Strategy and Tactics
Perhaps at no time since the advent of transurethral prostatectomy by Dr. Hugh Hampton Young more than a century ago has the repertoire of urologic techniques advanced as rapidly as during the last decade. Today’s urologist has access to a vast array of ever-expanding technologies, with seemingly novel iterations presented every week. Minimally invasive approaches have replaced several time-honored fundamental urologic procedures. The manual and mental skills required to appropriately evaluate and perform these advanced procedures has generated a substantial increase in expectations for urologists and their patients. For the contemporary urologist, choosing a correct operative strategy now incorporates not only appreciation of historical methods but also a critical evaluation of current evidence. Additionally, in this era of expanding oversight and scrutiny, understanding quality measures and grading of complications has now become a fundamental aspect of surgical practice.
This atlas is designed primarily to assist the urologic surgeon in developing an appropriate tactic to approach the myriad technical issues involved with urologic operative procedures. However, the limitations to this type of didactic lesson are readily apparent and surgical skill is gained primarily through experience at the operative table. Several axioms heard—usually rather stridently—during surgical training are worth repetition as they represent fundamental principles to drive superior technique and should become second nature to the experienced surgeon. These elemental strategies were eloquently and enthusiastically described by Dr. Hinman in the prior edition of his atlas and are paraphrased and expanded below.
Foremost, having a strategy involves knowledge of your patient and their pathology. Although unexpected findings are frequent during surgery, attention to detail and preoperative knowledge of the patient and the disease process can minimize the element of surprise, which could affect patient outcomes. Be compulsive about detail. Dr. Hinman counseled us to ensure adequate exposure; fend off difficult planes and vascular traps; use delicate technique; irrigate debris; obtain good hemostatis; close dead spaces; and provide adequate drainage. We are directed to have a plan, promote a team effort, and be gentle, but not indecisive. Dr. Hinman reminds us to tie sutures just to approximate the tissue; dissect and follow the natural tissue planes; work from known to unknown; keep tissues moist and covered; and above all, to keep calm and conduct yourself like a leader. Even with the technical advances that have almost revolutionized urologic surgery, these fundamental principles of preparation and technique remain applicable.
With these mentoring concepts, the continued mission of this atlas is to share the knowledge, and admonitions, of experts with pronounced and specialized surgical experience. Reviewing the chapters prior to embarking on a particular procedure should provide the urologist with access to not only a critical resource in step-by-step technique but also serve as a caution for the pitfalls of which one must beware. Surgery is an apprenticeship learned literally at the shoulder of those who have chosen to impart their skills. Foremost, the ultimate goal of this atlas is to serve and benefit our patients.
Initiatives to improve quality of surgical care have translated globally into enhanced safety and outcomes for urology patients. Spearheading this initiative is the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). ACS NSQIP is the preeminent nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care, with particular emphasis on the private sector. ACS NSQIP encompasses a variety of customizable tools, training, and data management that may be utilized by your hospital or health delivery system. ACS additionally provides an online risk calculator to determine risk of potential complications from surgical interventions based on their expansive database. ( http://www.riskcalculator.facs.org/ )
The Joint Commission is an independent, not-for-profit organization that accredits and certifies the majority of health care organizations and programs in the United States. Accreditation by the Joint Commission reflects an organization’s commitment to meeting defined performance measures. In collaboration with the Centers for Medicare and Medicaid Services (CMS), the Joint Commission have developed national initiatives for quality benchmark metrics including the Surgical Care Improvement Project (SCIP). SCIP is a national program aimed at reducing perioperative complications, including timely use and discontinuation of perioperative antibiotics, initiation of venous thromboembolism prophylaxis, as well as perioperative beta-blocker administration. Many hospitals have implemented SCIP measures in preoperative “time-out” procedures as well as integrated these quality metrics into care pathways. Several of the current SCIP measures are discussed in the following sections and may be accessed at http://www.jointcommission.org/assets/1/6/SCIP-Measures-012014.pdf .
