41 Care of the genitourinary surgical patient
Adrenalectomy: Partial or total excision of one or both adrenal glands.
Bladder Neck Operation (Y-V Plasty): A plastic repair of the bladder neck for correction of stricture.
Chordee: Downward bowing of the penis as a result of congenital malformation or hypospadias with fibrous bands.
Circumcision: Excision of the foreskin (prepuce) of the glans penis.
Cystectomy: Excision of the bladder and adjacent structures; may be partial (excision of a lesion) or total (excision of a malignant tumor). This operation usually involves the additional procedure of ureterostomy.
Cystolithotomy: Opening of the bladder for removal of stones.
Cystoscopy: Direct visualization of the urethra, prostatic urethra, and bladder by means of a tubular lighted telescopic lens.
Cystotomy: An incision into the bladder.
Epididymectomy: Excision of the epididymis from the testis. This procedure is rarely done but may occasionally be indicated for treatment of persistent infection.
Epispadias: Urethral meatus situated in an abnormal position on the upper side of the penis. Surgical correction involves plastic repair.
Extracorporeal Shock Wave Lithotripsy: Use of shock waves through a liquid medium into the body to disintegrate stones.
Heminephrectomy: Partial excision of the kidney.
Hydrocelectomy: Excision of the tunica vaginalis of the testis for removal of a hydrocele (a fluid-filled sac).
Hypospadias: A deformity of the penis and malformation of the urethral wall in which the urinary meatus is located on the underside of the penis, either short of its normal position at the tip of the glans or on the perineum or scrotum. This condition is often associated with chordee. Surgical correction involves plastic repair; penile straightening and urethral reconstruction (urethroplasty) are usually done in two or more stages.
Intravenous Pyelogram: A radiologic procedure in which intravenous dye is injected to assist in the visualization of renal structure. This procedure is used to diagnose abnormalities and look for blockages.
Kidney Transplant: Removal of a donor kidney with nephrectomy and ureterectomy, followed by transplantation of the donor kidney into the recipient’s iliac fossa.
Nephrectomy: Removal of a kidney; used in treatment of some congenital unilateral abnormalities that cause renal obstruction or hydronephrosis; sometimes necessitated by the presence of tumors or severe injuries.
Nephrostomy: An opening into the kidney for temporary or permanent drainage.
Nephrotomy: An incision into the kidney.
Nephroureterectomy: Removal of a kidney and the entire ureter that drains it.
Orchiectomy: Removal of the testis or testes. This procedure renders the patient sterile.
Orchiopexy: Suspension of the testis within the scrotum. This procedure is used in the treatment of an undescended or cryptorchid testis to bring it into the normal intrascrotal position.
Penile Implant: A penile prosthesis implanted for treatment of organic sexual impotence.
Percutaneous Nephrolithotomy: Removal or disintegration of renal stones with passage of a nephroscope through a percutaneous nephrostomy tract.
Phimosis: Tightness of the foreskin so that it cannot be drawn back from over the glans; also, the analogous condition in the clitoris.
Prostatectomy: Enucleation of prostatic adenomas or hypertrophied masses.
Pyeloplasty: Revision or reconstruction of the renal pelvis.
Pyelostomy: An incision into the renal pelvis for drainage or for irrigation of the renal pelvis.
Pyelotomy: Incision into the renal pelvis.
Radical Prostatectomy: Common surgical treatment for prostate cancer in young men where the entire prostate is removed.
Spermatocelectomy: The removal of a spermatocele, which usually appears as a cystic mass within the scrotum, attached to the upper pole of the epididymis. A spermatocele is usually caused by an obstruction of the tubular system that conveys the sperm.
Transurethral Surgery: Piecemeal resection of the prostate gland and of tumors of the bladder and bladder neck and fulguration of bleeding vessels and of tumors with a resectoscope passed into the bladder via the urethra.
Urethral sling: Midurethral sling used as treatment for stress incontinence. A piece of mesh is introduced along the midurethral section using an introducer through either a retropubic approach or a vaginal approach.
Ureterectomy: Complete removal of one or both of the ureters.
Ureterolithotomy: Incision into the ureter and removal of stones.
Ureteroneocystostomy (Ureterovesical Anastomosis; Vesicopsoas Hitch Procedure): Division of the ureter from the urinary bladder and reimplantation of the ureter into the bladder at another site.
Ureteroplasty: Reconstruction of the ureter.
Ureteroscopy: Direct visualization of the ureters and upper urinary tract with the use of a lighted semirigid scope that passes through the urethra and bladder.
Ureterostomy, Cutaneous (Anastomosis of Transplant; Bricker Operation; Ureteroileostomy): Diversion of the urinary stream with anastomosis of the ureters into an isolated loop of ileum that is brought out through the abdominal wall as an ileostomy.
Urethral Dilatation and Internal Urethrotomy: Gradual dilation of the urethra and lysis of a urethral stricture.
