PART

II Basics of Urologic Surgery

8 Principles of Urologic Surgery: Perioperative Care

Simpa S. Salami, MD, MPH

T
he perioperative care of the urology patient continues to evolve radiograph. The routine ordering of a PT/PTT in a patient not currently
as newer tools and techniques are introduced and as the popula- on anticoagulation or in a patient without a prior history of a bleeding
tion ages. Over the past two decades, the economics of health disorder or increased bleeding with other surgical procedures is
care have added increasing pressure for more outpatient surgery, controversial, and these tests can be omitted in the majority of
decreased hospital stays, and decreased complication rates. It has patients. Any woman of childbearing age, unless the ovaries or
become the standard of care for patients undergoing even the most uterus have been previously surgically removed, must undergo a
sophisticated and complex urologic procedures to be admitted on urine pregnancy test on the morning of surgery (Halaszynski et al.,
the same day as the surgery and discharged to home the day after 2004). The value of a preoperative ECG in identification of underlying
surgery. Further, although the practice of urology continues to move acute cardiac disease and prediction of perioperative cardiac morbidity
toward office-based and nonsurgical treatments, the diversity of is also controversial. Some studies have shown that ECG abnormalities
genitourinary disease requires that the practicing urologist be familiar have no significant added predictive value (van Klei et al., 2007; Liu
with perioperative surgical principles to improve clinical care and et al., 2002), whereas others found that an abnormal ECG preop-
outcomes. This chapter provides the reader with basic tools to eratively is a predictor of an adverse cardiac event in patients
understand the preoperative assessment and optimization, intraopera- undergoing noncardiac surgery (Noordzij et al., 2006; Biteker et al.,
tive and postoperative management approaches necessary to promote 2012; Shoyeb et al., 2006). Nonetheless, current recommendations,
a culture of patient safety and effective and efficient clinical care, in general, suggest that a preoperative ECG be obtained from patients
and to ensure optimal surgical outcomes. older than 40 years of age or those with a history of cardiac disease.
Similarly, the routine preoperative use of a chest radiograph, in the
absence of preexisting cardiopulmonary disease, is not indicated.
PREOPERATIVE EVALUATION Overall, even an ASA Task Force on Pre-anesthesia Evaluation could
not make firm recommendations other than “preoperative tests may
The acuity of surgical patients is increasing as the population ages be ordered, required, or performed on a selective basis for purposes of
and as patients present with more significant comorbidities. The guiding or optimizing perioperative management” (Committee on
urologic surgeon is responsible for ensuring that the patient Standards and Practice Parameters et al., 2012).
has been thoroughly evaluated by the other physicians on the
health care team and arrives in and leaves the operating room American Society of Anesthesiologists
in the most optimized medical condition. The preoperative use of Classification and Risk
appropriate medical specialist consultations not only will result in
improved patient safety and outcomes but will also obviate the need Approximately 27 million patients undergo surgery each year in the
for unnecessary cancelled surgeries resulting from the inadequacy United States, and 8 million (30%) have significant coronary artery
of medical optimization. disease or other cardiac comorbidities. Appropriately, the cardiovas-
cular system is targeted during the preoperative assessment of patients.
The ASA classification was first developed in 1961 and has been
PRESURGICAL TESTING revised to categorize risk into six stratifications (Box 8.1).
The goal of the classification system is to assess the overall physical
The goal of presurgical testing is to identify an undiagnosed comorbid- status of the patient before surgery (not to assess surgical risk), and
ity, an undertreated pre-existing medical problem, or a significant although quite subjective, it remains a significant independent predic-
exacerbation of existing comorbid illness that may affect the operative tor of mortality (Davenport et al., 2006). Other tools to assess the
course and/or outcome (Townsend et al., 2015). Ideally, the preopera- preoperative risks were developed by multivariate statistical analysis
tive evaluation should be individualized on the basis of age, history, of patient-related factors correlated with surgical outcomes. One
physical examination findings, and the surgical procedure to be such scoring system, Goldman’s criteria (Table 8.1), assigns points
performed. Although most hospitals or ambulatory surgery centers to easily reproducible characteristics. The points are then added to
have requirements for baseline evaluation, routine testing in addition compute the perioperative risk for cardiac-related complications.
to history and physical examination has never been shown to be Another system, the Cardiac Risk Index, simplified this concept; it
cost-effective. In fact, the results of routine testing are less predictive uses only six predictors to estimate cardiac complication risk in
of perioperative morbidity than the American Society of Anesthesiolo- noncardiac surgical patients (Table 8.2) (Akhtar and Silverman, 2004).
gists (ASA) status or the American Heart Association (AHA) and
American College of Cardiology (ACC) guidelines for surgical risk.
A recent systematic review found no evidence to support routine PREOPERATIVE CARDIOVASCULAR EVALUATION
preoperative testing in patients undergoing noncardiac elective surgery
(Johansson et al., 2013). Most commonly, presurgical testing includes The preoperative cardiac evaluation, which consists of an initial
complete blood count (CBC); basic metabolic panel (BMP); pro- history, physical examination, and ECG, attempts to identify
thrombin time (PT), partial thromboplastin time (PTT), and potential serious cardiac disorders such as coronary artery disease,
international normalized ratio (INR) (controversial); electrocardio- heart failure, symptomatic arrhythmias, the presence of a pacemaker
gram (ECG); ABO/Rh blood typing and antibodies screen; and chest or implantable defibrillator, or a history of orthostatic hypotension

119
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120 PART II Basics of Urologic Surgery

(Fleisher et al., 2007a). In general, the guidelines use three categories

BOX 8.1 American Society of Anesthesiologists (ASA) of clinical risk predictors: clinical markers, functional capacity, and
Classification type of surgical procedure (Eagle et al., 2002).
1 ASA Class I Normal healthy patient
2 ASA Class II Patient with mild systemic disease Clinical Markers
3 ASA Class III Patient with severe systemic disease that The need for a general medical or cardiac evaluation before surgery
limits activity but is not incapacitating is dependent on patients’ comorbid condition and overall periopera-
4 ASA Class IV Patient with incapacitating disease that tive risk. The major clinical predictors of increased perioperative
is a constant threat to life cardiovascular risk includes a documented acute myocardial infarction
5 ASA Class V Moribund patient not expected to survive less than 7 days previously, a recent myocardial infarction (defined
24 hours with or without an operation as at least 7 days but less than 1 month before surgery), unstable
6 ASA Class VI A declared brain-dead patient whose angina, evidence of any ischemic burden by clinical symptoms or
organs are being removed for donor noninvasive testing, decompensated heart failure, significant arrhyth-
mias, and severe valvular disease. Intermediate predictors include
purposes
mild angina, previous myocardial infarction by history or pathologic
7 ASA Class E In the event of emergency surgery, an Q waves on ECG, compensated heart failure, diabetes, or renal
E is added after the Roman numeral insufficiency (creatinine >2 mg/dL). Minor predictors of risk are
(in I through V classes) advanced age, abnormal ECG, rhythms other than sinus (e.g., atrial
fibrillation), history of stroke, or uncontrolled systemic hypertension.
The historical dictum suggesting that elective surgery after myocardial
TABLE 8.1 Goldman’s Cardiac Risk Index infarction be performed after a 3- to 6-month interval is now currently
avoided (Tarhan et al., 1972). The ACC cardiovascular database
PATIENT RISK FACTORS POINTS committee stratifies risk on the basis of the severity of the myo-
cardial infarction and the likelihood of reinfarction based on a
Third heart sound or jugular venous distention 11 recent exercise stress test. However, in the absence of adequate
Recent myocardial infarction 10 clinical trials on which to base firm recommendations, it is reasonable
Nonsinus rhythm or premature atrial contraction 7 to wait 4 to 6 weeks after myocardial infarction to perform elective
on electrocardiogram surgery, keeping in mind the kind of cardiac intervention (stents or
More than five premature ventricular contractions 7 bypass grafting) and the need for antiplatelet therapy (see later).
Age older than 70 years 5
Emergency operations 4 Functional Capacity
Poor general medical condition 3
Functional capacity, or one’s ability to meet aerobic demands for
Intrathoracic, intraperitoneal, or aortic surgery 3
a specific activity, is quantified as metabolic equivalents of the
Significant valvular aortic stenosis 3 task (METs). For example, a 4-MET demand is comparable with a
For noncardiac surgery, the risk for cardiac complications is: patient’s ability to climb two flights of stairs. This simple measurement
6–12 points = 7% risk continues to be an easy and inexpensive method to determine a
patient’s cardiopulmonary functional capacity (Biccard, 2005). The
13–25 points = 14% risk
Duke Activity Status Index (Table 8.3), which has been validated in
>26 points = 78% risk several studies, allows the physician to easily determine a patient’s
functional capacity (Hlatky et al., 1989; Carter et al., 2002; Coutinho-
Modified from Akhtar S, Silverman DG. Assessment and management of Myrrha et al., 2014; Wu et al., 2016). In general, a capacity of 4
patients with ischemic heart disease. Crit Care Med 2004;32(4 Suppl): METs indicates no further need for invasive cardiac evaluation.
S126–S136.

Surgery-Specific Cardiac Risk

TABLE 8.2 Modified Cardiac Risk Index
Two important factors determine the surgery-specific cardiac risk: the
PATIENT RISK FACTORS POINTS type of surgery and the degree of hemodynamic stress. Surgery-specific
risk is stratified into high-, intermediate-, and low-risk procedures.
Ischemic heart disease 11 High-risk procedures include both major emergent surgeries, particu-
Congestive heart failure 10 larly in the elderly, and surgery associated with increased operative
Cerebral vascular disease 7 time resulting in large fluid shifts or blood loss. Intermediate risk
High-risk surgery 7 procedures include intraperitoneal surgery, laparoscopic procedures,
Preoperative insulin treatment for diabetes 5 and robotic-assisted laparoscopic surgeries. Low-risk procedures
Preoperative creatinine ≥2 mg/dL 4 include endoscopic procedures or superficial surgeries (i.e., not
Each increment in point increases the risk for perioperative involving entrance into a body cavity) (Eagle et al., 2002).
cardiovascular morbidity.

Modified from Akhtar S, Silverman DG. Assessment and management of PULMONARY EVALUATION
patients with ischemic heart disease. Crit Care Med. 2004;32(4 Suppl): Preoperative pulmonary evaluation is important in all urologic
S126–S136. procedures but critical in those surgeries involving the thoracic or
abdominal cavities. These procedures, which include intra-abdominal,
(Eagle et al., 1996, 2002). Furthermore, it is essential to define the laparoscopic, or robotic surgeries, can decrease pulmonary function
severity and stability of existing cardiac disease before surgery. during the operation or postoperatively and predispose to pulmonary
Cardiac-specific risk is also altered by the patient’s functional capacity, complications. Accordingly, it is prudent to consider pulmonary
age, and other comorbid conditions such as diabetes, peripheral functional assessment in patients who have significant underlying
vascular disease, renal dysfunction, and chronic obstructive pulmonary pulmonary disorder, significant smoking history, or overt pulmonary
disease (COPD). The ACC and AHA recently collaborated to develop symptoms. Pulmonary function tests that include a forced expiratory
guidelines regarding perioperative cardiac evaluation before surgery volume in 1 second (FEV1), forced vital capacity, and the diffusing

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 Chapter 8 Principles of Urologic Surgery: Perioperative Care 121

