41 Care of the genitourinary surgical patient
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.
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.
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.
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.
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.
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.
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. In caring for patients undergoing genitourinary surgeries, the perianesthesia nurse should have an understanding of anatomic location and normal function of this system. Adrenalectomy is included in this chapter for convenience and because of the proximity of the adrenal glands to the kidneys.
Although there is an increase in the use of noninvasive diagnostic procedure, several invasive diagnostic procedures are performed on patients with genitourinary disease. If patients require monitored anesthesia care (MAC), spinal anesthesia, or general anesthesia, they are admitted to the postanesthesia care unit (PACU) for postanesthesia care.
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 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
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
The patient should be observed for signs of sepsis, because infection may spread throughout the urinary tract or into the blood stream after a cystoscopy. If symptoms of sepsis, such as chills, tachycardia, tachypnea, flushing, and temperature elevation, are noted, the surgeon should be notified.
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).
FIG. 41-1 A, Types of large-diameter catheters. 1, Conical tip urethral catheter, one eye. 2, Robinson urethral catheter. 3, Whistle-tip urethral catheter. 4, Coudé hollow olive-tip catheter. 5, Malecot self-retaining, four-wing urethral catheter. 6, Malecot self-retaining, two-wing catheter. 7, Pezzer self-retaining drain, open-end head, used for cystotomy drainage. 8, Foley-type balloon catheter, one limb of distal end for balloon inflation (i), one for drainage (ii). 9, Foley-type, three-way balloon catheter, one limb of distal end for balloon inflation (i), one for drainage (ii), and one to infuse irrigating solution to prevent clot retention within the bladder (iii). B, Straight catheter.
(A, From Canale ST, Beaty JH: Campbell’s operative orthopaedics, ed 11, St. Louis, 2008, Mosby. B, From Potter PA, Perry AG: Fundamentals of nursing, ed 7, St. Louis, 2009, Mosby.)
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 alcohol or povidone-iodine (Betadine), the needle inserted, and a specimen withdrawn.
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 are 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.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 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
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
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
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
(From deWit S: Fundamental concepts and skills for nursing, ed 3, St. Louis, 2009, Saunders.)
In looking at urinary retention after spinal anesthesia, Feliciano and colleagues performed a retrospective, descriptive, exploratory study. This study evaluated incidence of postoperative urinary retention (POUR) and how it affects the length of stay (LOS) as well as the characteristics of POUR. A log of patients receiving spinal anesthesia was kept and reviewed for patient inclusion in the study. Of the 102 charts reviewed, complete data was available for 90 patients who met inclusion criteria that included 18 years of age or older, having spinal anesthesia only, and admission to the postanesthesia care unit (PACU) without an indwelling catheter. The incidence of POUR in the study facility was found to be 44.1%. Patients with POUR averaged a longer LOS by 26 minutes. POUR was defined as urine greater than 500 mL of bladder volume upon admission with inability to void for 30 minutes or longer. Complications of POUR include damage to the detrusor muscle and ischemia, increased vulnerability to urinary tract infections from high bladder pressures, tachycardia, and hypertension.
Nursing assessment should include assessing for POUR. This can be accomplished with the use of a noninvasive bladder scan at the bedside. By instituting a protocol for assessment of POUR, the patient physically and psychologically benefits with a decrease in LOS in the PACU, patient comfort, and prevention of complications of bladder distention.
Source: Feliciano T, et al: A retrospective, descriptive, exploratory study evaluating incidence of postoperative urinary retention after spinal anesthesia and its effect of PACU discharge, J Perianesth Nurs 23(6):94-400, 2008.