Pre-op

Page updated Winter 2021.
DisclaimerMedicine is an ever-changing science.  We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable resources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original resources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.

Pre-op checklist

Patient Evaluation

Primary problem evaluation

Stroke risk assessment

Cardiac evaluation

Pulmonary evaluation

Other systems evaluation

Frailty assessment

Social needs assessment

Support person 

Pregnancy test

Urine analysis and culture

Other tests

Imaging

Consulting Patient

Risks and benefits

Goals and expectations

Pre-op education

Stop smoking: at least 4 weeks before surgery

Stop alcohol drinking:  at least 4 weeks before surgery

Addressing alcohol and drug issues

Nutrition support, if needed

Pre-operative fasting

Pre-op Carb loading

Bowel preparations, if needed

Order Sets, Communications and Paperwork 

OR scheduler communication- book OR case.

Procedure specific orders- put OR case order. 

Admission center - bed request: if pre-op admission

Admission orders: if pre-op admission

Informing OR:  in case of emergency         

History and physical exam   

Consent

Procedure

Blood Transfusion

Advance care planning

Anesthesia communication- for:

The transversus abdominis plane (TAPblock

Epidural analgesia 

Pre-op Medications 

Pre-op prophylactic antibiotics 

Anticoagulation management

Diabetic medications management

Steroids management

Other medications management

Procedure specific medication


Antibiotic Prophylaxis

Open, Laparoscopic or Robotic Surgery

Not required

Circumcision

Penile biopsy

Cefazolin (Ancef)Single dose

Inguinal and scrotal cases

Penile surgery

Urethroplasty

Renal surgery

Partial cystectomy

Prostatectomy

Involving small intestine

Unasyn or Cefoxitin or Cefotetan -Single dose


Involving large bowel

Vaginal surgery

Urethral sling procedures

Implanted prosthetic devices 

Unasyn <24 hours

Inflatable Penile Prosthesis

Artificial Urinary Sphincter

Sacral Neuromodulator

Endoscopic Procedures

None

Antimicrobial prophylaxis is not recommended for routine cystoscopy or for urodynamic studies in healthy adults in the absence of infectious signs and symptoms.


Augmentin- Single dose

Cystoscopy


Cefazolin  

Percutaneous renal surgery <24 hours

UreteroscopySingle dose

TURP, TURBT, laser enucleative and ablative proceduresSingle dose

Radical Cystectomy

Agent as above guideline

For 24 hours

Percutaneous Procedures

Cefazolin Single dose

Prostate brachytherapy or cryotherapy


Ciprofloxacin (Cipro)- Single dose

Transrectal prostate biopsy

Shock-wave lithotripsy

None

Shock wave lithotripsy does not require antimicrobial prophylaxis if the pre-procedural urine microscopy is negative for infection.

Cefazolin Single dose

Lengthy procedure

Antimicrobial prophylaxis should be stopped after wound closure and case completion, even in the presence of a drain.


Catheter removal

Fluoroquinolone

Antimicrobial prophylaxis for about 24 hours may be considered at the time of clinical procedures such as trials of voiding, or removal of catheter or drain tubing, or stent or nephrostomy tube, especially when other patient and procedural risk factors are present.


Antibiotic Prophylaxis- Indwelling Orthopedic Hardware

Not recommended 

Total joint inserted >2 yr ago

Pins, plates, screws

Ampi + Genta

Ampicillin 2 g IV 

gentamicin- 1.5 mg/kg IV

Total joint inserted  <2 yr ago 

Aberrant host factor(s)

Endocarditis Prophylaxis

GU and GI procedures

Not recommended 

Respiratory tract or infected skin

Reasonable only for patients with prosthetic cardiac valve, previous IE, congenital heart disease, cardiac transplantation.

Options: Cover Enterococci with:

Ampicillin  2 g IM or IV

Vancomycin - If cannot to
Elective Surgery in Patients with Previous Coronary Intervention

Elective urologic surgery should be delayed for 14 days after coronary balloon angioplasty, 30 days after bare metal stent implantation, and one year after drug-eluting stent implantation.