TABLE 8.3 Duke Activity Status Indexa and evaluated before surgery. Patients are usually aware of a prior
diagnosis of hepatitis, and they should be questioned regarding the
ACTIVITY YES NO timing of diagnosis and the precipitating factors. This history is
particularly important if a member of the health care team is
Can you take care of yourself such as eating, 2.75 0 inadvertently stuck with a needle or cut with a scalpel during the
dressing, bathing, or using the toilet? surgical procedure. A review of systems should include questions
Can you walk indoors such as around 1.75 0 regarding pruritus, excessive bleeding, abnormal abdominal distention,
your house? and weight gain. On physical examination, jaundice and scleral
Can you walk a block or two on level ground? 2.75 0 icterus may be evident with serum bilirubin levels higher than 3 mg/
Can you climb a flight of stairs or walk up 5.50 0 dL. Skin changes such as caput medusae, palmar erythema, spider
a hill? angiomas, and clubbing all indicate hepatic dysfunction. Severe
Can you run a short distance? 8.00 0 manifestations include abdominal distention, encephalopathy,
Can you do light work around the house such 2.70 0
asterixis, or cachexia. Again, identification of underlying hepatic
illness is important in the preoperative risk assessment of the patient.
as dusting or washing dishes?
Although the estimation of perioperative mortality is limited by the
Can you do moderate work around the house 3.50 0 lack of high-quality clinical studies, the use of the Child classification
such as vacuuming, sweeping floors, or and model for end-stage liver disease (MELD) score offers a reasonable
carrying in groceries? estimation.
Can you do heavy work around the house 8.00 0 The Child classification assesses perioperative morbidity and
such as scrubbing floors or lifting and mortality in patients with cirrhosis and is based on the patient’s
moving heavy furniture? serum markers (bilirubin, albumin, PT) and severity of clinical
Can you do yardwork such as raking leaves, 4.50 0 manifestations (i.e., encephalopathy and ascites). Mortality risk for
weeding, or pushing a power mower? patients undergoing surgery stratified by Child class is as follows:
Can you have sexual relations? 5.25 0
Child Class A—10%, Child Class B—30%, and Child Class C—76%
to 82%. The Child classification also correlates with the frequency
Can you participate in moderate recreational 6.00 0
of complications such as liver failure, encephalopathy, bleeding,
activities such as golf, bowling, dancing, infection, renal failure, hypoxia, and intractable ascites. Independent
doubles tennis, or throwing a baseball risk factors other than the Child class that can increase the mortality
or football? rate in patients with liver disease include emergency surgery and
Can you participate in strenuous sports such 7.50 0 COPD (Pearce and Jones, 1984; O’Leary et al., 2009; O’Leary and
as swimming, singles tennis, football, Friedman, 2007).
basketball, or skiing? The MELD score is perhaps a more accurate assessment of
perioperative mortality in patients with hepatic dysfunction. The
a
The most widely recognized measure of cardiorespiratory fitness is maximal score is derived from a linear regression model based on serum
oxygen consumption (V̇ O2peak) measured in mL/kg/min. The Index score bilirubin, creatinine levels, and the INR. It is more accurate than
correlates directly with V̇ O2peak and therefore is an indirect measure of the Child classification in that it is objective, gives weights to each
maximal METs. variable, and does not rely on arbitrary cutoff values (Teh et al.,
Duke activity status index (DASI) = Sum of values for all 12 questions 2007). Clinicians can use a website (http://mayoclinic.org/meld/
Estimated peak oxygen uptake (V̇ O2peak) in mL/min = (0.43 × DASI) + 9.6 mayomodel9.html) to calculate the 7-day, 30-day, 90-day, 1-year,
METs (metabolic equivalents of the task) = V̇ O2peak × 0.286 (mL/kg/min)−1 and 5-year surgical mortality risk on the basis of the patient’s
Modified from Hlatky MA, Boineau RE, Higginbotham MB, et al. A brief age, ASA class, INR, serum bilirubin, and creatinine levels. A
self-administered questionnaire to determine functional capacity (the Duke recent study also found that the MELD score was tightly correlated
Activity Status Index). Am J Cardiol. 1989;64(10):651–654. with 30-day mortality risk in all patients undergoing colorectal surgery
regardless of the presence of liver disease (Hedrick et al., 2013).
Taken together, the Child classification and the MELD score comple-
ment each other and provide an important assessment of the risk
capacity of carbon monoxide are quite easily performed and provide associated with surgery in cirrhotic patients (O’Leary and Friedman,
a preoperative baseline. Patients with an FEV1 of less than 0.8 L/ 2007; O’Leary et al., 2009).
sec or 30% of predicted are at high risk for complications (Arozullah
et al., 2003). Specific pulmonary risk factors include COPD, smoking,
preoperative sputum production, pneumonia, dyspnea, and obstructive SPECIAL POPULATIONS
sleep apnea. It has been shown that smokers have a fourfold Elderly
increased risk for postoperative pulmonary morbidity and as high
as a 10-fold higher mortality rate (Fowkes et al., 1982). In general, It is estimated that by 2050 the number of Americans older than
it is interesting to note that patients with restrictive pulmonary disease 65 years of age will more than double to 89 million individuals,
fare better than those with obstructive pulmonary disease because with more than 20% older than 85 years of age (Jacobson et al.,
the former group maintains an adequate maximal expiratory flow 2011). Accordingly, octogenarians and nonagenarians are undergoing
rate, which allows for a more effective cough with less sputum produc- an increasing number of surgeries annually. Because of elderly patients’
tion (Pearce and Jones, 1984). In addition to the specific pulmonary special physiologic, pharmacologic, and psychological needs, a unique
risk factors, general factors contribute to increased pulmonary set of health care challenges is encountered. It is still unclear whether
complications such as increased age, lower serum albumin levels, advanced age independently predicts surgical risk or whether it is
obesity, impaired sensorium, previous stroke, immobility, acute renal coexisting medical conditions that adversely affect surgical outcomes.
failure, and chronic steroid use. However, in a large study published by Turrentine, the authors showed
that increased age independently predicted morbidity and mortality
(Turrentine et al., 2006). This confirmed the study by Vemuri, who
HEPATOBILIARY EVALUATION also found increased age to be an independent risk factor for morbidity
and mortality in patients undergoing aneurysm surgery (Vemuri
Survival of patients with advanced liver disease has improved over et al., 2004). Within the urologic literature, Liberman et al. reported
the past decade, thus surgery is being performed more frequently 90-day mortality rates after radical cystectomy in patients younger
in these patients. Furthermore, patients with mild to moderate hepatic than 70 years, 70 to 80 years, and older than 80 years of 2%, 5.4%,
disease are often asymptomatic. These patients need to be identified and 9.2%, respectively (Liberman et al., 2011). The studies suggest

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122 PART II Basics of Urologic Surgery

that independent of comorbidities, perhaps the elderly patient cannot obstetrician, perinatologist, and anesthesiologist is essential (Kizer
meet the increased functional demand required during the periopera- and Powell, 2011). These specialists will help determine the optimum
tive and postoperative periods. Notably, hypertension and dyspnea technique to monitor the status of the fetus. Fetal heart rate monitors
were the most frequently seen comorbid risk factors in patients older and tocometer monitoring for uterine activity are used before and
than 80 years of age, and preoperative transfusion history, emergency after the procedure. Postoperative pain is best managed with narcotic
operation, and weight loss best predicted postoperative morbidity. analgesics because they have not been shown to cause birth defects
Additionally, each 30-minute increment of operative time increased in humans when used in normal dosages. Nonsteroidal anti-
the odds of mortality by 17% in octogenarians (Turrentine et al., inflammatory medication should be avoided because of the risk for
2006). A unique and important factor in the perioperative care of premature closure of the ductus arteriosus. Chronic use of narcotics
the elderly is in the identification and prevention of delirium. Often during pregnancy may cause fetal dependency, and it is recommended
overlooked as “sundowning,” delirium can be the first clinical sign that the pregnant postsurgical patient be weaned off narcotic use as
of metabolic and infectious complications (Townsend et al., 2015). soon as possible.

Morbid Obesity Nutritional Status

The careful selection of the morbidly obese patient for elective surgery Malnutrition compromises host defenses and increases the risk for
is of paramount importance. With the rising incidence of obesity, perioperative morbidity and mortality. Adequate nutritional status is
one must carefully weigh and balance the risk associated with any essential for proper wound healing, mounting appropriate immune
surgical procedure with the natural history of the disease when response to infections, return of bowel activity, and maintenance of
deciding the optimal time of the surgery in the morbidly obese. It vital organ function (Evans et al., 2014). The preoperative evaluation
is estimated that patients with a body mass index (BMI) of 45 kg/ and classification of the patient’s nutritional status typically consist of
m2 or higher may lose anywhere from 8 to 13 years of life expec- assessment of any recent weight loss and measurement of laboratory
tancy (Fontaine et al., 2003). Cardiac symptoms such as exertional values, such as lymphocyte count and serum albumin. A 20-pound
dyspnea and lower extremity edema are nonspecific in morbidly weight loss in the preceding 3 months before surgery is considered
obese patients, and many of these patients have poor functional to be a reflection of severe malnutrition. The lymphocyte count and
capacity. The physical examination often underestimates cardiac serum albumin level reflect visceral protein status, with lower levels
dysfunction in the severely obese patient. Severely obese patients indicating malnutrition (Reinhardt et al., 1980). Several assessment
with more than three coronary heart disease risk factors may require tools have been validated to quantitate nutritional status, including the
noninvasive cardiac evaluation (Poirier et al., 2009). Obesity is Subjective Global Assessment (http://subjectiveglobalassessment.com).
associated with a vast array of comorbidities. Morbidly obese patients There are two methods for nutritional support. Total parenteral
often have atherosclerotic cardiovascular disease, heart failure, systemic nutrition (TPN) is used for patients who are severely malnourished
hypertension, pulmonary hypertension related to sleep apnea and and who have a nonfunctioning gastrointestinal (GI) tract. Several
obesity, hypoventilation, cardiac arrhythmias, deep vein thrombosis, studies have shown that 7 to 10 days of preoperative parenteral
history of pulmonary embolism, and poor exercise capacity. There nutrition improves postoperative outcome in undernourished patients
are also numerous pulmonary abnormalities that result in a ventilation (Von Meyenfeldt et al., 1992). However, its use in well-nourished
perfusion mismatch and alveolar hypoventilation. Obesity is a risk or mildly undernourished patients either is of no benefit or increases
factor for postoperative wound infections, and, when appropriate, the risk for sepsis (Veterans Affairs Total Parenteral Nutrition Coopera-
laparoscopic surgery should be considered. tive Study Group, 1991). Enteral nutrition, on the other hand, has
fewer complications than TPN and can provide a more balanced
Pregnancy physiologic diet. Enteral nutrition is accomplished via a feeding
tube, gastrostomy, or feeding jejunostomy. Enteral nutrition has the
Urologic surgery in the pregnant woman is most commonly related added benefits of maintaining the gut-associated lymphoid tissue,
to the management of renal colic and urinary tract stones. The stones enhancing mucosal blood flow, and maintaining the mucosal barrier.
can be discovered during the sonographic evaluation of the fetus in There are hundreds of enteral products on the market, and most
an asymptomatic pregnant woman or during the evaluation of the have a caloric density of 1 to 2 kcal/mL. These formulas are also
pregnant woman who is experiencing renal colic. The fetus is at lactose free and provide the recommended daily allowances of
the highest risk from radiation exposure from the preimplantation vitamins and minerals in less than 2 L/day. Patients receiving enteral
period to approximately 15 weeks’ gestation. Because the radiation feedings must be monitored for improvement in nutritional status,
dose that is associated with congenital malformations is 10 cGy, the GI intolerance, and fluid and electrolyte imbalance. Preoperative
evaluation of renal colic in the pregnant patient is performed usually enteral feedings can decrease postoperative complication rates
with sonography (radiation dose with abdominal computed tomog- by 10% to 15% when used for 5 to 20 days before surgery (ASPEN
raphy [CT]—1 cGy; intravenous pyelogram—0.3 cGy). In general, Board of Directors and the Clinical Guidelines Task Force, 2002).
a surgical procedure in the pregnant woman should be delayed, The guidelines recommend postoperative parenteral nutrition in
if at all possible, until the baby is mature enough for delivery patients who are unable to meet their caloric requirements within
unless significant harm to the mother or fetus will result. The 7 to 10 days. Just as in the perioperative state, enteral feedings are
indications for operative intervention in the pregnant patient are preferred over parenteral nutrition when feasible (Sigalet et al., 2004).
discussed elsewhere in this book. Anesthetic risks during pregnancy Moreover, the routine use of postoperative TPN has not proven
concern both the mother and the fetus. During the first trimester, useful in well-nourished patients or in those with adequate oral
the fetus may be directly exposed to the teratogenic effects of certain intake within 1 week after surgery.
anesthetic agents. Later in pregnancy, anesthesia places the mother Complications can occur with either enteral nutrition or parenteral
at risk for preterm labor and the fetus at risk for hypoxemia secondary nutrition. Dislodgement of nasoenteral tubes and percutaneous
to changes in uterine blood flow and maternal acid-base imbalance. enteral catheters can result in pulmonary and peritoneal complica-
These risks seem to be greatest during the first and third trimesters. tions. Adynamic ileus may also occur because of decreased splanchnic
For semi-elective procedures, an attempt should be made to delay perfusion, sympathetic tone, or opiate use. With regard to TPN,
surgery until after the first trimester. However, one must consider establishing central access is associated with a significant risk for
the continued exposure of the underlying condition in relation to complications. These include pneumothorax or hemothorax secondary
the operative risks to both the mother and fetus. The second trimester to poor line placement and chylothorax secondary to thoracic duct
is the safest time to perform surgery because organ system dif- injury. Line sepsis is the most common complication of indwelling
ferentiation has occurred and there is almost no risk for anesthetic- central catheters and necessitates catheter removal. Venous thrombosis
induced malformation or spontaneous abortion. When one is with associated thrombophlebitis and extremity edema has been
contemplating surgery on a pregnant patient, consultation with the reported. Catheter thrombosis has also been reported and can be

