Urology Preoperative Planning Note

Date: [Date of note]

Patient: [Patient name and identifiers per local convention]

Planned Procedure: [Procedure name(s) with laterality/site if applicable]

Planned Date: [Date if scheduled / pending]

Facility: [Facility or surgical center if known]

Referring Clinician: [Name and role if applicable]

Reason for Visit

[One- to two-line statement of purpose: preoperative counseling and planning for the specified urologic procedure(s) and indication] (If multiple procedures are planned, list each component.)

Clinical Summary & Indication

[Narrative summary of the operative problem and clinical trajectory] (Include the working diagnosis; symptom burden and course; prior management attempts and outcomes; and key anatomic or oncologic details that affect candidacy and approach. Conclude with the patient's stated goals and priorities, using brief direct quotes for values-based preferences. Only include details that impact decision-making, approach selection, or perioperative risk mitigation.)

Options Considered & Decision-Making

• [Option 1: Observation / active surveillance] (Brief pros and cons, including consequences of no intervention when relevant.)
• [Option 2: Medical/non-procedural management] (Brief pros and cons.)
• [Option 3: Alternative surgical approach or technique] (Brief pros and cons; note differences in recovery, success, and risk profile.)
• [Other reasonable options as applicable]

[Decision rationale] (Concise narrative stating why the proposed procedure aligns with the patient's values, goals, and clinical situation. Document that questions were invited and answered.)

Risk/Benefit Counseling

Procedure explanation: [Plain-language description of proposed procedure and expected benefits: symptom relief, oncologic control, diagnostic clarification as applicable]

Material risks discussed: [Bleeding/transfusion], [Infection/UTI/sepsis], [Injury to adjacent structures], [Ureteral injury/stricture/leak], [Need for stent or nephrostomy], [Urinary retention/incontinence], [Erectile and/or ejaculatory dysfunction], [Anesthesia risks], [DVT/PE], [Device-specific complications if applicable] (Tailor to procedure; include risks that are common or severe even if rare.)

Patient-specific risk modifiers: [Anticoagulation use], [CKD], [Prior pelvic surgery or radiation], [Immunosuppression], [OSA], [Frailty/low functional capacity], [Other relevant factors]

Expected postoperative course: [Anticipated catheter/stent/drain and duration], [Pain expectations], [Activity restrictions and recovery milestones], [Red flags prompting urgent evaluation]

Understanding assessment: [Patient verbalized understanding / teach-back performed / additional teaching provided]

Pertinent Medical History

(Include only conditions that inform operative or anesthesia risk, antibiotic selection, anticoagulation planning, or postoperative logistics.)

• [Cardiovascular disease and status]
• [Pulmonary conditions including OSA/CPAP use]
• [Renal or hepatic dysfunction]
• [Diabetes and control]
• [Bleeding history or coagulopathy]
• [Prior anesthesia complications]
• [Prior abdominal/pelvic surgery or radiation]
• [Substance use: tobacco, alcohol, chronic opioids]
• [Allergies: antibiotics, latex, contrast]
• [Functional capacity: >4 METs / ≤4 METs / unknown] (Include for moderate-to-high risk cases or older/frail patients.)

Medications

(Focus on high-risk perioperative medications.)

• Anticoagulants/Antiplatelets: [Agent, dose, indication, prescriber]
• Immunosuppressants/Steroids: [Agent(s)]
• Diabetes medications: [Agent(s) with perioperative considerations]
• Chronic opioids/benzodiazepines: [Regimen]
• Other high-risk perioperative meds: [e.g., SGLT2 inhibitors, MAOIs]
• [Medication uncertainties: unknown agent/dose — will verify with pharmacy records or PCP]

Data Reviewed

• Vitals: [Pertinent values with date]
• Focused exam: [Pertinent positives and negatives only]
• Imaging: [Modality, date, key findings relevant to plan]
• Endoscopy/Cystoscopy: [Date and key findings]
• Pathology: [Diagnosis, grade, margins as applicable]
• Key labs: [Creatinine/eGFR], [Hemoglobin], [PSA if applicable], [Other relevant]
• Urinalysis/Urine culture: [Date, result; organism and susceptibilities if positive] (Clearly distinguish treated vs untreated.)
• Items ordered today: [List] (pending)

Assessment

1. [Primary operative diagnosis]: [One-line assessment summarizing indication and status]
2. [Key comorbidity impacting perioperative course]: [One-line impact statement]
3. [Additional problems as applicable with one-line impact statements]

Preoperative readiness: [Ready to proceed / Proceed pending: (list specific optimization items)]

Plan

Surgical Plan

• Procedure: [Final planned procedure with laterality/site and approach]
• Anesthesia: [general / regional / MAC / local]
• Positioning: [lithotomy / flank / supine / other]
• Equipment/implants: [Anticipated equipment, devices, adjuncts]
• Contingencies: [Possible stent, staging, conversion, biopsy]
• Stop/go criteria: [e.g., postpone if febrile, untreated positive culture, uncontrolled BP]
• Disposition: [outpatient / observation / admission], expected LOS, anticipated catheter/stent/drains

Infection Risk Mitigation

• Urine culture: [Required / not required]; target timeframe: [X days prior to surgery]
• If culture positive or ASB: [Targeted antibiotic, duration, timing relative to surgery]
• If symptomatic UTI: [Treatment plan and decision on surgical delay]
• Perioperative prophylaxis: [Antibiotic per institutional protocol, adjusted for allergies/resistance]
• If culture pending: Surgery contingent on results; [responsible party] to review and confirm

Anticoagulation Plan

(Include only if patient uses anticoagulants or antiplatelets.)

• Agent and indication: [Agent] for [indication]
• Procedure bleeding risk: [low / moderate / high]
• Management: [Continue / Hold]; if hold: last dose [date], restart goal [timeframe]
• Bridging: [indicated / not indicated]; if yes, managed by [service]
• Coordination: [Anticoagulation clinic / cardiology / PCP contacted]
• Counseling: Thrombotic vs bleeding risk tradeoff discussed
• (If plan not finalized: Do not stop medication until confirmed; [who will finalize and when].)

Preoperative Testing & Optimization

(Include only tests or consults that will change management.)

• Labs: [CBC, BMP, type & screen if transfusion risk meaningful]
• Cardiac/pulmonary evaluation: [Indicated / not indicated]; if yes, reason: [indication]
• Optimization goals: [Smoking cessation, diabetes control, CPAP adherence, anemia management]
• Delegated to preadmission testing/anesthesia: [Specify what is delegated]

Patient Instructions

• NPO: Per institutional protocol
• Medication instructions: [Specifics for morning of surgery / anesthesia will provide final guidance]
• Logistics: Transportation and postoperative caregiver requirements reviewed
• Activity: [Work restrictions and estimated time off if discussed]
• Special pathways: [ERAS, bowel prep, stoma marking if applicable]

Follow-up

• Appointments: [Timing and purpose: pathology review, catheter removal, stent removal, void trial]
• Postoperative studies: [Imaging or labs and timing if planned]
• Return precautions reviewed: Fever, urinary retention, severe pain, heavy hematuria/clots, signs of thromboembolism

Consent Documentation

Risks, benefits, and alternatives discussed as above. Patient agrees to proceed with [planned procedure]. Questions were answered, and understanding was assessed via [teach-back / patient verbalization]. [Signed informed consent on file / consent form to be completed on day of surgery]. Blood products: [consent obtained / patient declines / restrictions: (specify)].