Chapter 17 · Greater Boston Urology · Massachusetts
APPs are central to perioperative flow: preoperative optimization, postoperative rounding, and the phone triage that keeps recovering patients safe at home. This chapter covers what to expect after our common procedures and how to handle the…
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APPs are central to perioperative flow: preoperative optimization, postoperative rounding, and the phone triage that keeps recovering patients safe at home. This chapter covers what to expect after our common procedures and how to handle the complications. Detailed anticoagulation and antibiotic prophylaxis protocols are in Chapter 28.
Sterilize the urine before instrumentation: obtain a preoperative urine culture and TREAT a positive culture before any procedure that traumatizes the urothelium. This is one of the very few times we treat “asymptomatic” bacteriuria — because instrumenting infected urine causes bacteremia and sepsis.
Anticoagulation/antiplatelet planning: coordinate holding and bridging with the prescribing clinician, weighing procedure bleeding risk against thrombotic risk. Never stop antiplatelets in a patient with a recent coronary stent without cardiology input (Chapter 28).
Antibiotic prophylaxis: follow AUA best-practice guidance by procedure type — the right drug, given within 60 minutes of incision, and stopped within 24 hours (Chapter 28).
GLP-1 agonists: these delay gastric emptying and raise aspiration risk under sedation. Flag them explicitly and follow current anesthesia guidance on holding them (Chapter 24).
Special counseling: warn the anesthesia and cataract-surgery teams about tamsulosin (intraoperative floppy iris syndrome). Review diabetes medications and hold as directed. Confirm the patient has a ride home and a responsible adult.
Optimize what is optimizable: smoking cessation (even 4 weeks helps wound healing), glycemic control, and nutrition.
Procedure |
Normal recovery |
Call for… |
UroLift |
Mild dysuria, urgency, and hematuria for days to ~2 weeks; usually no catheter; ejaculation preserved |
Inability to void, fever, heavy bleeding with clots |
Prostatic artery embolization (PAE) |
Post-embolization syndrome is EXPECTED — pelvic discomfort, low-grade fever, malaise, urinary frequency for several days. Symptoms improve gradually over weeks to months as the gland shrinks |
High fever with rigors, inability to void, severe pain, or signs of non-target embolization (rectal/perineal pain, skin changes) |
TURP / laser enucleation (ThuLEP) |
Transient hematuria and irritative voiding for weeks; a short-term catheter; retrograde ejaculation is the norm |
Heavy bleeding or clots, clot retention, fever, inability to void after catheter removal |
Ureteroscopy + stent |
Flank/bladder discomfort, urgency, and hematuria from the stent (expected — not heavy bleeding to worry about). Treat stent colic with Pyridium/Uro-MP + mirabegron (Chapter 7) |
Fever, intractable pain/vomiting; confirm the stent-removal date |
Prostate biopsy |
Hematuria, hematospermia (can last weeks to months — warn them), mild soreness, minor rectal bleeding |
FEVER OR RIGORS — sepsis until proven otherwise, go to the ER. Also: heavy bleeding, inability to void |
TURBT |
Hematuria and irritative symptoms for 1–2 weeks; catheter for 1–2 days |
Clot retention, fever, severe pain (consider bladder perforation) |
Radical/partial nephrectomy |
Incisional soreness, fatigue for weeks; monitor renal function |
Fever, worsening pain, bleeding, low urine output, wound drainage (urine leak) |
Radical prostatectomy |
Catheter for ~1–2 weeks; expected temporary incontinence and ED; pelvic bruising |
Fever, calf pain/leg swelling or chest pain (VTE), catheter dislodgement, escalating pain, wound issues |
Cystectomy + urinary diversion |
Prolonged recovery; stoma/diversion teaching; mucus in the urine is NORMAL with bowel diversions |
Dehydration, obstruction/ileus, stoma changes or low output, fever, metabolic acidosis |
InterStim / PNE |
Mild site soreness; the device is programmed and adjusted over weeks |
Site infection, lead migration (sudden loss of effect or a change in stimulation location), persistent pain |
Urinary retention after surgery: very common after anesthesia and pelvic procedures. Scan the bladder, catheterize, start an alpha-blocker, and plan a voiding trial. Do not let a patient sit in retention because “they will probably go.”
Fever work-up: distinguish the expected low-grade fever of the first 24–48 hours (atelectasis, inflammatory response, post-embolization syndrome) from true infection. A RIGOR after urologic instrumentation is a warning sign of bacteremia and deserves respect.
Bleeding/clot retention: 3-way catheter and CBI (Chapters 2 and 14); check labs and anticoagulation; start a 5-ARI for prostatic bleeding.
Venous thromboembolism: pelvic oncologic surgery (especially cystectomy and prostatectomy) carries meaningful VTE risk, and it often occurs AFTER discharge — extended prophylaxis is used for major pelvic cancer surgery. Keep DVT/PE high on the differential for any postoperative leg swelling, calf pain, dyspnea, or chest pain, and do not dismiss it.
Ileus: common after open/bowel surgery. Supportive care, ambulation, and patience — but exclude an obstruction or a urine leak if it is prolonged or accompanied by fever.
Urine leak / urinoma: suspect after partial nephrectomy or reconstructive surgery — persistent drain output, fever, ileus, or flank pain. Check the drain fluid creatinine (a level far above serum confirms urine). Management is drainage and stenting.
Lymphocele: after pelvic lymph node dissection — a fluid collection causing pain, leg swelling, or DVT. Drain if symptomatic.
Rounding mindset
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APPs run perioperative flow: optimizing patients before surgery, setting expectations for recovery after our common procedures, and managing the post-op problems that come back by phone. Detailed anticoagulation and antibiotic prophylaxis protocols live in Chapter 28.
The preoperative checklist that keeps a case from being cancelled — or from becoming a sepsis call.
Select a box to open its teaching details.
Preoperative optimization, postoperative rounding, and the phone triage that keeps recovering patients safe at home are all APP-owned work.
Instrumenting infected urine causes bacteremia and sepsis. This is one of the very few times we treat asymptomatic bacteriuria.
Detailed protocols are in Chapter 28.
Normal recovery versus 'call us' — procedure by procedure, so your phone advice matches what the surgeon told them.
Select a box to open its teaching details.
Hematuria with a stent is expected; hematuria with clot retention after a TURP is not. Anchor every call to the operation.
BPH procedures
Endoscopic and diagnostic procedures
Major oncologic surgery
Most bad outcomes after discharge come from a patient who did not know when to call.
The complications that land on the APP — what to do, and what not to dismiss.
Select a box to open its teaching details.
Most bad outcomes after discharge come from a patient who did not know when to call.