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 Chapter 8 Principles of Urologic Surgery: Perioperative Care 123

treated with thrombolytic agents (ASPEN Board of Directors and collapse. Atrial fibrillation may also be present in 20% of hyperthyroid
the Clinical Guidelines Task Force, 2002). patients (Klein and Ojamaa, 2001). With regard to hyperthyroidism,
careful attention should be given to the airway because the trachea
can be compressed or deviated by a large goiter. In general, antithyroid
PREPARATION FOR SURGERY medications such as propylthiouracil or methimazole, as well as
β-blockers, are continued on the day of surgery. In the event of
Management of Medications thyroid storm, iodine and steroids may be necessary (Schiff and
Preoperative Optimization Strategies Welsh, 2003). Hypothyroidism is usually associated with an increased
sensitivity to medications such as anesthetic agents and narcotics.
Optimization of Comorbid Illness. Just as adequate preoperative Severe hypothyroidism can be associated with myocardial dysfunction,
evaluation is important, optimization of comorbid illness is critical in coagulopathy, electrolyte imbalance, and a decreased GI motility.
improving surgical outcomes and in reducing perioperative morbidity Symptoms include lethargy, cold intolerance, hoarseness, constipation,
and mortality. With regard to cardiac disease, many studies have dry skin, and apathy. The decrease in metabolic rate produces
evaluated the prophylactic use of nitrates, calcium-channel blockers, periorbital edema, thinning of the eyebrows, brittle hair, dry skin,
and β-blockers for patients who are at risk for perioperative myocardial hypothermia, bradycardia, and a prolonged relaxation of the deep
ischemia. Only β-blockade has been shown to improve outcomes tendon reflexes (Murkin, 1982). Once the diagnosis has been
(Pearse et al., 2004). In a landmark study, Mangano et al. reported confirmed by a low thyroxine level and an elevated thyroid stimulating
that there was an improvement in outcomes with the prophylactic use hormone level, thyroid replacement with levothyroxine can be initi-
of atenolol in patients undergoing vascular surgery (Mangano et al., ated (Schiff and Welsh, 2003).
1996). Similarly, a retrospective, cooperative group study of more The evaluation of the patient either taking corticosteroids or
than one-half million patients showed that perioperative β-blockade suspected of having an abnormal response of the hypothalamic-
is associated with a reduced risk for death among high-risk patients pituitary-adrenal (HPA) axis is also important. There is a wide
undergoing major noncardiac surgery (Lindenauer et al., 2005). In variability in HPA suppression in patients receiving exogenous steroids.
addition to β-blockade, the concept of goal-directed therapy, employ- Nonetheless, it seems clear that the administration of oral steroids
ing the judicious use of fluids, inotropes, and oxygen therapy to equivalent to less than 5 mg of prednisone for any duration of time
achieve therapeutic goals may further reduce perioperative risk (Pearse does not cause clinically significant suppression of the HPA axis. By
et al., 2004). This concept was validated by Shoemaker, who reported contrast, any patient taking more than 20 mg of prednisone or
an impressive reduction in mortality from 28% to 4% (P < .02) its equivalent per day for more than 3 weeks or who is clinically
when goal-directed therapy was used (Shoemaker et al., 1988). cushingoid has probable HPA axis suppression (LaRochelle et al.,
Specific preoperative interventions can decrease pulmonary 1993). HPA suppression can occur even in patients using potent
complications. Smoking must be discontinued at least 8 weeks topical steroids at doses of 2 g/day and in patients using inhaled
before surgery to achieve a risk reduction. Patients who discontinue corticosteroids at doses of 0.8 mg/day. Although the duration of
smoking less than 8 weeks before surgery may actually have a higher functional HPA axis suppression after glucocorticoids have been
risk for complications because the acute absence of the noxious stopped is debatable, perioperative supplemental steroids are recom-
effect of cigarette smoke decreases postoperative coughing and mended for patients who have received HPA axis–suppressive doses
pulmonary toilet (Pearce and Jones, 1984). However, patients who within 1 year of surgery. A low-dose adrenocorticotropic hormone
stop smoking at least 8 weeks preoperatively will significantly (ACTH) stimulation test can be used to assess the HPA axis and the
lower their complication rate, and patients who have ceased need for stress steroids. For patients who take 5 mg of prednisone
smoking for more than 6 months have a pulmonary morbidity or the equivalent each day, no supplemental steroids are necessary,
comparable with that of nonsmokers (Warner et al., 1989). The and the usual daily glucocorticoid dose may be given in the periopera-
use of preoperative bronchodilators in COPD patients can dramatically tive period. For those in whom the HPA axis is presumed to be
reduce postoperative pulmonary complications. Aggressive treatment suppressed or is documented to be suppressed, then 50 to 100 mg
of preexisting pulmonary infections with antibiotics and the pretreat- of intravenous hydrocortisone is given before the induction of
ment of asthmatic patients with steroids are essential in optimizing anesthesia, and 25 to 50 mg of hydrocortisone is given every 8
pulmonary performance. Likewise, the use of epidural and regional hours thereafter for 24 to 48 hours until the usual steroid dose
anesthetics, vigorous pulmonary toilet, rehabilitation, and continued can be resumed. Minor procedures under local anesthesia do not
bronchodilation therapy is all beneficial (Arozullah et al., 2003). require stress-dose steroids (Schiff and Welsh, 2003).
As with cardiopulmonary comorbidities, the preoperative manage-
ment and optimization of diabetic patients are quite important. Antithrombotic Therapy
Perioperative hyperglycemia can lead to impaired wound healing
and a higher incidence of infection (Golden et al., 1999). Hypo- Most urologic patients have medical comorbidities; urologists fre-
glycemia in an anesthetized or sedated diabetic patient may be quently encounter patients on chronic vitamin K antagonist therapy
unrecognized and carries its own significant risks. Non–insulin- (e.g., warfarin) or antiplatelet therapy for the management of atrial
dependent diabetic patients may need to discontinue long-acting fibrillation, mechanical heart valves, or coronary artery disease.
hypoglycemics because of this risk for intraoperative hypoglycemia. Perioperative management including interruption of this antithrom-
Shorter-acting agents or sliding-scale insulin regimens are prefer- botic therapy can be a challenging problem. Unlike venous throm-
able, in general. It is recommended that blood glucose levels be boembolism (VTE) pharmacologic prophylaxis, warfarin and
controlled between 80 and 250 mg/dL. Frequent fingerstick glucose antiplatelet therapies have been shown to be associated with significant
checks and a sliding scale short-acting insulin regimen are used in bleeding complications after surgery. Therefore, urologists must
the postoperative period. Once the patient is eating, the usual insulin carefully consider and balance the risks and benefits of interruption
regimen can be resumed. Patients who manage their diabetes with of chronic anticoagulation to determine the best course of periopera-
the use of insulin pumps should continue their basal insulin infusions tive management of these medications.
on the day of surgery. The pump is then used to correct the glucose Chronic anticoagulation with warfarin is most frequently encoun-
level as it is measured. It is important to know the sensitivity factor tered in patients with atrial fibrillation, mechanical heart valves, or
that corrects the glucose so that the patient’s sugars can be managed prior VTE. The pharmacologic half-life of warfarin is 36 to 42
in the operating room (Townsend et al., 2015). hours, and therefore most guidelines recommend cessation of
Patients with either hyperthyroidism or hypothyroidism should therapy 5 days before surgery to ensure an INR less than 1.5.
be evaluated by an endocrinologist, and surgery should be deferred Recently, several new oral anticoagulants (e.g., apixaban, dabigatran,
until a euthyroid state has been achieved. The greatest risk in the and rivaroxaban), have been introduced to improve efficacy, decrease
hypothyroid patient is thyrotoxicosis, or thyroid storm, which patient variability, and improve patient convenience. Each of the
can manifest with fevers, tachycardia, confusion, and cardiovascular new medications has different pharmacologic properties, and therefore

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124 PART II Basics of Urologic Surgery

TABLE 8.4 Risk Stratification for Arterial or Venous Thromboembolism Events During Perioperative Period in Patients
on Chronic Anticoagulant Therapy

INDICATIONS FOR ANTICOAGULANT THERAPY

RISK STRATUM MECHANICAL HEART VALVE ATRIAL FIBRILLATION VTE

Low Bileaflet aortic valve prosthesis CHADS2 score of 0–2 (and Single VTE occurred >12 mo ago and no
without atrial fibrillation and no prior stroke or transient other risk factors
no other risk factors for stroke ischemic attack)
Moderate Bileaflet aortic valve prosthesis CHADS2 score of 3–4 VTE within the past 3–12 mo
plus one or more of the Nonsevere thrombophilic conditions (e.g.,
following: atrial fibrillation, heterozygous factor V Leiden mutation,
prior stroke or transient heterozygous factor II mutation)
ischemic attack, hypertension, Recurrent VTE
diabetes, congestive heart Active cancer (treated within 6 mo or
failure, age above 75 yr palliative)
High Any mitral valve prosthesis CHADS2 score of 5–6 Recent (within 3 mo) VTE
Any caged-ball or tilting disc Recent (within 3 mo) stroke or Severe thrombophilia (e.g., deficiency of
aortic valve prosthesis transient ischemic attack protein C, protein S, or antithrombin;
Recent (within 6 mo) stroke or Rheumatic valvular heart presence of antiphospholipid
transient ischemic attack disease antibodies; multiple abnormalities)

CHADS2, Congestive heart failure, hypertension, age, diabetes, stroke; mo, months; VTE, venous thromboembolism; yr, year.
Modified from Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention
of Thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):e326S–e350S.

it is imperative for the surgeon to be familiar with these medications antiplatelet therapy in these patients. Given the current lack of
to properly advise the patient (Douketis et al., 2012; Douketis, 2010). clinically useful alternatives to antiplatelet therapy, when surgery
The larger issue is whether patients require a bridge with short-term cannot be delayed (e.g., because of malignancy), the ACCP strongly
anticoagulation between the time of subtherapeutic INR and surgery. recommends continuing aspirin and clopidogrel during the periopera-
The decision is based on risk for a thrombotic event. Regarding atrial tive period in patients with drug-eluting stents (Douketis et al., 2012).
fibrillation, clinical scoring systems such as congestive heart failure, Nevertheless, communication between the urologist and the cardiolo-
hypertension, age, diabetes, stroke (CHADS2) stratify patients into gist throughout the perioperative period is essential to minimize
risk groups that predict risk for stroke while patients are not undergo- complications and maximize outcomes.
ing anticoagulation therapy. Patients with mechanical heart valves
can also be stratified into risk groups according to the location (mitral Bowel Preparation
vs. aortic) and type of valve used. Similarly, patients with a prior
history of VTE are stratified according to duration since the last VTE Since antibiotics were first shown to reduce infectious complications
and the patient’s risk for recurrent VTE (Table 8.4). In general, the in GI surgery, mechanical and antibiotic bowel preparation has
2012 American College of Chest Physicians (ACCP) guidelines been a mainstay of urologic surgery employing intestinal segments.
recommends that patients in the moderate- and high-risk groups The rationale for bowel preparation before intestinal surgery is to
undergo bridging anticoagulation with therapeutic-dose subcutane- decrease intraluminal feces and decrease bacterial colony counts to
ous low–molecular-weight heparin or intravenous unfractionated decrease the rate of anastomotic leak, intra-abdominal abscesses,
heparin (Douketis et al., 2012). and wound infections. The bacterial flora in the bowel consists of
An increasing number of patients are receiving chronic antiplatelet aerobic organisms, the most common of which are Escherichia coli
therapy in the prevention of cardiovascular events and, more impor- and Enterococcus faecalis, and anaerobic organisms, the most common
tant, in the prevention of coronary stent thrombosis. Although the of which are Bacteroides species and Clostridium species. The bacterial
former indication poses little controversy for the urologist, the latter concentration ranges from 10 to 105 organisms per gram of fecal
indication presents a significant and complex clinical challenge in content in the jejunum, 105 to 107 in the distal ileum, 106 to
which the urologist must weigh the risk for bleeding with the 108 in the ascending colon, and 1010 to 1012 in the descending
potentially devastating risk for perioperative stent thrombosis. Aspirin colon. The preparation itself consists of two components: antibiotic
and clopidogrel are the two most commonly used antiplatelet drugs preparation and mechanical preparation. Because there are only a
and are frequently used together. Both are irreversible inhibitors of few small series in the urologic literature, the rationale for each
platelet function and therefore need to be stopped 7 to 10 days must be inferred from the general surgery literature—specifically,
before surgery to minimize bleeding risk. Current recommendations from colorectal surgery literature.
require dual antiplatelet therapy for 6 weeks after bare metal Although preoperative parenteral antibiotic prophylaxis before
coronary stents and 12 months for drug-eluting stents. Premature intestinal surgery is well established and widely used, oral antibiotic
interruption of antiplatelet therapy has been associated with a preparation is still somewhat controversial. Several oral antibiotic
25% to 50% risk for significant myocardial infarction with resultant regimens are used today. The most commonly used regimen, oral
increased perioperative mortality (O’Riordan et al., 2009). In most neomycin and erythromycin, first became established in 1977 with the
patients, urologists should defer elective surgery until after antiplatelet landmark study by Clark et al. (Clarke et al., 1977). In a double-blind,
therapy can be safely interrupted. In a review of the literature, Gupta placebo-controlled study, 167 patients undergoing elective colonic
et al. recommended delay of elective urologic surgery for at least 30 surgery were randomized to receive mechanical bowel preparation
days for bare metal stents and, if possible, longer than 1 year for with or without oral neomycin and erythromycin. The overall rates of
drug-eluting stents (Gupta et al., 2012). Even then, because acute septic complications were 43% with mechanical-only preparation and
stent thrombosis has been described with drug-eluting stents after 9% with antibiotic plus mechanical preparation (P = .001). However,
12 months, urologists should strongly consider at least single-agent with current standards of the use of preoperative parenteral antibiotics,

