Genitourinary surgery involves procedures performed on the kidneys, ureters, bladder, urethra, and male genitalia. The genitourinary system can be the host of multiple problems, either congenital or acquired. When caring for patients undergoing genitourinary surgeries, the perianesthesia nurse should understand the anatomic location and normal function of this system for effective care.
Genitourinary surgery involves procedures performed on the kidneys, ureters, bladder, urethra, and male genitalia. The genitourinary system can be the host of multiple problems, either congenital or acquired.1,2 When caring for patients undergoing genitourinary surgeries, the perianesthesia nurse should understand the anatomic location and normal function of this system for effective care.
Education and research is increasing the community’s awareness of screening, leading to early detection of prostate, bladder, and kidney cancer.3,4 Improvements in treatment such as minimally invasive approaches make treatment less invasive and more tolerable for patients.2
AdrenalectomyPartial 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.
ChordeeDownward bowing of the penis as a result of congenital malformation or hypospadias with fibrous bands.
CircumcisionExcision of the foreskin (prepuce) of the glans penis.
CystectomyExcision 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.
CystolithotomyOpening of the bladder for removal of stones.
CystoscopyDirect visualization of the urethra, prostatic urethra, and bladder by means of a tubular lighted telescopic lens.
CystotomyAn incision into the bladder.
EpididymectomyExcision of the epididymis from the testis. This procedure is rarely done but may occasionally be indicated for treatment of persistent infection.
EpispadiasUrethral meatus situated in an abnormal position on the upper side of the penis. Surgical correction involves plastic repair.
Extracorporeal Shock Wave LithotripsyUse of shock waves through a liquid medium into the body to disintegrate stones.
HeminephrectomyPartial excision of the kidney.
HydrocelectomyExcision of the tunica vaginalis of the testis for removal of a hydrocele (a fluid-filled sac).
HypospadiasA 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 PyelogramA radiologic procedure in which intravenous (IV) dye is injected to assist in the visualization of renal structure. This procedure is used to diagnose abnormalities and look for blockages.
Kidney TransplantRemoval of a donor kidney with nephrectomy and ureterectomy followed by transplantation of the donor kidney into the recipient’s iliac fossa.
NephrectomyRemoval 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.
NephrostomyAn opening into the kidney for temporary or permanent drainage.
NephrotomyAn incision into the kidney.
NephroureterectomyRemoval of a kidney and the entire ureter that drains it.
OrchiectomyRemoval of the testis or testes. This procedure renders the patient sterile.
OrchiopexySuspension 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 ImplantA penile prosthesis implanted for treatment of organic sexual impotence.
Percutaneous NephrolithotomyRemoval or disintegration of renal stones with passage of a nephroscope through a percutaneous nephrostomy tract.
PhimosisTightness of the foreskin so that it cannot be drawn back from over the glans; also, the analogous condition in the clitoris.
ProstatectomyEnucleation of prostatic adenomas or hypertrophied masses.
PyeloplastyRevision or reconstruction of the renal pelvis.
PyelostomyAn incision into the renal pelvis for drainage or for irrigation of the renal pelvis.
PyelotomyIncision into the renal pelvis.
Radical ProstatectomyCommon surgical treatment for prostate cancer in young men where the entire prostate is removed.
SpermatocelectomyThe 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 SurgeryPiecemeal 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 SlingMidurethral 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.
UreterectomyComplete removal of one or both of the ureters.
UreterolithotomyIncision into the ureter and removal of stones.
Ureteroneocystostomy (Ureterovesical Anastomosis; Vesico-Psoas Hitch Procedure)Division of the ureter from the urinary bladder and reimplantation of the ureter into the bladder at another site.
UreteroplastyReconstruction of the ureter.
UreteroscopyDirect 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 brought out through the abdominal wall as an ileostomy.
Urethral Dilatation and Internal UrethrotomyGradual dilation of the urethra and lysis of a urethral stricture.
Urethral MeatotomyIncisional enlargement of the external urethral meatus for relief of stenosis or stricture.
UrethroplastyReconstructive surgery of the urethra.
Urethrovesical Suspension (Pubovaginal Slings)Suspension of the urethra with a permanent polypropylene mesh tape for the treatment of stress incontinence.
VaricocelectomyLigation and partial excision of dilated veins in the scrotum.
VasectomyExcision 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.
VasoepididymostomyAnastomosis of the vas deferens to the epididymis.
VasovasostomyAnastomosis of two separate segments of the vas deferens for reversal of a vasectomy.
Vesicourethral SuspensionSuspension of the bladder neck to the posterior surface of the pubis in women for treatment of stress incontinence.
When invasive diagnostic procedures are performed on patients with genitourinary disease, anesthesia may be administered based on the level of sedation that the patient requires.2,4 Regardless of whether patients require monitored anesthesia care (MAC), spinal anesthesia, or general anesthesia, they are admitted to the postanesthesia care unit (PACU) for postanesthesia monitoring.9 The duration of this monitoring is determined by the level of anesthesia administered. This monitoring will be continued for several hours if the patient is placed under general anesthesia; however, lower levels of anesthesia can allow for same-day discharges once the patient has been determined to be in stable condition.
