoside a , cefuroxime (second- generation cephalosporin), aminopenicillin–β-lactamase inhibitor + metronidazole |
| Involving large bowel, colon conduits | GNR, anaerobes | Clean-contaminated | Cefazolin + metronidazole, cefoxitin, cefotetan, or ceftriaxone + metronidazole, ertapenem b | Ampicillin–sulbactam, ticarcillin–clavulanate, piperacillin–tazobactam |
| Implanted prosthetic devices (e.g., artificial urinary sphincter, inflatable penile prosthesis, sacral neuromodulators) | GNR, S. aureus ; increasing reports of anaerobic + fungal organisms | Clean | Aminoglycosid a + first- or second- generation cephalosporin or vancomycin | Aminopenicillin–β-lactamase inhibitor (e.g., ampicillin–sulbactam, ticarcillin, tazobactam) |
| Inguinal and scrotal cases (e.g., radical orchiectomy, vasectomy, vasectomy reversal, varicocelectomy, hydrocelectomy) | GNR, S. aureus | Clean | Cefazolin | Ampicillin–sulbactam |
| Vaginal surgery, female incontinence (e.g., urethral sling), fistulae repair, urethral diverticulectomy | S. aureus , streptococci, enterococci, vaginal anaerobes, coagulase-negative staphylococci, group A streptococci | Clean-contaminated | Second-eneration cephalosporin (cofoxitin, cefotetan) preferred over first- generation cephalosporins because of better anaerobic coverage; cefazolin equivalent for vaginal anaerobic coverage in sling procedures | Ampicillin–sulbactam + aminoglycoside a + metronidazole, or clindamycin |
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