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 Chapter 8 Principles of Urologic Surgery: Perioperative Care 125

the benefit of oral antibiotic preparation was debated. Several older the incidence of postoperative ileus. However, to date there have
studies reported decreased infectious complications; however, these been no trials to support this assertion.
studies were small, and there have been no randomized controlled In the early postoperative period, most patients experience some
trials (RCTs) to document the benefit. The disadvantage of oral degree of primary ileus and delayed GI activity. Any patient with
antibiotic preparation is primarily related to increased incidence ileus lasting more than 72 to 96 hours after surgery should be
of pseudomembranous colitis secondary to Clostridium difficile evaluated for a mechanical bowel obstruction secondary to adhesions,
infection. In a retrospective analysis of 304 patients, Wren et al. an intra-abdominal pathologic process, or a retroperitoneal hemor-
reported a significantly decreased incidence of C. difficile colitis in rhage. Given that return of GI function is often the rate-limiting
patients who did not receive oral antibiotics before elective colorectal factor for hospital discharge, efforts to reduce ileus including mini-
surgery (2.6% vs. 7.2%, P = .03) (Wren et al., 2005). Inferring from mization of parenteral or oral opioid use, selective use of nasogastric
the colorectal literature, most current guidelines and a 2014 Cochrane tubes, and correction of electrolyte imbalances should be employed.
review recommend that antibiotics covering aerobic and anaerobic More recently, methods to accelerate GI recovery have been inves-
bacteria delivered orally or intravenously (or both) before elective tigated. Gum chewing—that is, sham feeding—was evaluated and
colorectal surgery reduce the risk for surgical wound infection reported to be associated with improvements in GI recovery and
by as much as 75% (Nelson et al., 2014). Despite the lack of level reduction in length of stay in patients undergoing colorectal surgery
1 evidence in the literature, a recent survey of colorectal surgeons (Ho et al., 2014). Alvimopan (Entereg) is a peripherally acting opioid
revealed that up to 87% of surgeons continue to administer oral antagonist that was approved by the U.S. Food and Drug Administra-
antibiotic bowel preparation before elective surgery (Zmora et al., tion (FDA) in 2008 to help restore bowel function after surgery.
2003). In the 2014 Cochrane review, however, it was acknowledged With the validation of alvimopan established in the colorectal lit-
that it is unknown whether oral antibiotics would have any beneficial erature, there have been several studies performed in patients
effect in reducing surgical wound infection when the colon is not undergoing cystectomy including a phase 4 trial whose findings
empty (Nelson et al., 2014). were recently published. Use of alvimopan compared with placebo
Mechanical bowel preparation predates the use of antibiotics in resulted in decreased length of stay of 2.6 days in patients undergoing
intestinal surgery and was thought to decrease the rate of anastomotic radical cystectomy (Kauf et al., 2014). Many high-volume centers
complications. Before the development of nonabsorbable liquids, are now incorporating both strategies into enhanced recovery after
patients underwent several days of oral laxatives, bowel irrigations surgery (ERAS) clinical pathways to reduce postoperative ileus and
via nasogastric tubes, and repeat enemas. These regimens were reduce hospital stays.
associated with significant patient discomfort and clinical morbidity
caused by electrolyte imbalances. The development of polyethylene
glycol solution (GoLYTELY) and sodium phosphate solution (Fleet INTRAOPERATIVE MANAGEMENT
Phospho-soda) reduced much of the electrolyte disturbance and Patient Environment
allowed for mechanical bowel preparation to be done in the outpatient
setting. Both regimens are suitable for most patients; however, Maintaining an optimal patient environment is critical for the overall
polyethylene glycol is preferred in the elderly and in patients with outcome of the patient. Although hypothermia can be therapeutic
renal insufficiency, congestive heart failure, existing electrolyte in certain situations of trauma and brain injury, for elective surgical
disturbances, and cirrhosis because it is completely nonabsorbable. procedures, hypothermia is associated with significantly increased
The benefit of mechanical bowel preparation has been assumed morbidity to the patient. There are two primary reasons for
for decades as evidenced by 99% positive response by colorectal hypothermia to develop in the operating room. Anesthetic agents
surgeons when asked if mechanical preparation is routinely used induce peripheral vasodilation, redistributing heat from the core
(Zmora et al., 2003). However, RCTs have called into doubt the true (trunk, head) with a resultant drop in immediate core temperature
benefit. Slim et al. published a meta-analysis of RCTs including a after induction. Throughout the rest of the surgical procedure,
total of 4859 patients (Slim et al., 2009). The analysis included 14 radiation and conductive heat loss account for most of the heat
trials including two large trials from the Netherlands and Sweden loss. Normothermia is defined as a core temperature between 36°C
(Contant et al., 2007; Jung et al., 2007). Overall, the analysis revealed and 38°C, and hypothermia of even 1°C to 2°C results in adverse
that mechanical bowel preparation provided no benefit for effects. Rajagopalan et al. performed a meta-analysis of RCTs and
anastomotic leak (odds ratio [OR] 1.12, 95% confidence interval reported that mild hypothermia (decrease of 1°C) resulted in a 16%
[CI], 0.82 to 1.53, P = .46); abdominal or pelvic abscess (OR increase in estimated blood loss and a 22% increase in transfusion
0.90, 95% CI 0.47 to 1.72, P = .75); or mortality (OR 0.91, 95% requirements (Rajagopalan et al., 2008). The increased bleeding
CI 0.57 to 1.45, P = .70). In fact, when overall surgical site infection risk is thought to result from a hypothermia-associated decrease in
(SSI) was considered, mechanical bowel preparation was associated clotting cascade enzymatic function and platelet aggregation. Even
with a significantly increased risk (OR 1.40, 95% CI 1.05 to 1.87, more significant is the increase in the risk for SSI associated with
P = .02). These results were reiterated in an updated Cochrane review, mild hypothermia (34°C to 36°C). Hypothermia increases the risk
which found no significant differences in anastomotic leak rate or for SSI by impairing immune mechanisms and vasoconstriction,
wound infection, need for reoperation, and mortality rates (Güenaga resulting in regional tissue hypoxia. In a landmark study, Kurz et al.
et al., 2011). The authors concluded that there was no evidence that with the Study of Wound Infection and Temperature Group tested
mechanical bowel preparation improves patient outcomes after in 200 patients undergoing elective colorectal surgery the hypothesis
elective colorectal surgery. Although similar studies have not been that hypothermia increases the rate of wound infection and hospital
done in patients undergoing elective urologic surgery, urologists can stay (Kurz et al., 1996). Hypothermia was associated with a three
make inferences from the colorectal literature and should reevaluate times increased risk for wound infection and a 2.6-day increase
the common practice of mechanical bowel preparation before urologic in hospitalization. More recent studies have confirmed these find-
intestinal surgery. To date, there have been multiple single-institution ings in general in other series of surgical patients (Mauermann and
reports suggesting equivalent SSI outcomes with or without bowel Nemergut, 2006). In its overall goal of reducing SSI, the SCIP has
preparation before radical cystectomy and urinary diversion (Zaid also included perioperative normothermia as one of its guidelines.
et al., 2013). Two specific exceptions are transrectal ultrasound-guided Strategies to improve maintenance of normothermia include regular
prostate needle biopsy and laparoscopic urologic surgery. Given the use of warming blankets, warmed intravenous fluids, warmed irriga-
portal of entry and subsequent risk for bacteremia, most urologists tion fluids (especially during transurethral resection of the prostate
have advocated for mechanical rectal cleansing with an enema before [TURP] and other prolonged endoscopic procedures), warmed
transrectal ultrasound-guided prostate needle biopsy. With regard humidified CO2 gas during laparoscopy, and increase in ambient
to laparoscopy, surgeons who perform minimally invasive procedures operating room temperature. Although there have been few studies
have long believed that preoperative bowel preparation improves in the urologic literature, the findings can be generalized to all
operative exposure because of bowel decompression and decreases surgical patients.

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126 PART II Basics of Urologic Surgery

Patient Safety operating room should be equipped with a hydraulic table, extra-long
instruments, additional padding, wide venous compression devices,
In 1991, Brennan et al. published their seminal work describing and side extensions to the operating table to ensure a safe operating
adverse events, defined as injuries caused by medical management room environment for the patient.
in hospitalized patients, revealing that 48% of the events accompanied
a surgical operation (Brennan et al., 1991; Leape et al., 1991). This Patient Positioning
important study inspired the publication of “To Err Is Human:
Building a Safer Health System,” a comprehensive study by the Although often given only a cursory evaluation, proper patient
Institute of Medicine on medical errors. Regarding surgical patients, positioning in the operating room can prevent potentially devastating
the most frequent venue of preventable injuries is the operating complications. Ultimately, proper positioning is the shared respon-
room. Although the surgeon is the “captain of the ship” and sibility of each member of the operating room team. Much of the
ultimately responsible, it takes cognizance and attention to detail knowledge and guidelines for avoidance of position-related injury
from each member of the operating room team to prevent iatro- are drawn from the anesthesia literature. In fact, based on a 1999
genic injuries to the patient. Three causes of immediately preventable study of the ASA Closed Claims Database, which found neuropathy
injuries are retractor-associated injuries, thermal injuries, and patient as second-leading cause of liability, the ASA published a practice
position–related injuries. There are several reports in the literature advisory for the prevention of perioperative peripheral neuropathies
documenting an increased rate of neuropathy (especially femoral (American Society of Anesthesiologists, 2018). The recommendations
nerve) after laparotomy with self-retaining retractors versus without are listed in Box 8.2. Although the exact mechanisms of peripheral
self-retaining retractors (Irvin et al., 2004). Careful attention to be neuropathy are not always known, the cause of position-related
certain that the lateral blades do not directly compress the psoas neuropathy is usually secondary to excessive stretch, prolonged
muscle and only cradle the rectus abdominal muscles will ensure compression, or ischemia. Given the variety of different patient
avoidance of femoral neuropathy. Furthermore, periodic reinspection positions used in urologic surgery, it is critical for the urologist to
of the retractor blades is also warranted. Many devices used in urologic be an active participant in the positioning of the patient and to
surgery employ thermal energy for desired effect and therefore can understand the potential patient compromise that accompanies each
result in thermal injury to the patient. These include Bovie cautery, position.
the argon beam coagulator, bipolar devices, and lasers. In both The supine position, used in abdominal, pelvic, and penile
endoscopic and laparoscopic surgery, high-wattage light sources are procedures, is in general considered the safest patient position.
used to illuminate the operative field. Although it is illuminated, However, several specific issues should be considered. Excessive
the ends of the light cords can result in burns when in direct contact upper extremity abduction (>90 degrees) can lead to tension on
with the patient (even through draping). These light sources should the brachial plexus, causing upper extremity neuropathy. The arm
be turned off or placed on standby at all times when not in use. board should be padded to avoid excessive pressure on the ulnar
Special mention is deserved for the morbidly obese patient. The groove and spiral groove of the humerus (radial nerve injury). In