Elective urologic surgery may be considered after 180 days in patients with drug-eluting stent implantation if the risk of surgical delay is greater than the risk of cardiac ischemia and stent thrombosis.

Pre-operative Carotid Artery Revascularization

Patients with symptomatic, high-grade carotid artery stenosis (>70 percent stenosis) should have carotid artery stenting or endarterectomy prior to elective urologic surgery. 

Previous Venous thromboembolism

Delayed the surgery for at least one month, and if possible three months, to permit discontinuation of anticoagulation pre-operatively.

Fasting
Clear liquids, not including alcohol, may be ingested up to two hours prior to surgery.

Preoperative oral carbohydrate can be administered safely except in patients with documented delayed gastric emptying or gastrointestinal motility disorders and as well in patients undergoing emergency surgery.

Preoperative oral carbohydrate loading should be administered to all non-diabetic patients before radical cystectomy. 

In diabetic patients, carbohydrate treatment can be given along with the diabetic medication.

500 mL of clear apple juice or cranberry cocktail 2 to 3 hours prior to surgery may  be helpful.

Light meal is allowed up to six hours prior to surgery.

No fried, fatty foods or meat >eight hours prior to surgery.

Bowel Prep

No bowel prep is needed for small intestine surgeries.

Bowel prep is given for large intestine surgeries.

Mechanical Bowel Prep combined with preoperative oral antibiotics is typically recommended for elective colorectal resections.

GoLYTELY

Reconstitute GoLYTELY powder with water before its use.

Drink at a rate of 240 mL (8 oz.) every 10 minutes, until 1 gallon is consumed or rectal effluent is clear. 

For nasogastric tube, rate is 1.2 to 1.8 liters per hour

Antibiotic prep

The oral antimicrobial should be given as three doses over approximately 10 hours the afternoon and evening before the operation and after the mechanical bowel prep.

The following oral antibiotic prep prior to colon surgery has been well studied and found to be effective and well tolerated:

Neomycin: 1 g oral  given at 2 pm, 3 pm, and 10 pm

Erythromycin base:1 g given at 2 pm, 3 pm, and 10 pm

Metronidazole: 500 mg may be substituted for erythromycin for better tolerability

 IV prophylaxis

As mentioned on antibiotic prophylaxis section.

Pre-op Medications Management

Cardiovascular Medications:

B- Blockers: Continue them

Alpha 2 agonists: Clonidine: Continue them

Calcium Channel Blockers: Continue them

ACE Inhibitors:

Withhold them in most cases on the morning of the surgery.

Resume them as soon as possible postoperatively.

If patient has heart failure or poorly controlled blood pressure, you may want to continue them. In that situation, decision should be made together with anesthesiology department. 

Angiotensin II receptor blockers: Same as ACE Inhibitors.

Diuretics:

Hold it on the morning of the surgery if it is used for hypertension or well controlled heart failure.

You may need to continue it in patients with heart failure and history of difficult to control fluid balance.  Watch potassium carefully in these patients.

Non-statin hypolipidemic agents: Discontinue them.

Statins: Continue them.

Digoxin: Continue it.

Pulmonary Medications:

B agonists: Continue them.

Anticholinergics: Continue them.

Theophylline: Discontinue them the evening before surgery.

Inhaled Glucocorticoids: Continue them.

Might need stress dose corticosteroid. See steroid section.

Systemic Glucocorticoids:

Continue them.

Might need stress dose corticosteroid. See steroid section.

Leukotriene inhibitors: Continue them.

Gastrointestinal Medications

H2 blockers: Continue them.

Proton Pump Inhibitors: Continue them.

Endocrine Medications

Oral contraceptives:

Discontinue them 4 weeks before surgery in patients or procedures that are associated with higher risk for Venous thromboembolism.

Postmenopausal hormones:

Discontinue them 4 weeks before surgery for procedures that are associated with higher risk for Venous thromboembolism.