Urethral Meatotomy: Incisional enlargement of the external urethral meatus for relief of stenosis or stricture.
Urethroplasty: Reconstructive surgery of the urethra.
Urethrovesical Suspension (Pubovaginal Slings): Suspension of the urethra with a permanent polypropylene mesh tape for the treatment of stress incontinence.
Varicocelectomy: Ligation and partial excision of dilated veins in the scrotum.
Vasectomy: Excision of a section of the vas deferens. This procedure is performed electively for birth control or before prostatectomy to prevent the spread of infection from the urethra to the epididymis.
Vasoepididymostomy: Anastomosis of the vas deferens to the epididymis.
Vasovasostomy: Anastomosis of two separate segments of the vas deferens for reversal of a vasectomy.
Vesicourethral Suspension: Suspension of the bladder neck to the posterior surface of the pubis in women for treatment of stress incontinence.
Nursing care after diagnostic procedures
Renal angiography
For a renal angiographic examination, a small catheter is threaded through the femoral artery into the aorta or renal artery, radiopaque dye is instilled, and radiographs are made.1 Local anesthesia is usually all that is needed; however, general anesthesia may be used for children or patients who cannot cooperate during the procedure. When the patient is admitted to the PACU, the groin area is inspected for bleeding at the site. A pressure-type dressing usually is present and can be replaced with a simple bandage after a few hours. Pedal pulses should be checked to ensure that no interruption of blood supply to the extremities has occurred. Urine output should be measured and closely monitored for hematuria. Special attention should be considered for the patient with renal insufficiency or renal failure. If possible, the leg should be kept straight. Fluids should be encouraged to facilitate excretion of the dye.2
Renal biopsy
Renal biopsy is usually performed at the bedside with only local anesthesia, although general anesthesia may be used for children. The patient should maintain bed rest in a flat supine position for as long as 4 hours. Some physicians ask for the patients with a previous transplant to maintain a side lying or prone position. Pillows can be used for positioning for comfort and to decrease the risk of skin breakdown. Vital signs are monitored, and the site of the biopsy is checked for bleeding. Coughing and other activities that increase abdominal venous pressure should be avoided. Fluids should be increased to 3000 mL daily, and the urine should be observed for occult blood.3
Cystoscopy
Diagnostic cystoscopy can be performed in a special procedures room with only local anesthesia and appropriate sedation.1 Children and patients who cannot or do not tolerate the procedure may need general anesthesia. This procedure can also be performed with spinal anesthesia.
On admission to the PACU, the patient is positioned to ensure airway patency if general anesthesia was used.4 The patient may have to lie flat on the back if spinal anesthesia was used, with a gradual increase in the head of bed if tolerated and allowed by physician orders. After the effects of anesthesia have been eliminated, the patient may assume a position of comfort. The patient may have back pain, a feeling of bladder fullness, and bladder spasms. These symptoms may become severe enough to necessitate analgesia. Belladonna and opium suppositories or intravenous opioids may be administered to relieve patient discomfort as prescribed by the surgeon.2,3
Oral fluid administration should be encouraged and started as soon as the effects of anesthesia are gone. Urine output should be monitored carefully. The patient can expect frequency of urination and a burning sensation because of trauma to the mucous membranes from the procedure; this condition may inadvertently cause voluntary retention.2,3 The urine may be pink tinged for several voidings, which is to be expected. Bright blood or clots in the urine, however, should be reported to the surgeon. Severe abdominal pain should be reported because it can indicate accidental urethral or bladder perforation or internal hemorrhage.5
General postoperative care
Assessment of the patient after genitourinary surgery involves particular attention to fluid and electrolyte balance. Intake and output records are especially important and must be accurately maintained. Postoperative care is directed primarily at urinary tract function, which is second in importance only to cardiorespiratory function. Maintenance of patency of the urinary tract often depends on the use of catheters, which come in a variety of shapes and sizes (Fig. 41-1).
The catheter should be anchored securely to the patient’s thigh with a leg strap and locking device with the tubing brought over the leg. The catheter should be secured to prevent undue tension on the urinary meatus. The connecting tubing should be attached to the bed linens so that no proximal loops of tubing lie below the distal tubing; this is a straight gravity drainage system. The tubing should never be under the patient, because compression of the tubing obstructs the flow of urine. The tubing should be checked frequently for kinks. The urine receptacle should always be kept below the bladder level to prevent urine reflux up the tubing. Particular attention must be paid to this principle during the transfer of patients.