BOX 8.2 American Society of Anesthesiologists Task Force Recommendations on the Prevention of Perioperative
Peripheral Neuropathies
PREOPERATIVE ASSESSMENT PROTECTIVE PADDING
• When judged appropriately, it is helpful to ascertain that • Padded arm boards may decrease the risk for upper extremity
patients can comfortably tolerate the anticipated operative neuropathy.
position. • The use of chest rolls in laterally positioned patients may
decrease the risk for upper extremity neuropathies.
UPPER EXTREMITY POSITIONING • Padding at the elbow and at the fibular head may decrease
• Arm abduction should be limited to 90 degrees in supine the risk for upper and lower extremity neuropathies,
patients; patients who are positioned prone may comfortably respectively.
tolerate arm abduction greater than 90 degrees.
• Arms should be positioned to decrease pressure on the EQUIPMENT
post-condylar groove of the humerus (ulnar groove). When • Properly functioning automated blood pressure cuffs on the
arms are tucked at the side, a neutral forearm position is upper arms do not affect the risk for upper extremity
recommended. When arms are abducted on arm boards, neuropathies.
either supination or a neutral forearm position is acceptable. • Shoulder braces in steep head-down positions may increase
• Prolonged pressure on the radial nerve in the spiral groove of the risk for brachial plexus neuropathies.
the humerus should be avoided.
• Extension of the elbow beyond a comfortable range may POSTOPERATIVE ASSESSMENT
stretch the median nerve. • A simple postoperative assessment of extremity nerve function
may lead to early recognition of peripheral neuropathies.
LOWER EXTREMITY POSITIONING
• Lithotomy positions that stretch the hamstring muscle group DOCUMENTATION
beyond a comfortable range may stretch the sciatic nerve. • Charting specific positioning actions during the care of patients
• Prolonged pressure on the peroneal nerve at the fibular head may result in improvements of care by (1) helping practitioners
should be avoided. focus attention on relevant aspects of patient positioning
• Neither extension nor flexion of the hip increases the risk for and (2) providing information that continuous improvement
femoral neuropathy. processes can use to effect refinements in patient care.

Modified from American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies. Practice advisory for the
prevention of perioperative peripheral neuropathies: a report by the American Society of Anesthesiologists Task Force on Prevention of Perioperative
Peripheral Neuropathies. Anesthesiology. 2000;92(4):1168–1182.

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 Chapter 8 Principles of Urologic Surgery: Perioperative Care 127

cases in which the arms are tucked at the patient’s side, care must of surgical procedures (Bowater et al., 2009). Given both the ethical
be taken to avoid excessive pressure on the hand and forearm. responsibility of the surgeon to decrease surgical morbidity and
Moreover, peripheral intravenous catheter infiltration must be identi- the recent policy shift by the Centers for Medicare and Medicaid
fied quickly because forearm compartment syndrome may develop. Services to withhold reimbursement for hospital admissions
One of the most frequent positions used in urology is the lithotomy secondary to specific SSI, it is mandatory for urologists to under-
position. Improper positioning can lead to transient and occasionally stand the principles behind and to practice SSI prevention.
prolonged lower extremity neuropathy. In a retrospective evaluation Along with antibiotic prophylaxis, proper hand washing and
of more than 190,000 cases from 1957 to 1991 involving the lithotomy scrubbing and sterile preparation of the operative field have always
position, persistent neuropathy was found in 0.03%; however, the been central to the prevention of SSI. For procedures involving the
same group in a prospective study of 991 patients reported an GI tract, mechanical and oral antibiotic bowel preparation had been
incidence of 1.5% (15 patients), with resolution of symptoms by 6 standard practice until more recent literature, calling into question
months in all but one patient (Warner et al., 1994, 2000). The basic its usefulness (discussed later). Preoperative hair removal has not
principle of positioning involves manipulation of both lower been associated with a decrease in SSI, but if performed, use of
extremities simultaneously with flexion of the hips at 80 to 100 mechanical clippers or depilatory creams as opposed to razors is
degrees with 30- to 45-degree abduction. The legs should be padded associated with a decreased risk for SSI (Wolf et al., 2008).
to avoid excessive compression against the stirrup. Particular caution The risk for SSI and therefore the recommendation for antibiotic
should be given to the patient’s hands to avoid entrapment within prophylaxis is composed of three factors: the patient’s susceptibility
the moving parts of the stirrups. to and ability to respond to localized and systemic infection, the
For most open and laparoscopic upper urothelial tract and renal procedural risk for infection, and the potential morbidity of infection.
procedures, the patient is placed in some degree of lateral decubitus First, patient-related factors, listed in Box 8.3, increase risk by decreas-
position. Proper padding of the patient is important, with appropriate ing natural defense mechanisms, increasing the local bacterial
anterior and posterior support to maintain the decubitus position. concentration, and/or altering the spectrum of bacterial flora. Second,
The most frequent focus of compromise involves positioning of the surgical procedure–specific factors can affect the route of entry, site
arms and the potential for brachial plexus injury. The ipsilateral arm of infection, and pathogen involved. This idea was first described
should be placed on the chest or an elevated arm rest or gel pad, in the landmark study from the National Research Council and later
or pillow (s) avoiding abduction of more than 90 degrees and excessive formalized by the CDC; specifically, surgical wounds are now classified
stretch on the shoulder. The contralateral arm should be placed on by degree of contamination (i.e., the inoculum of potential pathogen)
an arm board with ulnar padding. Furthermore, in patients in full (Box 8.4; Hart et al., 1968). To predict the risk for SSI, several scoring
flank position, an axillary roll should be placed just caudal to the systems have been developed incorporating patient-related factors
axilla (not in the axilla) to avoid compression of the contralateral with wound classification. Finally, the risk to the patient from SSI
brachial plexus. Finally, after the patient has been positioned and is an important consideration in determining the need for prophylaxis.
before sterile draping, the operating table should be fully rotated For example, routine cystoscopy in the evaluation of microhematuria
to ensure that the patient is adequately secured in all positions. in an otherwise young, healthy patient may not warrant prophylaxis;
Two patient positions used in specific urologic cases deserve however, the same procedure in an elderly, insulin-dependent diabetic
attention: the prone position for percutaneous nephroscopy and the (immunocompromised) does warrant prophylaxis given the high
full Trendelenburg position for robotic-assisted laparoscopic proce- likelihood that a postprocedural urinary tract infection would result
dures in the pelvis. In the prone position, special care should be in a significant deterioration in the patient’s overall health. Under-
taken to pad the torso, elbows, hips, and legs. The anesthesiologist standing the three factors together then allows the urologist to make
should ensure that the endotracheal tube and all vascular accesses a rational decision regarding the risks and benefits of antibiotic
are properly secured. Coordination of the entire team is required prophylaxis.
during transfer from the supine position on the stretcher to the Once the decision for antibiotic prophylaxis has been made,
prone position on the operating room table. A stretcher should the keys to successful prevention are the proper choice of antibiotic
always be available immediately in case of airway compromise and for the particular procedure and proper timing and administration
the need for rapid transfer to the supine position. Regarding the full of the antibiotic. The first key to successful prevention is the proper
Trendelenburg position for minimally invasive pelvic procedures, choice of antibiotic for the procedure in question. As mentioned
the primary issues involve the physiologic changes in respiratory earlier, surgery-specific factors affect the type of pathogen, route of
function, cardiovascular function, and increases in central venous entry, and likelihood of systemic infection. For example, the choice
and intracranial pressures. Patient positioning should focus on of antibiotic is different for TURP (need coverage for common urinary
properly padding and securing the patient to the operating table
to prevent cephalad sliding. Although fixed shoulder braces will
undoubtedly prevent patient movement, these braces should be
avoided because of the risk for brachial plexus compression and BOX 8.3 Patient Factors That Increase the Risk
resultant neuropathy. for Infection
• Advanced age
Antibiotic Prophylaxis
• Anatomic anomalies
In 1999 the Centers for Disease Control and Prevention (CDC) • Poor nutritional status
issued its third report on the prevention of SSI, highlighting the • Smoking
importance of standardization of prophylactic treatment to prevent • Chronic corticosteroid use
this universal surgical complication (Mangram et al., 1999). The • Immunodeficiency
report indicated that SSIs account for approximately 40% of
• Chronic indwelling hardware
nosocomial infections in surgical patients and potentially prolong
hospital stay by 7 to 10 days. A study of national SSIs from the • Infected endogenous or exogenous material
2005 Healthcare Cost and Utilization Project National Inpatient • Distant coexistent infection
Sample (HCUP NIS) calculated an increase in hospital stay of 9.7 • Prolonged hospitalization
days and in per-patient cost of $20,892 (de Lissovoy et al., 2009).
This translated nationally into an additional 1 million inpatient Data from Cruse PJ. Surgical wound infection. In: Wonsiewicz MJ. ed.
hospital days and additional health care cost of $1.6 billion. Bowater Infectious disease. Philadelphia, PA: Saunders; 1992:758–764; Mangram
et al. published a systematic review of meta-analyses (level 1 evidence) AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site
and concluded that there was substantial evidence that antibiotic infection, 1999. Hospital Infection Control Practices Advisory Committee.
prophylaxis was an effective prevention for SSI over a wide variety Infect Control Hosp Epidemiol. 1999;20(4):250–278; quiz 279–280.

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128 PART II Basics of Urologic Surgery