Tamoxifen:

Discontinue them 2 weeks before surgery for procedures that are associated with higher risk for Venous thromboembolism. 

If patient is taking it for breast cancer treatment, you might need to continue it and put the patient on appropriate venous thrombosis prophylaxis. Oncology consult is advised.

Raloxifene

Discontinue it 3 days before surgery for procedures that are associated with higher risk for Venous thromboembolism. It should be stopped no matter what the purpose of use is.

Hyperthyroidism medications: Continue them.

Hypothyroid medications: Continue them.

Bisphosphonates: Withhold them on the morning of the surgery.

NSAIDS

Discontinue them at least 3 days before surgery.

Ibuprofen can be stopped 24 hours before surgery.

Psychotropic Agents

Tricyclics

FDA advises that tricyclics be discontinued when possible. They should be tapered over 7-14 days before surgery.

SSRIs

Should be discontinued if patient needs antiplatelets or if patient is undergoing a procedure in which bleeding might cause significant morbidity like central nervous system procedures.

If we plan to discontinue it, it should be tapered off over several weeks before surgery.

Bupropion: Similar to SSRIs.

MAO inhibitors

Discontinue  unless anesthesia is comfortable with MAO safe protocol.

Lithium 

To be continued. Watch water and electrolyte perioperatively. Check thyroid function tests preoperatively.

Valproate: To be continued.

Antipsychotics: Should be discontinued in prolong QT interval.
 
Antianxiety medications: To be continued.

Psychostimulants: To be withheld on the day of surgery.

Naltrexone: Should be discontinued.

Neurologic Medications

Seizure  medications: To be continued.

Parkinson's medications: Should be continued. 

Migraine meds: Discontinue sumatriptan and similar 1 day before surgery.

Gout Medications

Colchicine: To be withheld on the day of surgery.

Allopurinol: Can be continued.

BPH Medications

To be continued unless patient is undergoing cataract surgery. Decision will be made by eye surgeon in the latter situation. 

Erectile Dysfunction Treatment

Hold Phosphodiesterase Type 5 Inhibitors 3 days before surgery.


Pre- op Anticoagulation Management

Medications List:

Aspirin- antiplatelet

Clopidogrel (Plavix)- antiplatelet

Unfractionated heparin

Low molecular weight heparin: Enoxaparin (Lovenox),Dalteparin (Fragmin)

Warfarin (Coumadin)

Dabigatran (PRADAXA)-  thrombin inhibitor

Apixaban (Eliquis)- factor Xa inhibitor

Rivaroxaban (Xarelto)- factor Xa inhibitor

Myocardial Infarction Preventions

Low-dose aspirin can be continued in perioperative period.

Stroke Prevention

If patient is on Clopidogrel or aspirin for secondary stroke prevention, continue aspirin.

After Cardiac Stent placement

Do not withdraw dual antiplatelet therapy within 12 months of drug eluding stent placement or within 3 months of bare metal stent placement.

Non-valvular Atrial Fibrillation

Warfarin would be stopped 5 days before the surgical procedure. 

Warfarin should be restarted 12 to 24 hours after surgery if the bleeding risk is acceptable.

Apixaban, dabigatran, or rivaroxaban, would be discontinued 2 to 5 days before elective surgery.

Rivaroxaban needs bridging with some other anticoagulant such as heparin.

For bridging indication, refer to bridging section.

Mechanical valves

After stopping warfarin, bridging anticoagulation with unfractionated heparin or low molecular weight heparin is recommended.

Bridging 

Indications:

Mechanical valves

Atrial fibrillation with very high risk of stroke

Venous thromboembolism within the previous 12 weeks

Recent coronary stenting

Previous thromboembolism during interruption of chronic anticoagulation

Bridging Procedure:

Unfractionated heparin should be started when the INR falls < 2.0 (usually 48 hours before surgery).

Heparin dose  needs to be adjusted to achieve an activated PTT 2-3 times the control. 