For a renal angiographic examination, a small catheter is threaded through the femoral artery into the aorta or renal artery. Before this procedure, special note should be taken of the kidney function because the contrast agents that are used in this procedure can further impair kidney function. In this case, acetylcysteine can be used as a kidney protectant which reduces the risk of further damage.10,11
During the procedure, a low-osmolality contrast agent is instilled and radiographs are made. Local anesthesia is usually all that is needed; however, general anesthesia may be used for children or patients who cannot remain still 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.9,10–12
Renal biopsy is usually performed at the bedside with only local anesthesia, although general anesthesia may be used for children or patients who cannot remain still during the procedure. The patient should maintain on bed rest in a supine position for up to 4 hours post procedure. If the patient has had a previous transplant, the provider may order the patient 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, straining, and other activities that increase abdominal venous pressure should be avoided. Fluids should be increased to 3000 mL daily, and the urine should be monitored for occult blood.12
Diagnostic cystoscopy may be performed in multiple arenas. In the hospital setting, a special procedures room is used, although this surgery may also be done in an outpatient procedure area in a specialist’s office. Anesthesia ranges from local anesthesia and sedation up to general anesthesia for patients who cannot tolerate the procedure or who cannot stay still. This procedure can also be performed with spinal anesthesia. Cystoscopy is commonly done by urologists in the office when only local anesthesia is required. Women with pelvic pain may have a cystoscopy during gynecologic surgery to see if there is a urologic component.7 Diagnoses including endometriosis, adhesions, insufficient ureteral flow (often checked upon completion of a hysterectomy or pelvic floor reconstruction), decreased bladder capacity, or IC are all possible causes of pain.5–8 In the case of IC, patients are followed by a urologist and treated on an outpatient basis with medication.8
On admission to the PACU, the patient is positioned to ensure airway patency if general anesthesia was used.9 The patient may have to lie flat on the back if spinal anesthesia was used, with a gradual increase in the head of the 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. IV pain medicine may be administered to relieve patient discomfort as prescribed by the surgeon. Patients who leave the hospital, surgery center, or physician’s office with a catheter are often prescribed medication to help with any discomfort of the catheter. The patients also need to be instructed on catheter self-care to prevent infection. For some patients, self-catheterization is recommended. In this case, the patient must be instructed on how to withdraw and reinsert the catheter while paying particular attention to trauma and the risk of infection.9,12
Ice chips and oral fluid administration should be encouraged and started as soon as the effects of anesthesia have worn off enough that it is safe to do so. 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. Female patients who undergo cystoscopy as an adjunct to their gynecologic procedure are often not aware of the potential side effects postoperatively that may occur, such as blood in their urine and/or burning. It is not unusual for patients to be fearful of waking up with a catheter because of a prior experience (e.g., someone pulling on the catheter) or stories they have heard from others. Oftentimes in the PACU, patients feel the urge to urinate, and nurses need to reassure them it is normal because of the catheter in place.
The urine may be pink-tinged in the PACU and for the next several times the patient voids. Bright blood or clots in the urine, however, should be reported to the surgeon immediately. Severe abdominal pain should be reported because it can indicate accidental urethral or bladder perforation or internal hemorrhage. Urine color might also change depending on medications the patients are given.
The patient should be observed for signs of sepsis because infection may spread throughout the urinary tract or into the bloodstream after a cystoscopy. If symptoms of sepsis, such as chills, tachycardia, tachypnea, flushing, and temperature elevation are noted, the surgeon should be notified. The surgeon should also be notified of difficulty in urinating, pressure, or the patient feeling that he or she is unable to completely empty the bladder.12 Patients need to be instructed that flank pain (low back pain) on either side can sometimes be indicative of a urinary tract infection, and the surgeon needs to be notified as well.
Assessment of the patient after genitourinary surgery involves particular attention to fluid and electrolyte balance.12 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).
Urethral catheters are used to drain urine from the bladder for decompression and accurate measurement of urine output. An indwelling catheter may be used after surgery and left in place until the patient’s condition is stable and the surgeon orders its removal. The catheter is attached to a sterile closed gravitational drainage collection system. The urine collection reservoir may be a large (usually 2000 mL) container or a small, calibrated chamber that can be emptied into a large reservoir after timed urine output volumes have been determined and recorded.
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.
For collection of a urine specimen from the closed system, a sterile syringe and needle are used. Some catheters have a small specially constructed port from which to draw specimens. On those catheters that do not have such a port the distal part of the catheter, close to the drainage tube, is used. The area is cleansed with povidone-iodine (Betadine)—provided the patient is not allergic; otherwise the surgeon is consulted for another choice—the needle inserted, and a specimen withdrawn.
