John Thomas Stoffel, MD, presented “Optimizing Urologic Surgical Outcomes: AUA Pre-operative White Paper Recommendations” during the 41st Annual Ralph E. Hopkins Urology Seminar on February 3, 2022, in Jackson Hole, Wyoming.
How to cite: Stoffel, John Thomas. “Optimizing Urologic Surgical Outcomes: AUA Pre-operative White Paper Recommendations” February 3, 2022. Accessed Apr 2024. https://grandroundsinurology.com/aua-urethral-stricture-guideline-review/
Optimizing Urologic Surgical Outcomes: AUA Pre-operative White Paper Recommendations
John Thomas Stoffel, MD, Associate Professor of Urology and Chief of the Division of Neurourology and Pelvic Reconstruction within the University of Michigan Department of Urology in Ann Arbor, Michigan, outlines the purpose of the AUA quality improvement and patient safety recommendations to serve as a standardized reference for urologists as they seek to optimize patient readiness for, and success after, surgery. The guidelines are broken down according to preoperative, intraoperative, and postoperative recommendations. Dr. Stoffel focuses on the preoperative aspects. He outlines the methodology involved in the creation of the recommendations, defines preoperative care, and then lists four areas of focus for preoperative readiness: functional status and cognitive status; cardiac, pulmonary, vascular; endocrine and gastrointestinal (GI); and preoperative rehabilitation. He equates functional status with frailty and explains that frail patients are at greater risk for myriad effects postoperatively. Dr. Stoffel outlines questions that urologists can consider with regard to frailty, such as those around weight loss, exhaustion, weakness, slow walking speed, and low physical activity. Dr. Stoffel then addresses cognition, explaining that cognition impairment impacts 22 percent of adults over age 71, and cites data that show patients with greater cognitive impairment have an increased incidence of one or more postoperative complications and patients with dementia are at four times greater risk of death after major surgery. Dr. Stoffel moves on to pulmonary assessment and highlights medical and surgical risk factors (e.g., pulmonary obstructive sleep apnea [OSA]). Dr. Stoffel explains that everyone needs a cardiac risk assessment before surgery. While not good for risk stratification, he advises a 12-lead electrocardiogram (EKG) for patients with coronary artery disease, cardiac arrhythmia, peripheral arterial disease, cerebrovascular disease, or other significant structural heart disease and explains that it’s good to compare preoperative baseline to any postoperative changes. Dr. Stoffel explains that risk of major adverse cardiac events (MACE) determines cardiac risk stratification. He references a National Surgical Quality Improvement Program (NSQIP) risk calculator and explains that patients with low risk of MACE need no further cardiac work up while those with elevated risk should be referred to a cardiologist. Dr. Stoffel addresses anticoagulation, explaining which patients should not stop anticoagulation therapy before turning to atrial fibrillation and then to diabetes, which he calls a tremendously impactful risk factor. He advises that HbA1c be measured before surgery and cites a UK recommendation to cancel elective surgery for blood sugar >400; he also advises scheduling surgery early in the day. Dr. Stoffel discusses whether steroid treatments should be stopped before surgery then explains that bowel preps are not recommended for cystectomy. Finally, Dr. Stoffel turns to prehabilitation, focusing on modifiable risk factors such as smoking cessation and diet. He concludes by emphasizing that preoperative care requires a team approach and a urologist’s goal should be to identify the patient groups in need of further evaluation. Dr. Stoffel references the AUA Optimizing Surgical Outcomes White Paper Series and explains that intraoperative safety and postoperative care will cross-thread with these preoperative efforts.
About The 41st Annual Ralph E. Hopkins Urology Seminar:
The Ralph E. Hopkins Urology Seminar is a multi-day meeting focused on training urologists in the latest in assessing, diagnosing, and treating urologic conditions in the clinical setting. Updates are provided on urologic cancers, stone disease, urologic reconstruction, female urology, infertility, emerging surgical techniques, and general urology. Dr. Stoffel presented this lecture during the 41st iteration of the meeting on February 3rd, 2022 in Jackson Hole, Wyoming.
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