Unfractionated heparin is stopped 4-6 hours before the procedure.

Unfractionated heparin needs to be restarted as early after surgery as bleeding stability allows.

Warfarin needs to be resumed as soon as possible postoperatively.

Unfractionated heparin is continued until the INR is in the therapeutic range for at least 48 hours.

Special Circumstances:

Shock wave lithotripsy

Anticoagulants and antiplatelet should be discontinued prior to SWL.

Percutaneous nephrolithotomy

Anticoagulants and antiplatelet should be discontinued prior to PCNL.

Ureteroscopy

No need to stop anticoagulants and antiplatelet. 

Transurethral Resection of the Prostate

If patient needs anticoagulants and antiplatelet, alternative treatment of the bladder outlet, like laser prostate surgery may be preferable. 

Prostate biopsy

Prostate biopsy can be performed if patient needs to stay on low dose aspirin or anticoagulant. There would be increased risk of minor bleeding. 

Preop Diabetes Medications

On Insulin

Long procedures 

Start IV insulin

Should be started early morning before surgery.

Short procedures

Insulin pump

Continue with usual basal infusion rate.

Subcutaneous injections- When breakfast and possibly lunch are missed:

On short and rapid acting agents:

Avoid morning dose of Regular, Lispro, Aspart, and Glulisine.

On two types of insulin only in the morning:

Give1/2 to 2/3 of total morning insulin as  long or intermediate acting insulin.

On two types of insulin two or more times a day:

Give 1/3 to 1/2 of total morning insulin as long or intermediate acting  insulin.

Give supplement short or rapid acting insulin if patient develops hyperglycemia.

D5W or D5 1/2NS

Start it at the rate of 75-125 cc/hr

Blood Sugar Check

Every hour. Should be done more frequently if BS< 100.

On Oral Medications or Noninsulin Injectables For Type II Diabetes

Hold them on the morning of the surgery.

In case of hyperglycemia, give subcutaneous short or rapid acting insulin.

Schedule subcutaneous insulin for post-op, until patient resumes eating.

Most of these medications can be restarted when patient starts eating.

Metformin should be delayed until you are sure renal function is OK. 

Corticosteroids management

Non-suppressed axis:

If steroid was used for less than 3 weeks.

If patient use 5 mg or less of prednisone or its equivalent.

Just continue patient's own dose.

Suppressed axis:

Prescribed glucocorticoid therapy (prednisolone ≥ 5 mg per day in adults across all routes of administration (oral, inhaled, topical, intranasal, intra‐articular), or standard dose inhaled glucocorticoids can be associated with inadequate adrenal cortisol reserve in a significant number of patients.

Minor surgery:

Morning dose only

Moderate Surgery:

Morning dose plus:

Additional Hydrocortisone:

50 mg, IV, before incision. Then 25 mg, IV, q8 hr.

Major surgery:

Morning dose plus:

Additional Hydrocortisone:

100 mg, IV, before incision. Then, 50 mg, IV, q8 hr

Then, taper by half per day to reach maintenance dose.

Fungal Prophylaxis

Asymptomatic Funguria:

Treatment or prophylaxis is not needed for:

Urinary catheter, nephrostomy or stent placement or exchange.

Prior to a low-risk urologic surgical procedure in otherwise low-risk patient.

Single-dose antifungal prophylaxis:

Prior to endoscopic, robotic, or open surgery on the urinary tract.

Longer course of periprocedural antifungal treatment:

Neutropenic patients

Symptomatic Fungal Urinary Tract Infections

Needs Antifungal treatment.

Refer to Urinary Tract Infection for policies.

Refer to other medications for doses.

Fungus Ball

Needs periprocedural antifungal treatment based on  sensitivities.

Five to seven days before and after the procedure. 

A shorter duration may be reasonable in cases of an immunocompetent host where the obstruction has been completely relieved. 

A longer course may be considered if part of fungus ball persists, and/or if repeated procedures are needed.