costs. Along with timing and duration, proper administration of

BOX 8.4 Surgical Wound Classification antibiotics implies proper dosage. Antibiotic dose is dependent on
CLEAN the patient’s body weight, renal function and hepatic function, and
duration of procedure (re-administration is required if longer than
• Uninfected wound without inflammation or entry into the
4 hours). A recent analysis of the Premier Perspectives Database
genital, urinary, or alimentary tract encompassing urologic procedures performed between 2007 and
• Primary wound closure, closed drainage 2012 revealed that compliance with AUA Best Practices increased
with time, but overall rates remain less than 60% (Mossanen et al.,
CLEAN CONTAMINATED 2015). A practicing urologist must be familiar with best practice
• Uninfected wound with controlled entry into the genital, guidelines and hospital policies to avoid underuse, overuse, or
urinary, or alimentary tract misuse of antimicrobial prophylaxis.
• Primary wound closure, closed drainage
Venous Thromboembolic Prophylaxis
CONTAMINATED
Venous thromboembolic complications are a major cause of poten-
• Uninfected wound with major break in sterile technique
tially preventable morbidity and mortality among surgical patients in
(gross spillage from gastrointestinal tract or nonpurulent the United States. A recent study from the Center for Quality Improve-
inflammation) ment and Patient Safety and the Agency for Healthcare Research and
• Open fresh accidental wounds Quality found postoperative VTE to be the second most common
cause of excess length of stay, charges, and mortality among surgical
DIRTY INFECTED patients discharged from acute care hospitals (Zhan and Miller, 2003).
• Wound with preexisting clinical infection or perforated Urology patients in particular have an increased incidence of VTE,
viscera estimated to be 10% to 40% in patients without any prophylaxis
• Old traumatic wounds with devitalized tissue (Geerts et al., 2008). Although these estimates are based on historical
studies conducted before the routine use of mechanical prophylaxis
and the recognition of the benefits of early ambulation, the increased
Data from Garner JS. CDC guideline for prevention of surgical wound
risk persists, with more recent studies reporting incidences of 1%
infections, 1985. Supersedes guideline for prevention of surgical wound
to 5%. Urologic patients followed prospectively in the European
infections published in 1982. (Originally published in 1995.) Revised. Infect
@RISTOS study developed VTE in 1.9% undergoing open surgery
Control. 1986;7(3):193–200; Simmons BP. Guideline for prevention of
despite a high rate of prophylaxis (Scarpa et al., 2007). For patients
surgical wound infections. Infect Control. 1982;2:185–196.
in the United Kingdom undergoing urologic procedures, Dyer et al.
reported an overall incidence of 0.66% including a 2.8% incidence
among patients undergoing radical cystectomy (Dyer et al., 2013).
Overall, VTE is the most important cause of nonsurgical mortality
tract pathogens) than for a cystectomy with planned sigmoid colon among urology patients (Forrest et al., 2009).
urinary diversion (need coverage for anaerobic bacteria). Another Although the use of perioperative mechanical prophylaxis (pneu-
important consideration is the rate of antibiotic resistance in the matic compression stockings or sequential compressive device) is
community. Although there is level 1 evidence for the use of fluo- fairly universal, pharmacologic prophylaxis is administered only after
roquinolones as prophylaxis for urologic endoscopic procedures, weighing the risk for VTE versus the risk for perioperative bleeding
the emerging Escherichia coli resistance in the community is complications (Table 8.6). Leonardi et al. reviewed and analyzed 33
changing practice patterns in many practices and high-resistance RCTs to assess the incidence of bleeding complications in general
hospitals. One resource that is particularly useful is the hospital surgery patients receiving pharmacologic prophylaxis (Leonardi et al.,
antibiogram. These reports are published monthly at most major 2006). Although there was a significantly higher rate of minor
hospitals and quantify the susceptibility and resistance of common complications (injection site bruising and wound hematoma),
organisms to a wide variety of antibiotics. A summary of the recent there was no significant difference in major complications (e.g.,
American Urological Association (AUA) best practice statement on GI tract bleeding [0.2%] or retroperitoneal bleeding [<0.1%]).
antibiotic prophylaxis is shown in Table 8.5. In 2012, the AUA issued Although these results are applicable in general to urology patients,
an amendment to the best practice statement with regard to prostate certain urologic procedures, such as TURP and partial nephrectomy,
biopsy, acknowledging the emerging resistance to fluoroquinolones have a specifically higher rate of bleeding complications. Regarding
and recommending cephalosporins and/or aminoglycosides in certain an individual’s risk for VTE, both surgery-related risk factors and
communities. patient-related risk factors must be considered. Surgical factors
Since the pivotal study by Classen et al., particular emphasis specific to urologic surgery to be weighed include general versus
has been placed on the timing of prophylaxis to be given within neuraxial anesthesia, supine versus dorsal lithotomy positioning,
2 hours of incision (Classen et al., 1992). This emphasis was abdominal versus pelvic surgery with or without lymphadenectomy,
exemplified by the Joint Commission’s Surgical Care Improvement and open versus laparoscopic approach. Patient-related risk factors are
Project (SCIP) guideline for administration of antibiotic prophylaxis listed in Box 8.5, with increasing age, malignancy, history of cancer
60 minutes before incision in a broader effort to decrease overall therapy, and others being fairly common among urology patients.
surgical complications by 25% by 2010. A multi-institutional trial In fact, both the @RISTOS study and a recent report on minimally
involving more than 4400 patients at 29 institutions reported results invasive radical prostatectomy confirmed several of these factors as
of their analysis on the optimal timing of antibiotic prophylaxis being associated with increased risk for VTE in urologic patients
(Steinberg et al., 2009). The results suggested an improvement in (Scarpa et al., 2007; Secin et al., 2008). In 2008, the ACCP issued
prevention of SSI when antibiotics were administered within 30 guidelines on the prevention of VTE with a strong recommendation
minutes of incision as compared with 31 to 60 minutes (adjusted that hospitals develop a formal, active strategy to address VTE preven-
odds ratio [OR] 1.48, P = .06). More importantly, this larger study tion. Although prior recommendations from the ACCP advocated
confirmed the significantly increased risk for SSI when antibiotics individualized risk assessment models to guide therapy, the current
were administered at the time of or after incision, with an adjusted recommendations advocate implementation of group-specific
OR of 2.20, P = .02. The duration of antibiotic prophylaxis is more thromboprophylaxis routinely for all patients who belong to each
controversial; however, most recommendations advocate no more of the major surgical groups (e.g., urologic surgery) (Geerts et al.,
than 24 hours in a patient without an established infection. Routine 2008). The AUA has published a best practice statement on the use
antibiotic use beyond 24 hours increases the risk for C. difficile colitis, of VTE prophylaxis in urologic patients (Forrest et al., 2009). These
increases the development of antibiotic resistance, and increases recommendations combine an individualized risk assessment model

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 Chapter 8 Principles of Urologic Surgery: Perioperative Care 129

TABLE 8.5 American Urological Association Best Practice Statement on Recommended Antimicrobial Prophylaxis for
Urologic Procedures

PROPHYLAXIS ANTIMICROBIALS OF ALTERNATIVE

PROCEDURE ORGANISM INDICATED CHOICE ANTIMICROBIALS DURATION
LOWER URINARY TRACT INSTRUMENTATION
Removal of external GU tract If risk factors Fluoroquinolone Aminoglycoside ± ≤24 hr
urinary catheter TMP-SMX ampicillin
First- or second-
generation
cephalosporin
Amoxicillin/clavulanate
Cystography, GU tract If risk factors Fluoroquinolone Aminoglycoside ± ≤24 hr
urodynamic study, TMP-SMX ampicillin
or simple First- or second-
cystoscopy generation
cephalosporin
Amoxicillin/clavulanate
Cystoscopy with GU tract All Fluoroquinolone Aminoglycoside ± ≤24 hr
manipulation TMP-SMX ampicillin
First- or second-
generation
cephalosporin
Amoxicillin/clavulanate
Prostate Skin Uncertain First-generation Clindamycin ≤24 hr
brachytherapy or cephalosporin
cryotherapy
Transrectal prostate Intestine All Fluoroquinolone Aminoglycoside + ≤24 hr
needle biopsy Second- or third- metronidazole or
generation cephalosporin clindamycin

UPPER URINARY TRACT INSTRUMENTATION

Shock wave GU tract All Fluoroquinolone Aminoglycoside ± ≤24 hr
lithotripsy TMP-SMX ampicillin
First- or second-
generation
cephalosporin
Amoxicillin/clavulanate
Percutaneous renal GU tract All First- or second- Ampicillin/sulbactam ≤24 hr
surgery Skin generation cephalosporin Fluoroquinolone
Aminoglycoside +
metronidazole or
clindamycin
Ureteroscopy GU tract All Fluoroquinolone Aminoglycoside ± ≤24 hr
TMP-SMX ampicillin
First- or second-
generation
cephalosporin
Amoxicillin/clavulanate

OPEN OR LAPAROSCOPIC SURGERY

Vaginal surgery GU tract All First- or second- Ampicillin/sulbactam ≤24 hr
(including urethral Skin generation cephalosporin Fluoroquinolone
sling procedures) Group B Aminoglycoside +
Streptococcus metronidazole or
clindamycin
Open or laparoscopic Skin If risk factors First-generation Clindamycin Single dose
surgery without cephalosporin
entering GU tract
Continued

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130 PART II Basics of Urologic Surgery

TABLE 8.5 American Urological Association Best Practice Statement on Recommended Antimicrobial Prophylaxis for
Urologic Procedures—cont’d

PROPHYLAXIS ANTIMICROBIALS OF ALTERNATIVE

PROCEDURE ORGANISM INDICATED CHOICE ANTIMICROBIALS DURATION
Surgery involving GU tract All First- or second- Ampicillin/sulbactam ≤24 hr
entry into GU tract Skin generation cephalosporin Fluoroquinolone
Aminoglycoside +
metronidazole or
clindamycin
Intestinal surgery GU tract All Second- or third- Ampicillin/sulbactam ≤24 hr
Skin generation cephalosporin Ticarcillin/clavulanate
Intestinal flora Aminoglycoside + Piperacillin/
metronidazole or tazobactam
clindamycin Fluoroquinolone
Implanted prosthesis GU tract All Aminoglycoside + first- or Ampicillin/sulbactam ≤24 hr
Skin second-generation Ticarcillin/clavulanate
cephalosporin or Piperacillin/
vancomycin tazobactam

GU, Genitourinary; hr, hour; TMP-SMX, trimethoprim-sulfamethoxazole.

Modified from Wolf JS Jr, Bennett CJ, Dmochowski RR, et al.; Urologic Surgery Antimicrobial Prophylaxis Best Practice Policy Panel. Best practice
policy statement on urologic surgery antimicrobial prophylaxis. J Urol. 2008;179(4):1379–1390.

TABLE 8.6 Mechanical and Pharmacologic Venous Thromboembolism Prophylaxis

PROPHYLAXIS DOSE ADVANTAGES DISADVANTAGES

Pneumatic compression N/A Can be used in patients with high No standards for size, pressure
stockings bleeding risk Individual models not specifically studied
Easily standardized for all patients Less effective than pharmacologic
Studied in multiple patient groups prophylaxis in high-risk groups
Low–molecular-weight 40 mg SC once daily Once-daily administration Not reversible
heparin Less risk for heparin-induced High cost
thrombocytopenia Relative contraindication in patients with
No blood monitoring necessary renal insufficiency
Low-dose unfractionated 5000 units SC q8h Reversible Needs readministration q8-12h
heparin Can be used safely in patients Heparin-induced thrombocytopenia
with renal insufficiency
Relatively inexpensive

with each type of urologic surgery. For example, a high-risk patient and perioperative monitoring have dramatically decreased the risks
(multiple patient risk factors) undergoing low-risk surgery may require associated with anesthesia. A recent study of New York hospital-based
pharmacologic prophylaxis, as might a low-risk patient undergo- and freestanding ambulatory surgical centers reported the risk for
ing high-risk surgery. The recommendations are summarized in all-cause mortality to be 1 in 49,012 and the rate of immediate
Table 8.7. admission to an inpatient facility to be 0.6% (Fleisher et al., 2007b).

Anesthetic Considerations Selection of Mode of Anesthesia

The basic tenet of anesthesia is to deliver hypnosis, amnesia, and An important role of the urologist in the anesthetic evaluation is to
analgesia while maintaining satisfactory operating conditions. An determine what mode of anesthesia is best for the particular patient
understanding of the basic pharmacologic principles, anesthetic and surgical procedure. The choice depends on patient-related factors
equipment and monitoring, and patient analgesia is important to including comorbidities, airway, and patient preference and procedural
any surgeon including the urologist for successful operative outcomes factors including complexity, duration, anatomic location, and
and avoidance of surgical complications. Although urologists are expected fluid and blood loss. A basic understanding of each method
performing increasingly more procedures in the office, the bulk of of anesthesia and the pharmacologic principles will aid the urologist
urologic surgery occurs in the operating room under monitored in making recommendations to the anesthesiologist.
anesthesia care, regional anesthesia, or general anesthesia. Current
practice in operative anesthesia employs a combination of inhala- Monitored Anesthesia Care
tional agents and intravenous medications along with analgesics (for
pain control) and benzodiazepines (for anxiolysis and amnesia). Although monitored anesthesia care is defined as conscious sedation
Of course, improved presurgical evaluation, pharmacologic drugs, under the care of an anesthesiologist in a monitored situation, it

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 Chapter 8 Principles of Urologic Surgery: Perioperative Care 131

TABLE 8.7 Patient Risk Assessment Model and

BOX 8.5 Patient-Related Factors Increasing Risk for
American Urological Association Best
Venous Thromboembolism
Practice Recommendations
• Surgery
PATIENT RISK STRATIFICATION
• Trauma (major trauma or lower extremity injury)
• Immobility, lower extremity paresis Low risk Minor surgery in patients younger than 40 yr with
• Cancer (active or occult) no additional risk factors
• Cancer therapy (hormonal, chemotherapy, angiogenesis
Moderate Minor surgery in patients with additional risk
inhibitors, radiotherapy)
risk factors
• Venous compression (tumor, hematoma, arterial abnormality)
Surgery in patients 40–60 yr with no additional
• Previous venous thromboembolism
risk factors
• Increasing age
• Pregnancy and the postpartum period High risk Surgery in patients older than 60 yr
• Estrogen-containing oral contraceptives or hormone Surgery in patients 40–60 yr with additional risk
replacement therapy factors (see Box 8.4)
• Selective estrogen receptor modulators Highest Surgery in patients with multiple risk factors (e.g.,
• Erythropoiesis-stimulating agents risk age older than 40 yr, cancer, prior venous
• Acute medical illness thromboembolism)
• Inflammatory bowel disease
• Nephrotic syndrome LEVEL
• Myeloproliferative disorders OF RISK RECOMMENDATIONS
• Paroxysmal nocturnal hemoglobinuria Low risk No prophylaxis other than early ambulation
• Obesity
Moderate Heparin 5000 units q12h SC starting after surgery
• Central venous catheterization
risk or
• Inherited or acquired thrombophilia
Enoxaparin 40 mg (for CrCl <30 mL/min, use
30 mg) SC daily
Modified from Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of
or
venous thromboembolism: American College of Chest Physicians evidence-
based clinical practice guidelines (8th edition). Chest. 2008;133(6 Pneumatic compression device if risk for bleeding
Suppl):381S–453S. is high
High risk Heparin 5000 units q12h SC starting after surgery
or
Enoxaparin 40 mg (for CrCl <30 mL/min, use
encompasses a wide range of levels of anesthesia from minimal 30 mg) SC daily
sedation to brief intervals of unconscious general anesthesia. Most or
commonly, anesthesiologists combine intravenous opioid analgesics Pneumatic compression device if risk for bleeding
and benzodiazepines to maintain a sufficient level of patient comfort
is high
and anxiolysis. Monitored anesthesia care is widely used in urology
in the ambulatory setting and is suitable for short-duration endoscopic Highest Enoxaparin 40 mg (for CrCl <30 mL/min, use
procedures, transrectal ultrasound-based procedures, and, when risk 30 mg) SC daily and adjuvant pneumatic
combined with a local anesthetic, superficial procedures of the external compression device
genitalia. Conscious sedation can be administered in the office setting, or
but only with proper monitoring of the patient during and after the Heparin 5000 units q8h SC starting after surgery
procedure. The Joint Commission has strict guidelines to ensure and adjuvant pneumatic compression device
that the patients receive the same level of monitoring as if under
the care of an anesthesiologist including a requirement for a
trained monitoring assistant, immediate access to airway and CrCl, Creatinine clearance; yr, year.
resuscitation equipment, and specific preprocedure and postpro- Modified from Forrest JB, Clemens JQ, Finamore P, et al. AUA Best Practice
cedure evaluations. Statement for the prevention of deep vein thrombosis in patients undergoing
urologic surgery. J Urol. 2009;181(3):1170–1177.