The American Urological Association (AUA) has additionally embarked on a collaborative initiative with the American Board of Internal Medicine (ABIM) Foundation to optimize utilization of resources, which may be particularly valuable for perioperative planning. In 2013, the American Urological Association (AUA) joined the Choosing Wisely campaign, designed to reduce overuse of tests and procedures, and support patients in their efforts to make smart and effective care choices. To this aim, the AUA has released a list of specific urologic tests and procedures that are commonly ordered but not always necessary. In 2015, the AUA expanded its list with an additional five recommendations. The full list identifies targeted, evidence-based recommendations that can support conversations between patients and physicians about what diagnostic testing or procedures are truly indicated. ( https://www.auanet.org/resources/choosing-wisely.cfm )
Preoperative Evaluation
With explosively expanding medical knowledge, the complete evaluation of the patient prior to undertaking any operative procedure, except in the most dire of circumstances, merits substantial consideration. As limits are pushed of both young and advanced age in the urology patient cohort, sufficient preoperative knowledge can dramatically impact the operative outcome and allow more efficient communication with colleagues from other medical and surgical disciplines.
Evaluation of Risks
The American Society of Anesthesiology (ASA) has created a Physical Status Classification System to describe preoperative physical condition and group patients at risk for experiencing an adverse event related to general anesthesia ( Table 1.1 ). ASA I represents a normal, healthy individual; ASA II, a patient with mild systemic disease; ASA III, a patient with severe systemic disease that is not incapacitating; ASA IV, a patient with an incapacitating systemic disease that is a constant threat to life; ASA V, a moribund patient who is not expected to survive for 24 hours with or without an operation; and ASA VI, a brain-dead organ donor. This classification system was recently updated by the ASA to include pertinent examples of each of the classes to assist both the surgeon and anesthesiologist in appropriate risk stratification and patient counseling.
| Classification | Definition | Example, Including, but Not Limited to: |
|---|---|---|
| ASA I | A normal healthy patient | Healthy, nonsmoking, no or minimal alcohol use |
| ASA II | A patient with mild systemic disease | Mild disease only without substantive functional limitations. Examples include (but not limited to: current smoker, social alcohol drinker, pregnancy, obesity (30<BMI<40), well-controlled DM/HTN, mild lung disease |
| ASA III | A patient with severe systemic disease | Substantiative functional limitations; One or more moderate to severe diseases. Examples include (but not limited to): poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥ 40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, premature infant PCA <60 weeks, history (3 months) or MI, CVA, TIA, or CAD/stents. |
| ASA IV | A patient with severe systemic disease that is a constant threat to life | Examples include (but not limited to): recent (<3 months) MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD, or ESRD not undergoing regularly scheduled dialysis. |
| ASA V | A moribund patient who is not expected to survive without an operation | Examples include (but not limited to): ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple-organ/system dysfunction. |
| ASA VI | A declared brain-dead patient whose organs are being removed for donor purposes |
Although cardiac status has long been appreciated as a significant risk factor for perioperative mortality, the past decade has witnessed remarkable changes in the evaluation and management of the cardiac patient. Important considerations regarding the widespread utilization of coronary revascularization, anticoagulation, and beta-blocker administration are of particular concern for the contemporary surgeon.
Of paramount consequence in the context of considering surgical interventions is the management of an ever-expanding repertoire of antithrombolytic medications. Oral anticoagulant (AC) and oral antiplatelet (AP) therapies require comprehensive attention in the perioperative period to avoid complications with surgical hemorrhage as well as the potential systemic repercussions of titration of these pharmaceuticals. To provide urology-specific directives for AC and AP management, the American Urologic Association (AUA) in collaboration with the International Consultation on Urological Disease (ICUD) have created a pragmatic review on “Anticoagulation and Antiplatelet Therapy in Urologic Practice” to provide guidance for the safe and effective use of oral agents in the periprocedural period. Key parameters addressed include discontinuation of AC/AP agents for elective to emergent surgery, procedures that can be safely performed without discontinuation of anticoagulation, and strategies to balance risks of surgical bleeding versus thrombotic events. Eighteen specific recommendations are provided by the AUA/ICUD to accommodate multiple considerations, along with several illustrative cases common to many urologic practices. Suggested procedures for discontinuation of AC/AP agents in the perioperative window is additionally outlined ( Table 1.2 ). Although this exceptional review provides an outstanding base for decision making, with the complex patient requiring urologic intervention maintained on AC/AP therapy, guidance from a multidisciplinary team including cardiology and primary care is often prudent to ensure optimal care is accomplished.
