Perioperative care and surgical management of patients with uremia is a major concern in urological surgery nowadays. Hyperkalemia, immunological dysfunction, and bleeding are key features of uremic patients. Careful management of these conditions is required as they are associated with higher perioperative comorbidities and complications. It is advisable to delay surgery in patients with elevated serum potassium and to provide tailored treatments for electrolyte imbalances including loop diuretics, polystyrene-binding resins, insulin in combination with dextrose, bicarbonate and calcium gluconate. Immunological dysfunction related to uremia makes antibiotic prophylaxis mandatory in renal surgery. Bleeding is another significant concern in chronic kidney disease (CKD)/uremic patients, often worsened by platelet dysfunction. Erythropoiesis-stimulating therapy and blood transfusion may be needed to ensure the patients’ surgical safety. For renal cell cancer surgeries, the opportunity to preserve partial renal function provided by partial nephrectomy should be balanced with the risks of the procedure itself. Kidney-sparing surgery should always be considered also in CKD patients affected by upper tract urothelial carcinoma with improved quality of life and better management of disease progression. CKD is, however, a condition which could both be the cause and the result of urinary stones, and the treatment of both ureteral and renal stones is frequently required in this setting.