Can silodosin be continued in the perioperative period?

Perioperative Management of Silodosin

Silodosin should be discontinued at least 1-2 weeks before elective ophthalmic surgery (particularly cataract surgery) due to the risk of intraoperative floppy iris syndrome (IFIS), but can generally be continued for non-ophthalmic surgeries following standard alpha-blocker perioperative management principles.

Key Considerations by Surgery Type

Ophthalmic Surgery (Cataract/Intraocular Procedures)

• Silodosin carries significant risk for bilateral IFIS during phacoemulsification, characterized by floppy iris billowing, iris prolapse through surgical incisions, and progressive pupillary miosis despite pharmacologic dilation 1
• Discontinue silodosin 1-2 weeks before planned cataract surgery to minimize IFIS risk, though the syndrome can occur even after discontinuation due to the drug's high alpha-1A selectivity 1
• Ophthalmologists must be informed of current or recent silodosin use, as surgical techniques (iris retractors, modified phacoemulsification parameters) may be required 1
• Silodosin has 583-fold greater affinity for alpha-1A receptors compared to alpha-1B receptors, making it more likely to cause IFIS than other alpha-blockers 2

Non-Ophthalmic Surgery

For general, orthopedic, or other non-ophthalmic procedures:

• Continue silodosin through the perioperative period in most patients with hypertension or benign prostatic hyperplasia, as it is reasonable to maintain antihypertensive therapy perioperatively 3
• The 2024 AHA/ACC guidelines recommend continuing most antihypertensive medications throughout the perioperative period to avoid complications from postoperative hypertension 3
• Silodosin's low incidence of orthostatic hypotension (<3%) makes it safer to continue compared to non-selective alpha-blockers 4, 2

Blood Pressure Management Considerations

• Monitor for perioperative hypotension, particularly in older adults (≥65 years) or those with baseline low-normal blood pressure 3
• Maintain intraoperative MAP ≥60-65 mm Hg or SBP ≥90 mm Hg to reduce risk of myocardial injury 3
• Restart silodosin as soon as clinically reasonable postoperatively if held, to avoid rebound hypertension and urinary retention 3

Common Pitfalls to Avoid

• Failing to obtain medication history for ophthalmic surgery: Always specifically ask about alpha-blockers including silodosin before cataract surgery 1
• Assuming all alpha-blockers have equal IFIS risk: Silodosin's extreme alpha-1A selectivity (583:1 ratio) creates higher IFIS risk than tamsulosin or other agents 2
• Abrupt discontinuation without urologic consultation: Stopping silodosin may precipitate acute urinary retention in men with significant prostatic obstruction 4, 5

Postoperative Resumption

• Resume silodosin when oral intake is tolerated and hemodynamic stability is confirmed, typically within 24-48 hours for most non-ophthalmic procedures 3
• For ophthalmic surgery, silodosin can be restarted immediately postoperatively once the intraocular procedure is complete 1
• Monitor for the most common adverse effect (abnormal ejaculation in 14-22% of patients), though this rarely leads to discontinuation 4, 5, 2

Evidence Quality Note

The perioperative management of silodosin specifically lacks high-quality guideline evidence. The recommendations here synthesize general perioperative antihypertensive management guidelines 3 with silodosin-specific pharmacology 2 and the well-documented IFIS risk in ophthalmic surgery 1. The decision framework prioritizes patient safety by preventing IFIS complications while maintaining urologic symptom control and blood pressure management for non-ophthalmic procedures.