| Anticoagulant Therapy | Time to Maximum Effect | Low-Risk Surgery: Normal Renal Function | High-Risk Surgery: Normal Renal Function | Notes |
|---|---|---|---|---|
| Warfarin | 5–7 days for therapeutic INR | Circulating vitamin K–dependent factors (II, VII, IX, X) | ||
| Unfractionated heparin | Immediate IV; within 6 hours SQ | Renal clearance: effective reversal with protamine | ||
| Low-molecular-weight heparin | 3–6 hours | Renal clearance: partial reversal with protamine | ||
| Fondaparinux | 2 hours | Renal clearance: not reversed with protamine | ||
| Dabigatran | 1.25–3 hours | Last dose 2 days before surgery | Last dose 3 days before surgery | Nonreversible; 80% renal clearance |
| Rivaroxaban | 2–4 hours | Last dose 2 days before surgery | Last dose 3 days before surgery | Nonreversible; 86% renal clearance |
| Apixaban | 1–3 hrs | Last dose 2 days before surgery | Last dose 3 days before surgery | Nonreversible; 25% renal clearance |
Much contradictory evidence has been published regarding utilization of β-blocker therapy and perioperative mortality following noncardiac surgery. Current recommendations from the American College of Cardiology and American Heart Association updated in 2014 principally suggest continuation of β-blocker therapy for patients already managed with such agents for chronic conditions, but the routine administration of β-blocker preoperatively in patients lacking significant cardiac risk is not advisable ( Box 1.1 ). Initiating β-blocker therapy on naïve patients should require the expertise of a cardiologist or anesthesiologist more suited to evaluate the risk parameters involved.
In patients undergoing surgery who have been taking β-blockers for chronic conditions, β-blockers should be continued (class I; level of evidence B).
It is reasonable for the management of β-blockers after surgery to be guided by clinical circumstances independent of when the β-blocker was started (class IIa; level of evidence B).
In patients with intermediate- or high-risk myocardial ischemia noted in preoperative risk stratification tests, it may be reasonable to begin perioperative β-blockers (class IIb; level of evidence C).
In patients with 3 or more Revised Cardiac Risk Index risk factors, it may be reasonable to begin β-blockers before surgery (class IIb; level of evidence B).
In patients with a compelling long-term indication for β-blocker therapy but no other Revised Cardiac Risk Index risk factors, initiating β-blockers in the perioperative setting to reduce perioperative risk is of uncertain benefit (class IIb; level of evidence B).
In patients in whom β-blocker therapy is initiated, it may be reasonable to begin perioperative β-blockers long enough in advance to assess safety and tolerability, preferably more than 1 day before surgery (class IIb; level of evidence B).
β-Blocker therapy should not be started on the day of surgery (class III [harm]; level of evidence B).
Issues with pulmonary function and postoperative recovery from intubation are most frequently a consequence of preexisting conditions that place the patient at particular pulmonary risk. In patients with obstructive lung disease or severe asthma, it is best to consult with the pulmonologist or anesthesiologist about the safest route to provide the surgical intervention. Intubation may be avoidable, but regardless, appropriate counseling requires recognition of the hazards. Patients who smoke should be counseled not only on their risks for multiple malignancies but additionally for the jeopardy of prolonged respiratory failure and poor wound healing.
