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Perioperative Care of the Surgical Patient: Genitourinary Cancers
Introduction
Good perioperative planning, which begins at the time the decision is made to perform surgery and continues through the postoperative recovery phase after discharge, is crucial to achieving successful outcomes in urological cancer surgery. Improvements in surgical technology and technique paired with enhanced recovery and perioperative optimization programs have been shown to reduce patient morbidity and mortality following major urological surgery.
Common urological malignancies and surgical management options are outlined in Table 26.1 . Frequent endoscopic procedures are common in the treatment of bladder cancer; however, owing to the aging population that this condition affects, perioperative morbidity can be misleadingly high. Patients at risk of anesthetic and surgical complications can be identified via predictive indices, such as the Charlson Comorbidity Index (CCI), patient Eastern Cooperative Oncology Group (ECOG) status, and American Society of Anesthesiology (ASA) scores. Early identification of common issues, such as anticoagulation, diabetic control, and pain management needs, allows for adequate preparation and better control when issues arise.
The practice landscape in urological cancer surgery has changed dramatically over the last 15 years, where a significant rise in the adoption of minimally invasive approaches has been seen. , This has resulted in a change in the nature of complications following major urological cancer surgery. Radical prostatectomy (RP) was previously considered a procedure that carried significant morbidity and risks, whereas most centers that practice robotic RP now only require their patients to have overnight admissions. Radical cystectomy (RC), on the other hand, has surpassed RP as having the highest surgical complication rate. This has led to a strong body of research looking at the impact of Enhanced Recovery After Surgery (ERAS) protocols in RC surgery. ,
Perioperative Assessment and Optimization
Perioperative assessment commences the moment surgical intervention for treatment of the given malignancy is proposed. This is initiated by the urologist or other treating clinician upon meeting the patient, however, can quickly expand to include a much larger multidisciplinary team. Establishing fitness for surgery is a complex and multifactorial decision that can be made within moments in some instances or take months in others. In the first instance, a thorough history of the presenting complaint, past medical history, and medications, as well as physical examination, are essential.
Cardiopulmonary evaluation is important prior to any major urological surgery. Pulmonary function testing may be beneficial for patients with chronic obstructive pulmonary disease (COPD) to determine their baseline function prior to surgery or to assess those with undiagnosed COPD; however, spirometry alone does not determine postoperative risk. Particular attention should be paid to patients with germ-cell tumors who have undergone neoadjuvant chemotherapy with bleomycin, etoposide, and cisplatin (BEP). Pulmonary fibrosis is a well-documented side effect of bleomycin; therefore preoperative pulmonary function tests should be considered prior to proceeding with anesthetic for retroperitoneal lymph node dissection (RPLND). Many patients undergoing urological cancer surgery have preexisting risk factors for cardiovascular disease. Furthermore, it may also be necessary to cease preventative antiplatelet and anticoagulant therapy prior to surgery due to risk of intra- and postoperative bleeding. Guidelines highlight the need for clinicians to weigh up these risks on an individual basis. Bridging anticoagulation should be used for patients at especially high risk in the perioperative period.
Validated perioperative assessment scoring systems are now widely used across all surgical specialties as a guide to surgical planning, perioperative care interventions, and as an adjunct to informed patient decision-making ( Box 26.1 ). A range of nonsurgical management options exist for some urooncological conditions, most commonly radiotherapy used for the treatment of prostate and bladder cancer, as well as ablative options for renal cancer. As such, perioperative consideration together with the patient serves an important role in guiding the best standard of care. The multidisciplinary team meeting (MDTM) is recognized as a gold standard for cancer care delivery globally. It provides a forum for interdisciplinary discussion regarding patient care and involves surgeons, medical oncologists, radiation oncologists, pathologists, radiologists, and specialty cancer nurses, among others. Decision-making at the MDTM can be significantly impacted, however, in the event of lack of patient-specific information or knowledge of the patient's wishes.
BOX 26.1
Validated Perioperative Assessment Scoring Systems
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