Regional Anesthesia
Regional anesthesia incorporates different levels of anesthesia directed for major abdominal procedures, thereby avoiding the adverse effects
toward the surgical site, including local anesthesia, spinal anesthesia, of high doses of intravenous opioids (i.e., respiratory depression,
and epidural anesthesia. The use of local anesthetics is typically GI dysfunction). Spinal anesthesia is suitable for most urologic
combined with monitored anesthesia care for superficial procedures endoscopic procedures and lower abdominal surgical procedures
in an isolated anatomic location. The keys to proper local anesthetic and is limited only by the duration of anesthesia required. Spinal
administration are avoidance of intravascular injection and knowledge anesthesia avoids the cardiopulmonary effects and complications
of pharmacology. The two most commonly used drugs are lidocaine of general anesthesia. Several factors affect the spinal level and efficacy
and bupivacaine, with the primary differences being the onset and of administration. In general, larger volume and increased doses
duration of action. Infiltration of local anesthetics before surgical result in longer duration and increased cephalad migration. The
incision decreases nociceptor sensitization and conduction and results addition of low-dose opioids and/or vasoconstrictors prolongs the
in decreased postoperative pain and analgesic requirements. duration of analgesia while reducing the dose of anesthetic. The
Spinal and epidural anesthesia involves injection of anesthetic anesthetic-related adverse effect is hypotension as a result of sym-
(most commonly lidocaine or bupivacaine) into the subarachnoid pathetic blockade and occurs in 10% to 40% of patients (Di Cianni
space or epidural space with direct effect on the spinal cord, resulting et al., 2008). The primary technique-related complication is
in sensory, motor, and sympathetic blockade. In urologic procedures, post–dural puncture headache (results from cerebrospinal fluid
epidural anesthesia is most useful for postoperative pain management leak) with an incidence of less than 2% with currently used

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132 PART II Basics of Urologic Surgery

29-gauge pencil-tipped needles (Turnbull and Shepherd, 2003). advantageous during induction for hypovolemic and asthmatic patients.
Overall, spinal anesthesia has become safe, with the incidence of Propofol is among the most commonly used anesthetic agents,
serious neurologic deficits being 0.05%. especially in outpatient surgery. It has a rapid onset, produces
excellent bronchodilation in patients with reactive airway disease,
General Anesthesia and, perhaps most important, is associated with smooth, nausea-free
emergence from anesthesia. Its primary adverse effect is significant
Inhalational General Anesthesia. Inhalational drug development blood pressure reduction. Midazolam, never used as a single agent,
has emphasized inhalational agents that facilitate rapid induction and produces profound amnesia and anxiolysis while having a rapid onset
emergence and are nontoxic. Two of the most important characteristics and short duration and producing minimal cardiac side effects. Although
of inhalational anesthetics are the blood/gas solubility coefficient these agents induce unconsciousness and amnesia, opioids have become
(B/G) and the minimum alveolar concentration (MAC). The B/G an integral component to all forms of anesthesia. Opioids result in
refers to the serum uptake of the inhaled agent, and the MAC is a significant analgesia without an increase in cardiac side effects. Opioids
measure of the potency of a volatile anesthetic (i.e., the serum level also results in decreased requirements of other agents when used in
required to prevent movement in response to a skin incision in 50% combination, thus reducing the overall cardiopulmonary side effects of
of patients). The various inhalational agents differ not only in the anesthesia. Opioids themselves are differentiated in their potency, onset
B/G and MAC but also in their cardiopulmonary effects. Obviously, a of action, duration of action, and metabolism and excretion. Fentanyl
basic understanding of these properties is important for the urologic (synthetic opioid) is probably the most widely used because of its
surgeon, especially during instances of surgical complication. potency (100 to 150 times that of morphine), rapid onset, and
Nitrous oxide (NO) is one of the most commonly used agents short duration of action. Newer synthetics are geared toward shorter
because of its propensity for rapid induction and emergence; however, duration and more rapid metabolism.
because of its low potency, it is often combined with other agents. For major operative cases, complete neuromuscular relaxation is
Because of NO’s high B/G and tendency to increase the volume required for sufficient exposure and successful outcome. Although
and pressure of closed spaces, its use is contraindicated in certain full relaxation can be achieved with intravenous and inhalational
clinical situations such as small bowel obstruction and pneumo- agents, the dose required is extremely high. The use of intravenous
thorax. During laparoscopic abdominal procedures, surgeons neuromuscular blockers allows for neuromuscular relaxation and
often prefer to avoid the use of NO because of resultant bowel minimization of inhalational and intravenous drugs. There are two
distention and subsequent interference in the operative field. types of neuromuscular blockers: depolarizing drugs, which
Although this effect is debated in the surgical literature, El-Galley depolarize the plasma membrane of skeletal muscle fibers, making
et al. reported significantly increased bowel distention and surgical the fibers resistant to further stimulation by acetylcholine, and
interference with NO use in patients undergoing laparoscopic donor nondepolarizing drugs, which block the binding of acetylcholine
nephrectomy (El-Galley et al., 2007). to cholinergic receptors on the presynaptic and postsynaptic
Once introduced in the 1950s, halothane rapidly became one of the membrane. Succinylcholine, the only depolarizing drug on the
most commonly used anesthetic agents because of its high potency. market, is chosen for its rapid onset (used in rapid induction
However, halothane has several important risks that have since sequences), relatively short duration (around 5 minutes), and rapid
limited its use. It has significant cardiac effects and can precipitate metabolism. Its use is limited because of the risk for malignant
failure in patients with left ventricular dysfunction. Furthermore, it hyperthermia (when used in combination with volatile inhalational
sensitizes the myocardium to the effects of catecholamines (relevant agents), hyperkalemia, and bradycardia in children. When succinyl-
for local anesthetics injected into the surgical site). Finally, there is choline is contraindicated, nondepolarizing agents are used. Several
a 1 in 35,000 incidence of fulminant hepatitis, which can be lethal nondepolarizing drugs are available and differ in routes of metabolism
as a result of overaccumulation of toxic metabolites. More recent and adverse effects. Furthermore, multiple medications including
advancements in inhalational agents have focused on reduction in desflurane can alter the metabolism of these drugs and potentiate
toxicity while maintaining the potency and rapidity of halothane. their actions. The most important consideration in the use of
Three of the most commonly used current agents are isoflurane, neuromuscular blockers is the assessment of adequate return of
sevoflurane, and desflurane. Isoflurane, less expensive than the other neuromuscular function after withdrawal of the drug.
agents because of the availability of generic equivalents, is widely The most common complication of neuromuscular-blocking drugs
used as a result of its low cardiac depression, lower myocardial is inadequate reversal resulting in respiratory failure and reintubation.
sensitization to catecholamines, and minimal metabolism. The Numerous reports in the literature correlate residual neuromuscular
primary unique toxicity is a variable response to tachycardia, which blockade with increased postoperative pulmonary complications in
can lead to significantly increased myocardial oxygen consumption. the postanesthesia care unit (PACU) and in the postoperative period.
Unlike isoflurane, which has a putrid odor, sevoflurane is often used The concept of train-of-four fade ratio (TOF) was developed to
for inhalation induction (odorless) because of its rapid induction and devise an objective measure of adequate neuromuscular function.
emergence, decreased incidence of postoperative nausea (important This concept refers to the magnitude of the fourth of four twitches
in outpatient surgery), and minimal cardiac toxicity. It is, in general, in response to maximal stimuli to the ulnar nerve delivered at
the preferred agent for difficult airways requiring mask induction 0.5-second intervals. Historically, a TOF of 0.7 (meaning that the
and in patients with severe bronchospastic disease. Desflurane, like fourth twitch was 70% the magnitude of the first twitch) correlated
isoflurane, has a pungent odor and is not used for inhalational with adequate return of neuromuscular function; however, more
induction. Its primary advantage over isoflurane is a more rapid recent standards have raised the threshold to 0.9 as an indicator of
recovery in patients requiring anesthesia for more than 3 hours. complete return of neuromuscular function (Kopman et al., 1997).
Intravenous General Anesthesia. Intravenous anesthesia consists Currently, anesthesiologists use several clinical assessments including
of a combination of induction agent, opioid, and neuromuscular head lift, tongue depressor test, and hand grip to estimate a TOF of
relaxant. Anesthesiologists often prefer intravenous induction with a 0.9. A recent study revealed that with use of clinical assessments alone,
combination of inhalational and intravenous agents for maintenance 16% and 45% of patients 2 hours after a single intubating dose of
of anesthesia. Intravenous induction offers several advantages in that neuromuscular blocker had a TOF of less than 0.7 and less than 0.9,
it is rapid, minimizes patient discomfort, and is preferred by children respectively, in the PACU (Debaene et al., 2003). As such, quantitative
and most adults. Thiopental, the oldest and least expensive agent, is TOF measurement (acceleromyography) should be combined with
a suitable choice for uncomplicated situations but is limited in more clinical assessments before extubation in the operating room.
complex cases because of its significant vasodilation, cardiac depression,
and risk for bronchospasm, especially in patients with reactive airway Skin Preparation
disease. Ketamine is a preferred choice for procedures that are brief and
superficial because of its profound amnesia and somatic analgesia. It Sterile skin preparation is fundamental in the prevention of SSI for
is associated with increased arteriolar and bronchomotor tone and is any procedure. Currently the most commonly used skin antiseptics are