Nutrition
Special emphasis should be given to assessment of the patient’s preoperative nutritional status as many urology patients, particularly those with malignancy or renal dysfunction, may have recent weight loss or nutritional deficits related to chronic illness. Preoperative evaluation of risk factors may include both serum laboratories in addition to consultation with nutrition specialists for high risk individuals. Indeed, the Joint Commission requires nutritional assessment occur within 24 hours of hospital admission. Nutritional deficiency can predispose the patient to issues with poor wound healing as well as hematologic and immunologic compromise. In severe cases, hyperalimentation may be required to overcome the nutritional barrier preventing safe operative management. Evolving literature across surgical disciplines is migrating practice to early enteral feeding regimens as part of comprehensive care pathways to expedite patient recovery and hospital discharge.
Venous Thromboembolism (VTE) Prophylaxis
Of increasing concern in the perioperative period is the incidence of thromboembolic complications and the associated repercussions including pulmonary embolism. With recognition of the heightened risk in the surgical patient, the American College of Chest Physicians created extensive guidelines detailing pharmacologic and mechanical strategies for prevention of deep vein thrombosis (DVT). For consideration of urology-specific needs, the AUA best practice policy statement “Prevention of Deep Vein Thrombosis in Patients Undergoing Urologic Surgery” was developed ( Table 1.3 ). This policy statement integrates available evidence from the urologic and surgical literature into treatment strategies for pharmacologic and mechanical prophylaxis for each category of urologic surgery and include patient risk stratification. It is imperative to review these best practice recommendations and incorporate them into an inclusive perioperative approach to diminish the risk for DVT and PE.
| Patient Risk Stratification | Description | Prophylactic Treatments |
|---|---|---|
| Low risk | Minor surgery in patient <40 years with no additional risk factors | No prophylaxis other than early ambulation |
| Moderate risk | Minor surgery in patients with additional risk factors Surgery in patients aged 40–60 years with no additional risk factors | Heparin 5000 units every 12 hours subcutaneous OR Enoxaparin 40 mg subcutaneous daily OR Pneumatic compression device if risk of bleeding is high |
| High risk | Surgery in patients >60 years Surgery in patients aged 40–60 years with additional risk factors | Heparin 5000 units every 12 hours subcutaneous OR Enoxaparin 40 mg subcutaneous daily OR Pneumatic compression device if risk of bleeding is high |
| Highest risk | Surgery in patients with multiple risk factors (e.g., age >40 years, cancer, prior VTE) | Enoxaparin 40 mg subcutaneous daily AND adjuvant pneumatic compression device OR Heparin 5000 units every 8 hours subcutaneous AND adjuvant pneumatic compression device |
Anesthesiology Evaluation
Issues involving anesthesia evaluation are becoming more prevalent with the continual amplification of patient acuity and procedure complexity, many of which are now managed on an outpatient basis. Appropriate attention is mandated to control preoperative hypertension and electrolyte abnormalities as these may become more pronounced during general anesthesia. The preoperative anesthesia evaluation is designed to assess basic cardiac, pulmonary, and systemic risk factors that may influence tolerance and recovery from both anesthesia and the surgical procedure. Although frequently there are mechanisms in place to notify the surgeon of any abnormalities uncovered by these tests, it remains the responsibility of the operative surgeon to review all available data prior to the procedure and assess the fitness of the patient to proceed with the planned surgical procedure.
Preparation for Surgery
Outpatient Surgery
Many contemporary urologic surgeries are amenable to performance on an outpatient basis. Indeed, even for major procedures such as radical prostatectomy, length of hospital stay barely exceeds 24 hours. Therefore, special consideration must be given to patient preparation and counseling in advance of the date of surgery. Thoroughly informing the patient and family on the general pragmatic concerns and recovery expectations can noticeably decrease patient anxiety, ease work flow on the day of surgery, and expedite discharge planning.
Although overall most patients amenable to outpatient surgery have fewer risk factors than patients slated for hospital admission, preoperative evaluation by anesthesia in advance of the day of surgery is recommended. Outpatient surgeries are particularly suited for the pediatric population as they are generally well tolerated and allow the child to recover in their home environment.
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