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Topic Suggestion Description

Date submitted: October 31, 2013

Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.
• What is the optimal antimicrobial prophylaxis regimen for urologic procedures, as categorized by type of procedure: removal of external urinary catheter; cystography, urodynamic study or simple cystourethroscopy; cystourethroscopy with manipulation; perineal prostate procedures (brachytherapy, cryotherapy, perineal prostate biopsy); transrectal prostate biopsy; shock wave lithotripsy; percutaneous renal procedures; ureteroscopy; vaginal surgery (includes urethral sling procedures); open/laparoscopic/robotic surgery without entering urinary tract; open/laparoscopic/robotic surgery involving entry into the urinary tract; open/laparoscopic surgery/robotic surgery involving intestine; open/laparoscopic surgery involving implanted prosthesis?
• What is the optimal regimen to prevent venous thromboembolism, as categorized by type of procedure: transurethral surgery; anti-incontinence and pelvic reconstructive surgery; Urologic laparoscopic and/or robotically assisted urologic laparoscopic procedures; open Urologic surgery?
• When and in whom can anti-coagulation / anti-platelet therapy (AC/AP) be stopped in preparation for elective, urgent, or emergent urologic surgery?
• What urologic procedures can be safely performed without discontinuing AC/AP (specifically, ASA 81mg, ASA full dose, other anti-platelet agents such as clopidogrel, and anticoagulation with heparin or coumadin)?
• What are the current periprocedural strategies that adequately balance the risk of major surgical bleeding versus the risk of major thrombotic event?
• What are the risks of non-supine positioning for surgery (e.g., prone, lithotomy, flank, etc.), including nerve and brachial plexus injuries, myonecrosis/rhabdomyolysis, ocular injury and others.

Importance

Describe why this topic is important.
According to the Centers for Disease Control and Prevention (CDC) 51.4 million inpatient surgeries took place in the US (2010), more that 1,500,000 of which, include surgeries on the urinary system. Perioperative Considerations in Urologic Surgery is an extremely important topic not only because of the magnitude of patients who undergo urologic surgery, but also because of the potential for variance in clinical practice, severity of adverse outcomes and overall patient safety. This topic is essential to ensuring the quality and efficacy of care being provided to patients. The patients affected by variable perioperative management is broad, children undergoing antireflux procedures associated with recurrent urinary tract infections (UTIs), adult women undergoing continence procedures, men and women undergoing stone procedures and urologic oncology procedures. The elderly patient with low grade bladder tumors commonly undergoes outpatient bladder procedures.

Accordingly, a major area of focus, particularly specific to urologic surgery, includes surgical site infections (SSIs) and UTIs, which are a common cause of patient morbidity. Surgical site infections complicate up to 5% of clean extra-abdominal operations and up to 20% of intra-abdominal procedures. UTIs are the most common type of nosocomial infection, and are frequently postoperative in nature. Surgical site infections almost double the direct costs of hospitalization, and patients with SSI are more likely to be readmitted, require stay in the intensive care unit, and suffer mortality. Although the effectiveness of perisurgical antimicrobial prophylaxis in reducing SSIs and postoperative UTIs is well established, surveys have demonstrated wide variation in utilization of periprocedural antimicrobial prophylaxis, including inappropriate selection of agents, improper timing of administration, and excessive duration of prophylaxis. Quality standards have been developed for urologic procedures, but a consensus-based best practice statement and not a methodologic grading of the literature to develop a high quality guideline. Targets of a research review would include perioperative cleansing by the patient, periprocedural skin preparation and shaving, the timing of urine microscopy, cultures results and periprocedural antibiotics to allow adequate sterilization of the surgical site. The clinic setting is also a source of tremendous patient variability in the use of periprocedural antibiotics for cystoscopy and urodynamics. Techniques of draping drape permeability and perioperative clothing may allow for development of evidence-based best practices which may be applicable to other procedural practices as well.

Deep vein thrombosis (DVT) with its potential fatal sequela of pulmonary thromboembolism (PTE) is a common complication of surgical procedures and thus an issue of importance for practicing urologists. In fact, PTE is one of the most common causes of nonsurgical death in patients undergoing urologic surgery. In addition to the mortality associated with PTE, long-term complications such as post-thrombotic syndromes can occur with significant morbidity and economic impact.

According to the United States Centers for Disease Control and Prevention (CDC), 49% of the US population has at least one risk factor for cardiovascular disease. Similarly, as reported by the World Health Organization (WHO), cardiovascular disease causes more than half of all European deaths making it essential for the surgeon to have familiarity with the most common medical risks that can affect the outcome of a procedure. The widespread use of oral AC/AP agents and the advent of new therapies complicate the perioperative management of urological patients. Yet approximately 10% per year of the patients on these medications will require an invasive procedure.

The AUA has produced two documents that have helped direct perioperative care for Urologic surgery, including "Best Practice Policy Statement on Urologic Surgery Antimicrobial Prophylaxis" and "Best Practice Statement for the Prevention of Deep Vein Thrombosis in Patients Undergoing Urologic Surgery." These documents have helped to standardize and improve perioperative care for Urologic surgery, but they are becoming outdated (both published in 2008). In order to help direct perioperative care for Urologic surgery supported by the best evidence, a new systematic review is warranted. The AUA intends to use this systematic review as the basis for a new "Clinical Practice Guideline on Perioperative Care for Urologic Surgery."

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?
The AUA has a rigorous, evidence based, high quality guideline development and dissemination process. The AUA Board of Directors has mandated that the AUA increase its number of guidelines as well as periodically assess existing guidelines on a regular basis; as such, the AUA Guidelines team develops and /or revises a minimum of three new guidelines per year and assesses existing guidelines every two years. The AUA publishes guidelines on its website as well as on the National Guidelines Clearinghouse (NGC) and G-I-N websites, and these are accompanied by pocket guides and smartphone APPs for physicians as well as patient education materials. Following a guideline's publication, a summary manuscript is published in the Journal of Urology, which has extensive readership spanning both national and international clinical communities. Additionally, the AUA widely disseminates information about its guidelines through its annual meeting, the AUA Health Policy Brief, AUA News and through its Board of Directors and members. In addition, AUA is utilizing informaticists to help make guideline statements more actionable and relevant for electronic health records (EHRs). The creation of an AHRQ evidence report on Perioperative Considerations in Urologic Surgery will enable the AUA to develop a guideline to enhance physician knowledge and reduce treatment inequalities among both the urologic and primary care medical communities.

Nominator Information

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Professional Society
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American Urological Association (AUA)
Please tell us how you heard about the Effective Health Care Program
The AUA has previously partnered with AHRQ in the development of evidence reports on the Management of Female Overactive Bladder (OAB), Urinary Retention, Medical Recurrent Nephrolithiasis, Cryptorchidism and Bladder Cancer. The AUA has developed high quality clinical practice guidelines, utilizing the evidence reports developed on all of the topics AUA has submitted to AHRQ.
In keeping with its vision to serve as a premier professional association for the advancement of urologic patient care, the AUA continually works to fulfill the need for quality, evidence-based education for medical professionals. The AUA produces and disseminates Clinical Practice Guidelines, fostering the highest principles of urologic care by ensuring that members are current on the latest peer-reviewed evidence and practices in the field.