Mucus, 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.2,9
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.13 The report from the perioperative nurse should include the amount of intraoperative irrigation and the duration of the procedure.14 During the immediate postanesthesia phase, patient confusion should be monitored and differentiated from confusion resulting from amnesiacs, opioids, or hyponatremia (see also the Prostatic Surgery section in this chapter).12,13
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.13
At the completion of a urologic procedure, a suprapubic catheter may be used to drain residual urine from the bladder. A temporary catheter can be placed into the urinary bladder via a stab wound through the lower abdomen and into the anterior bladder wall. The catheter is sutured in place, and a dressing is applied (usually a type of dressing that allows direct observation of the puncture site). The catheter is connected to a straight gravitational drainage system. Care of the suprapubic catheter is similar to that of the urinary catheter. The catheter should be taped securely with a loop made to prevent tension on the bladder wall or the abdomen. The skin around the puncture site should be kept clean and dry. The catheter tubing should be checked periodically for kinks and to ensure that the stopcock valve is open to allow the urine to drain from the bladder.
A suprapubic catheter can also be placed into the urinary bladder via abdominal incision and cystostomy.2 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.13,14
Ureteral catheters are used to drain urine or splint the ureters while they heal.15,16 Ureteral catheters may be used when there is a risk of occlusion of the ureter, as with stones. In the event of a ureteral injury or surgery around the ureter that may result in significant swelling/inflammation postoperatively, a ureteral stent is used to ensure that the ureter remains open. The stent may remain in place for several weeks postoperatively and will be removed in the urologist’s office. In the case of a more extensive injury, ureteral reimplantation is done laparoscopically (with or without the assistance of the robot) or via laparotomy. The approach taken will depend on the specific location of the injury and laparoscopic skill of the surgeon. Reimplantation may require the ureteral stent to remain in place for a longer period of time. The catheters can be placed through the urethra (during cystoscopy) or through abdominal or flank incisions.15,16 Care of ureteral 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.15,16
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 nursing staff must be sure to avoid situations that can cause dislodgment or displacement of these catheters or stents, which could be disastrous to the outcome of the surgery. Special care must be taken during patient transfer to ensure that catheters or stents stay in place. One person should be assigned this responsibility during the transfer. If the catheters or stents become dislodged despite all the precautions taken, the surgeon must be notified immediately.15,16
Optimal fluid intake is exceptionally important for the patient after surgery. Increased fluids should be given orally if the patient can tolerate this preferred route. Intake should be increased to total of 3000 mL in a 24-hour period. Special consideration regarding the 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.12
Care of dressings varies according to the procedure and can include anything from a bulky dressing to Steri-Strips or bandages. Many patients are allergic to latex or adhesives, and this must be taken into account when dressings are used.14 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.12 (Excessive staining that is unexpected for a particular procedure and indicates a complication is 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.9,12
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 can arrive with nasogastric tubes, the care of 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 when bladder distention is present or postvoid residual urine is suspected. This portable battery-operated device can be used at the bedside as a noninvasive replacement of intermittent catheterization (Fig. 41.2). By using ultrasound, you are reducing any risk of infection that would be present with unnecessary catheterization. Additionally, this is a painless procedure, which is not true of 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 may need to be performed to relieve urinary retention; this procedure is typically done with volumes greater that 200 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. The physician’s orders should reflect when they should be contacted with regard to residual urine and recatheterization. The physician will determine whether the patient needs to be discharged with a catheter in place. The perianesthesia nurse should include how to care for the catheter and when to return to see the urologist in any discharge instructions.
Discomfort after genitourinary surgery can be relieved with the administration of various types of opioids as well as other medications. These medications may include IV morphine, hydromorphone, or fentanyl and/or oral oxycodone or hydrocodone or opium suppositories. Pain management may include a pain pump such as IV hydromorphone for inpatients. IV nonsteroidal anti-inflammatory drugs (NSAIDs) and/or IV acetaminophen may also be given as a nonopioid adjunct. Patients are gradually converted from IV medication to oral pain medications as soon as possible after the procedure, and almost always before discharge. Many larger hospitals have a pain management service, and surgeons can order pain management services to evaluate the patient for pain when pain is not adequately controlled. Educating the patient on side effects of pain medications such as sedation, nausea, and/or constipation should be included in the postoperative discharge teaching.
In an outpatient setting, oral medications such as oxycodone and hydrocodone may be prescribed for use after discharge. It is important to stress to patients that they use nonprescription medications for pain such as NSAIDs, as long as there is no sensitivity to them, to decrease the amount of opioids needed. See Chapter 31 for more information on pain management.
The physiology of the need to void should be explained to the patient before surgery and again at time of discharge. The patient should be instructed not to attempt to void around the catheter because exertion of pressure causes the bladder muscles to contract and results in painful bladder spasms. Increasing fluid intake decreases bladder irritability and spasms. As the nerve endings become fatigued, the frequency and severity of the spasms diminish.
Procedures that involve the kidneys and ureters include excision of tumors and obstructions to urine flow (e.g., stones), reconstruction of urine outflow tracts, repair of lacerations or injury, correction of deformities, excision of a kidney, and total organ transplant.