Mucus or blood, or both, can clog the tubing and prevent urine flow. Irrigations should be administered only according to the surgeon’s orders. All irrigations are sterile procedures and can be either continuous or intermittent. For intermittent irrigation, a large sterile Toomey syringe and sterile irrigating solution (usually normal saline solution alone or with a selected antibiotic) are used. Care must be taken to keep all parts of the drainage system sterile. This action may be accomplished by placing a small sterile plastic cover on the drainage tubing while the irrigation is performed. Irrigations should never be given with pressure. When the bladder is irrigated, no more than 30 mL should be instilled at one time, unless ordered otherwise by the surgeon.1
After transurethral resection of the prostate (TURP), continuous irrigation is usually preferred. With continuous irrigation, normal saline solution is typically connected with a three-way urinary catheter. Nursing care should include vigilant monitoring of patients for hyponatremia and the development of TURP syndrome.6 The report from the perioperative nurse should include the amount of intraoperative irrigation and the duration of the procedure. During the immediate postanesthesia phase, patient confusion should be monitored and differentiated from confusion as a result of amnesiacs, opioids, or hyponatremia (see also the Prostatic Surgery section in this chapter).
If hyponatremia is diagnosed, treatment may include the administration of hypertonic saline solution for a gradual increase in the patient’s serum sodium level. Care includes monitoring for signs of intracellular to extracellular fluid shifts. As fluid moves back into the extracellular space, pulmonary edema and heart failure can occur quickly.6
Suprapubic catheters
A suprapubic catheter can also be placed into the urinary bladder via abdominal incision and cystostomy.1 This procedure is typically done for more permanent or long-term use of the suprapubic catheter. The surgeon may choose this method if conventional methods of treatment for urinary incontinence fail, as with spinal cord injury or neurogenic bladder. The care of the catheter is the same as with the puncture wound, but the nurse should also apply nursing care that relates to the abdominal incision.
Ureteral catheters
Ureteral catheters are used to drain urine or splint the ureters while they heal. The catheters can be placed through the urethra or through abdominal or flank incisions.1 Care of these catheters is essentially the same as that for urethral catheters. Attention to patency must be especially meticulous because the renal pelvis can hold only 5 mL without overdistention and damage to the kidneys.1,2
Sterile irrigations are undertaken only as ordered by the physician. Only 5 mL of fluid should be used for the irrigation via gravitational flow. Irrigations should never be given with pressure, such as with a syringe and plunger. The nurse must be sure to avoid situations that can cause dislodgement or displacement of these catheters, which could be disastrous to the outcome of the surgery. Special care must be taken during patient transfer to ensure that these catheters stay in place. One person should be assigned this responsibility during the transfer. If the catheters should become dislodged despite all the precautions taken, the surgeon must be notified immediately.1,5
Intake
Optimal fluid intake is exceptionally important for the patient after surgery; increased fluids are the general rule. Fluids should be given orally if the patient can tolerate this preferred route, and intake should be increased to total of 3000 mL in a 24-hour period. Special consideration regarding type and amount of fluids should be taken with any patient with renal insufficiency. Parenteral fluid therapy is indicated for a short time until the effects of anesthesia have passed and is continued only if the oral route of intake is inadequate.2,4
Dressings
Care of dressings varies according to the procedure and can include anything from a bulky dressing to Steri-Strips or bandages. Dressings applied after urinary tract surgery often become soaked with blood and urine. They should be reinforced as necessary, and the surrounding skin should be kept clean and dry to prevent unnecessary excoriation and breakdown.3 (Excessive staining that is unexpected for a particular procedure and indicates a complication is so indicated in the discussion of the specific procedure later in this chapter.) Excessive bleeding and hemorrhage are ever-present dangers of this surgery, because the kidneys and prostatic bed are extremely vascular. Vital signs must be monitored closely, and all avenues of output, especially the incisions and drainage tubes, should be evaluated frequently for bleeding.2,3
Abdominal distention
All patients should be assessed for abdominal distention after surgery that involves abdominal and flank incisions (see Chapter 40 for care of the patient after an abdominal incision because the same care applies after genitourinary surgery). These patients often arrive with nasogastric tubes, the care for which is discussed in Chapter 40. In addition, the patient should be assessed for distention caused by overfilling of the bladder because of an inability to void or a malfunction of the catheters.
Bladder ultrasound scan is a noninvasive method to assess bladder volume for determining bladder distention or postvoid residual urine. This portable battery-operated device can be used at the bedside as a noninvasive replacement to intermittent catheterization (Fig. 41-2). This painless procedure eliminates discomfort, embarrassment, and risks associated with catheterization. Data from the bladder ultrasound scan can be printed and become part of the patient’s chart. Depending on the volume and whether the patient is capable of voiding, straight catheterization should be performed to relieve urinary retention; this procedure is typically done with volumes greater that 300 mL. A bladder ultrasound scan can be repeated as necessary and has been shown to decrease the risk of urinary tract infections associated with intermittent catheterization.7
FIG. 41-2 Using a bladder scanner to determine amount of urine in the bladder.
(From deWit S: Fundamental concepts and skills for nursing, ed 3, St. Louis, 2009, Saunders.)
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