Routine Preoperative Medical Evaluations Before Radical Prostatectomy: Are They Worth It?

Most surgeons recommend preoperative medical evaluation (PME) to optimize patients before elective surgery. Such evaluations are commonly sought before urologic procedures. However, until recently, there was little data available to demonstrate the benefits of routine PME or to help surgeons decide when to recommend these evaluations.

What is a PME?

A PME is performed by an internal medicine physician and includes an assessment of the surgical candidate’s medical history, a physical examination and a review of diagnostic test results. Following PME, the evaluating physician may recommend additional diagnostic testing and/or specific recommendations for the patient’s perioperative management.

Glickman Urological & Kidney Institute Chief Resident Nima Almassi, MD, in collaboration with staff Howard Goldman, MD, and Venkatesh Krishnamurthi, MD, developed and implemented the first study to evaluate the efficacy of routine PME prior to radical prostatectomy. Dr. Almassi presented the results at the American Urological Association’s 2018 Annual Meeting.

“It’s important to note that prior to an elective urologic surgery, all patients are evaluated by the surgeon and the anesthesiology team,” explains Dr. Almassi. “Our study demonstrates that the additional layer of evaluation offered by routine PME rarely yields changes in a patient’s perioperative management, with no difference in surgical outcomes compared to patients who do not undergo PME.”

Analyzing the impact of PME

The researchers examined a total of 383 Cleveland Clinic patients who underwent radical prostatectomy in 2014. They compared patients who had standard urologic and anesthesiology evaluation with patients who had the standard evaluation plus PME. Then they looked at the frequency with which PME led to changes in patient management before surgery. Only 2 percent of patients who had standard evaluation plus PME underwent additional diagnostic testing or perioperative management recommendations based on the PME — all of which were minor in scope.

“We observed that the majority of PMEs are ordered for routine preoperative evaluation without a specific clinical question,” reveals Dr. Almassi. “PMEs rarely affect perioperative management, with no difference in surgical outcomes after radical prostatectomy. These findings strongly suggest that routine referrals for PME without a specific clinical question can be safely omitted without negatively impacting patient outcomes.”

Improving decision-making and quality

In the past, decisions regarding PME referrals were made at the discretion of the surgeon. “Our study provides firm data to help guide the decision-making process and efficiently manage patients before they undergo urologic surgery,” notes Dr. Almassi. “The results will help physicians recommend PME only for prostate cancer patients with specific clinical indications, thus improving quality of care and patient experience while helping reduce healthcare costs.”

Quality improvement is an essential focus among healthcare organizations. “Our research demonstrates the importance of applying science to the realm of patient safety and quality improvement, which helps optimize the value of care,” explains Dr. Almassi. “Reducing the number of PMEs helps reduce the number of unnecessary clinic visits, saving patients time and money. It also reduces the financial burden on the healthcare system.”

Evaluating a referral algorithm

Dr. Almassi’s team has developed a referral algorithm that incorporates previously published evidence-based guidelines from the American College of Cardiology to help identify patients who should have a referral for PME. “We are in the process of evaluating the referral algorithm to consider how it impacts referrals for PME and whether it affects patient outcomes after surgery,” notes Dr. Almassi.