OBJECTIVE To determine the incidence of, and predictors for, the acute confusional state (ACS) in older patients after urologic surgery. ACS is among the most common complications after surgery in older patients. It is associated with increased postoperative morbidity, longer hospital stays, and greater mortality. Agitation caused by ACS might have deleterious consequences in a large proportion of older patients, especially after urologic surgery. Only a few studies, of highly selected urologic procedures, have been reported, and all showed an astonishingly low percentage of patients with this distressing condition. METHODS We examined 100 consecutive, older patients (age 60 years or older), prospectively, before and after urologic surgery, to determine both the incidence of, and the predictors for, ACS. RESULTS Only 7 of the 100 patients developed postoperative ACS. The risk factors identified were preoperative cognitive deficits, pre-existing depression, impaired vision, and the operative time. CONCLUSIONS These results suggest that postoperative ACS is relatively rare after urologic surgical procedures; however, patients who are likely to develop ACS can be identified, prompting consideration for prophylactic antidelirium care.