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 Chapter 8 Principles of Urologic Surgery: Perioperative Care 133

alcohol, povidone-iodine, or chlorhexidine based. Whichever antiseptic There are well-documented risks associated with blood transfusion,
is chosen, the solution should be applied in concentric circles from and these risks should always be discussed with the patient before
the center of the surgical site and allowed to dry before incision. The administration. Hemolytic transfusion reactions occur as a result of
Cochrane Wound Study group recently published their updated incompatibility between donor and recipient (either ABO or non-ABO
analysis on various preoperative skin preparations. The authors incompatibility). Transfusion reactions occur relatively frequently
found some evidence that preoperative skin preparation with 0.5% and, if identified early, can be treated with rare catastrophic events.
chlorhexidine in methylated spirits was associated with lower rates The early signs and symptoms include fever, chills, chest pain,
of SSI after clean surgery than alcohol-based povidone iodine hypotension, and bleeding diathesis occurring during or immediately
paint but were unable to report conclusive evidence of superior after transfusion. Reactions may also occur in a delayed fashion,
efficacy of one particular skin preparation (Dumville et al., 2013). characterized by significant intravascular hemolysis secondary to
Furthermore, although the CDC clearly recommends preoperative recipient antibodies. The treatment of transfusion reaction is centered
showering or bathing to reduce SSI, there is no evidence that bathing on fluid resuscitation, cessation of the transfusion, and alkalinization
with an antiseptic solution reduces the rate of infection (Webster of the urine to prevent renal failure. The most common cause of
and Osborne, 2015). Regarding hair removal, the CDC recommends transfusion-related fatality is transfusion-related acute lung injury
that if hair removal is performed, it should be performed immediately (TRALI). This entity accounted for 55% of transfusion mortality
before the surgical procedure and performed with clippers (rather than from 2005 to 2007. The injury is characterized by noncardiogenic
shaving) to avoid breakage in the continuity of the integument and pulmonary edema and manifests 1 to 2 hours after transfusion.
the resulting bacterial colonization (Mangram et al., 1999). Although no specific treatment other than supportive measures is
indicated, most patients recover without significant sequelae.
Transfusion Considerations Finally, one of the most feared complications (at least in the public
eye) is the transmission of bacterial or viral infection. Although the
Given the vascular nature of urologic organs, the urologist often risk for hepatitis virus and human immunodeficiency virus (HIV)
confronts the issue of blood loss in the perioperative period. Therefore, transmission was unacceptably high in the 1970s and 1980s, the
it is imperative that the urologist understand the implications and initiation of more stringent screening procedures for high-risk
risks associated with blood product transfusion. Additionally, the populations and the development of nucleic acid amplification
urologist should be familiar with transfusion alternatives for patients technology (polymerase chain reaction [PCR] and transcription-
who will not accept blood transfusions, such as Jehovah’s Witnesses. mediated amplification) have resulted in dramatically reduced risk
Before the acquired immunodeficiency syndrome (AIDS) epidemic, and incidence of viral transmission. Currently, the risk for HIV and
blood transfusion was liberally administered, often for any patient hepatitis C transmission is approximately 1 in 2 million cases,
with a hematocrit less than 30%. However, fear and concern about whereas the risk for hepatitis B transmission is 1 in 200,000.
the infectious risk led to the convening of a National Institutes of The highest risk for infectivity occurs with platelet transfusion, in
Health (NIH) panel to develop consensus recommendations for the which bacterial contamination develops at a rate of 1 in 5000 units
indication of blood product transfusion (National Institutes of Health, (Eder et al., 2007).
1988). The principles in these guidelines are reflected by the ASA Given the proximity of major vascular structures to several geni-
practice guidelines issued in 2006 (American Society of Anesthesiolo- tourinary organs, occasionally the urologist is faced with a clinical
gists Task Force on Perioperative Blood Transfusion and Adjuvant situation in which a large-volume blood loss occurs, although very
Therapies, 2006). To summarize, the guidelines indicate that high–blood loss procedures in urology are uncommon. Traditionally,
transfusion is rarely indicated with hematocrit greater than 30% component transfusion would not begin until more than 6 units
and often indicated for a hematocrit less than 21%. For levels of PRBCs had been given to the patient. More recently, evidence
between 21% and 30%, clinical factors such as risk for complica- from the trauma literature supports the use of an increased ratio
tions from inadequate oxygenation should guide the need for of platelets to FFP to red blood cells (RBCs)—that is, massive
transfusion, balancing the risks and benefits. In general, patients transfusion protocol. The protocol is triggered in the anticipation
with relatively minor comorbidities can tolerate hematocrit of greater of greater than 10 units of PRBCs per 24 hours and mobilizes blood
than 21%. Patients with moderate to severe comorbidity (e.g., sig- bank and hospital resources to provide an adequate supply of RBCs
nificant pulmonary compromise, coronary artery disease, or vascular and component transfusion. A study from Ball et al. demonstrated
insufficiency, or with signs or symptoms of hypovolemic, hemorrhagic improved abdominal wall closure rates among patients with high-
shock) may not tolerate a hematocrit less than 30%. Ultimately, grade liver injuries when a massive transfusion protocol was used
until technology is available to directly measure inadequate oxygen- (Ball et al., 2013).
carrying capacity, the urologist should individualize each patient’s Several management strategies and transfusion alternatives are
management based on the clinical situation. available for the management of patients with religious or other
A major advancement in blood banking and product transfusion obligations not to accept blood transfusion. Contrary to popular
has been the development of component therapy allowing for beliefs, Jehovah’s Witnesses’ refusal of blood transfusion does
administration of specific fractions of whole blood. Packed red blood not indicate or translate to refusal of medical care. Importantly,
cells (PRBCs) are equivalent to whole blood minus the plasma they have respect for life and seek the best (bloodless) medical
component. Whereas the hematocrit in whole blood is 40%, it is and surgical care available. Although all will not accept the four
70% in PRBC units. These units are reconstituted and administered major blood components (RBCs, white blood cells, platelets, and
with crystalloid. Given the lack of the remaining components, in plasma), some may accept minor blood fractions such as albumin,
instances of massive PRBC transfusions and associated bleeding, immunoglobulins, and clotting factors. A detailed discussion should
platelets and occasionally fresh frozen plasma (FFP) are given to be held with the patient, in conjunction with the anesthesiologist,
avoid dilutional coagulopathy. Platelet transfusion is rarely given to determine what is acceptable and what is not before initiating
empirically except in patients with significant thrombocytopenia treatment. In the surgical patient, acceptable strategies include the
(<50,000/mm3) and a planned surgical procedure or with moderate use of electrocautery, cell salvage, intraoperative hemodilution,
thrombocytopenia (50,000 to 100,000/mm3) and either a high-risk high-dose erythropoietin, and iron. Major surgical procedures have
procedure or evidence of platelet dysfunction. Similarly, empirical been performed with success without the use of blood transfusion,
transfusion with FFP for massive transfusion is not standard practice. and some studies indicate that patients managed without blood had
The current indications for FFP transfusion are immediate reversal better outcome compared with those who received blood transfu-
of warfarin-induced coagulopathy, replacement in patients with sion. Although there is currently no substitute for blood transfusion,
specific clotting factor deficiencies, and evidence of bleeding and several hemoglobin-based blood substitutes have been evaluated in
INR greater than 1.5. According to ASA guidelines, in patients various trials, but translation into routine clinical practice has been
with massive transfusion and no INR readily available, FFP should hindered by side effects or complications resulting from their use
be given after replacement of 1 blood volume. (Natanson et al., 2008).

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134 PART II Basics of Urologic Surgery

Pain Management minimizing the CNS and GI adverse effects of intravenous opioid
medications. Block et al. performed a meta-analysis of randomized
Equally important to intraoperative anesthetic considerations, proper trials to review the efficacy and concluded that epidural analgesia,
pain management after surgery is crucial to minimizing postoperative regardless of agent or location of catheter placement, provided better
complications and delayed recovery. Untreated acute pain not only pain control than parenteral opioids (Block et al., 2003). In fact, a
is unacceptable for the patient, but also may increase the risk for recent review of RCTs found that in patients undergoing general
complications by causing increased physiologic stress in the anesthesia, the use of concomitant epidural analgesia resulted in
recovery period. The neural process, referred to as nociception, involves decreased perioperative mortality and improved comorbidity end
signal transduction from noxious stimuli via sensory afferent nerves points across multiple organ systems (Pöpping et al., 2014).
to the spinal cord and cerebral cortex, resulting in the perception
of pain. Analgesia aims to block the pain sensation along various
points of this signal transduction pathway. KEY POINTS
Opioids are perhaps the most commonly used analgesic medications • Proper preoperative evaluation of the patient will prevent
in the immediate postoperative period. These drugs primarily act in the unanticipated cancellations and decrease the risk for
central nervous system (CNS) at both the dorsal root ganglion and the postoperative complications.
cerebral cortex to modulate the perception of pain. Administration can • The indications for preoperative cardiac testing depend on
be oral, intravenous, neuraxial, or transdermal. In general, the choice of three groups of factors: the functional capacity of the
route of administration is dependent on the patient’s severity of pain patient, cardiac risk factors, and surgery-specific risk
and ability to take oral medications. Although typically very effective for factors.
providing analgesia, opioids can cause decreased GI activity resulting in • SSIs are one of the leading causes of perioperative
ileus, respiratory depression, sedation, and mental confusion. Weaker complications and increased hospital stay. Antibiotic
(less potent) opioids such as hydrocodone and codeine may minimize prophylaxis is indicated in virtually all surgical procedures.
these adverse effects but are often combined with acetaminophen and • VTE is a common complication of urologic procedures,
should be used with caution in patients with hepatic insufficiency. and the AUA recommends either mechanical or
Additionally, opioid (mis)use has resulted in addiction and opioids pharmacologic prophylaxis (or both for patients at highest
epidemics in the United States (Jalal et al., 2018). risk) for all urologic procedures.
Physicians have a tremendous role to play in curbing the opioid • Proper understanding of the pharmacologic principles of
crisis currently plaguing the United States (Waljee et al., 2017). In anesthesia will allow the urologist to actively participate in
an effort to improve pain control and thus quality of care, advanced the decision-making process of choosing which mode of
practice providers and surgeons often prescribe large amounts of anesthesia will be appropriate for a particular patient and
narcotics, the majority of which are not used by the patients, and procedure.
this contributes to dispersion of opioids into the community, misuse, • Current guidelines advocate blood product transfusion for
abuse, and addiction (Lee et al., 2017; Theisen et al., 2018a, 2018b; a hematocrit less than 21% in most patients unless there
Fujii et al., 2018; Cron et al., 2018). To underscore the significance are specific cardiopulmonary risk factors.
of opioid overprescription, new persistent opioid use in patients • Perioperative hypothermia of even 1°C to 2°C is
undergoing minor and major surgeries has been reported to be up to associated with increased estimated blood loss and
5.9% and 6.5%, respectively (Brummett et al., 2017). Thus, there are increased risk for SSI.
ongoing efforts to evaluate the judicious use of narcotic pain medicines
in patients undergoing urologic surgery. For kidney stone management,
for example, a recent analysis of 22,609 patients demonstrated a wide ACKNOWLEDGMENTS
variation in opioid-prescribing patterns (Leapman et al., 2018). In a
retrospective analysis of 104 patients undergoing ureteroscopy, 10% Thanks to Manish A. Vira, MD, and Joph Steckel, MD, FACS, who
(5/52) of patients managed initially without narcotics and 17% (9/52) wrote the previous version of this chapter.
of patients managed initially with narcotics but sought additional
medical care because of inadequate pain control, suggesting that
patients undergoing ureteroscopy can be safely managed without SUGGESTED READINGS
narcotic pain pills (Large et al., 2018). Ongoing studies at various American Society of Anesthesiologists Task Force on Perioperative Blood
institutions will provide insight into the judicious use of narcotic Transfusion and Adjuvant Therapies: Practice guidelines for perioperative
analgesia after urologic surgeries. blood transfusion and adjuvant therapies: an updated report by the American
Nonsteroidal anti-inflammatory drugs (NSAIDs) are being Society of Anesthesiologists Task Force on Perioperative Blood Transfusion
employed in the postoperative setting more frequently now to avoid and Adjuvant Therapies, Anesthesiology 105(1):198–208, 2006.
Brennan TA, Leape LL, Laird NM, et al: Incidence of adverse events and
the unwanted effects of opioids. These medications act by inhibition negligence in hospitalized patients. Results of the Harvard Medical Practice
of cyclooxygenase enzyme activity, resulting in decreased prostaglandin Study I, N Engl J Med 324(6):370–376, 1991.
production. Prostaglandins are the primary mediators of nociceptor Douketis JD, Berger PB, Dunn AS, et al: The perioperative management of
activation at the tissue level. Multiple studies have demonstrated antithrombotic therapy: American College of Chest Physicians evidence-based
that the appropriate use of NSAIDs can result in decreased use clinical practice guidelines (8th edition), Chest 133(6 Suppl):299S–339S, 2008.
of opioid analgesics and decreased nausea and vomiting after Eagle KA, Berger PB, Calkins H, et al: ACC/AHA guideline update for periopera-
anesthesia (Rawlinson et al., 2012). In a randomized study of patients tive cardiovascular evaluation for noncardiac surgery—executive summary:
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ketorolac was associated with improved pain scores and reduced Task Force on Practice Guidelines (Committee to Update the 1996
Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac
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well tolerated but should be avoided in patients with renal insuf- Geerts WH, Bergqvist D, Pineo GF, et al: Prevention of venous thromboem-
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For major abdominal surgery in which prolonged opioid use is Wolf JS Jr, Bennett CJ, Dmochowski RR, et al: Best practice policy statement
expected, neuraxial analgesia (i.e., epidural) can provide significant on urologic surgery antimicrobial prophylaxis, J Urol 179(4):1379–1390,
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anesthetic medications are infused in the epidural space via catheter and
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 Chapter 8 Principles of Urologic Surgery: Perioperative Care 134.e1

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 Chapter 8 Principles of Urologic Surgery: Perioperative Care 134.e3

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