Urological procedures

Question 1

Take a moment to be amazed:

Answer 1

Each individual kidney consists of at least 1 million and up to 2 million nephrons.
If the nephrons in both kidneys are taken out and placed end to end horizontally, they will cover a distance of 16 kilometers (approx. 9 miles).

Question 2

Urinalysis purpose and methods

Answer 2

Purpose:
Routine screen
Assess systemic disorders
Metabolic
Endocrine
Evaluate renal or urinary tract disease
Prenatal  evaluation

Methods:
Physical appearance
Dipstick evaluation
Microscopic evaluation

Question 3

Obtaining a Voided Sample

Answer 3

Male-Expose the glans and urethral meatus, cleanse with a sterilizing agent and dry with sterile cloth. Collect mid-stream urine in a sterile container.

Female-Separate labia to expose urethral meatus. Cleanse the meatus front to back with sterilizing agent. Keep the labia spread and collect mid-stream urine in a sterile container

Question 4

Situations where a voided sample is not adequate

Answer 4

Vaginitis
Menses
Extremes in age
Morbid obesity

Question 5

If the patient cannot void

Answer 5

urine can be obtained by catheterization.
Urethral, Suprapubic, Nephrostomy

Pediatrics usually obtained with a bag frequently called a “Puck” Pediatric Urine Collection Kit

Question 6

Urinalysis Physical appearance

Answer 6

Color
Pink-usually blood
Orange-frequently medications
Blue/green-drugs or ingested dyes, Pseudomonas
Brown/black-myoglobin, bilirubin, rhubarb, medication

Clarity
Cloudy-excess protein or cellular material, infection

Question 7

Dipstick evaluation

Answer 7

Specific gravity- State of hydration
Ketones- Diabetes or starvation
pH- Kidney disease or urinary tract infection
Protein- Kidney disease
Glucose- Diabetes (Threshold is > 180 mg/dL)
Blood- Kidney disease, clotting disorders, stones, cancer
Bilirubin- Liver damage
Leukocyte esterase- Urinary tract infection
Nitrites- Urinary tract infection

• If leukocytes and nitrates are positive there is a 74% predictive value for UTI, and 97% predictive value if both are negative

Question 8

urinalysis- microscopic evaluation

Answer 8

White blood cells - Infection
Red blood cells - Kidney disease, decreased coagulation, cancer
Epithelial cells - Usually contamination but may indicate cancer
Casts - Kidney disease
Crystals - Kidney stones
Bacteria or yeast - Infection

Question 9

microscopic eval: test results

Answer 9

Rare/trace	- under 2  
Occasional/1+		3-5
Frequent/2+		5-9
Many/3+		Large amt
TNTC/4+ 	      Packed field

Question 10

Blood in the urine

Answer 10

RBC’s:
Glomerulonephritis
Cancer
Clotting disorders
Exercise
Stones

WBC’s:
Infection
Inflammation
Injury

Question 11

Casts

Answer 11

RBC casts are indicative of glomerulonephritis, with leakage of RBC’s from glomeruli, or severe tubular damage.

WBC casts are most typical for acute pyelonephritis

Question 12

Crystal formation can be caused:

Answer 12

by an augmentation of concentration beyond the super saturation capacity. This is typically caused by dehydration.
by a decreased supersaturation capacity. This situation could be caused by a decrease in inhibitors of concentration, a neutralization of these inhibitors, by some electrolytes, or a by pH change.
by the presence of crystals with a promoter effect on the crystallization of another species. Crystallization of calcium oxalate promoted by amorphous urates is a good example of this phenomenon.

Question 13

most common crystals and their causes

Answer 13

Calcium Oxalate are most common. The presence of these crystals is without any clinical meaning.

Uric Acid crystals are mainly due to a poor dilution volume at an acidic pH

Question 14

Bacteria

Answer 14

Almost always caused by infection in the urinary tract. E. Coli is the most common organism.

Question 15

24 hour urine collection

Answer 15

Total protein
Calcium, sodium, potassium
Creatinine (Cr)and creatinine clearance (CrCl)
Clearance = Urine Cr (x) Total volume/Plasma Cr (x) Time

Question 16

Urine protein electrophoresis

Answer 16

Measures the levels of both major types of protein in the urine (albumins and globulins).

Question 17

Catheterization of the Bladder indications

Answer 17

Acute urinary retention
Obtain uncontaminated sample
Diagnostic studies (Urodynamics, cystourethrogram)
Monitor urine output – ICU, postoperatively
Measure residual volume
Surgery on adjacent structures
Urinary tract surgery

Question 18

Catheterization of the Bladder contraindication and complications

Answer 18

Contraindications
Known urinary tract obstruction (stricture)
Reconstructive surgery of urethra or bladder neck
Combative or uncooperative patient
Pelvic trauma – suspect urethra injury
Acute infection of the prostate and/or urethra (relative)

Complications
Infection
Hematuria
Urethral stricture

Question 19

Catheterization of the Bladder

Answer 19

Select catheter usually 16-18 French
Check balloon of the catheter
Sterile draping and gloving
Aseptic technique – the hand that cleans and holds the labia or penis should not touch the catheter
Retract foreskin or labia and cleanse the urethral meatus and surrounding area with antiseptic solution
2% lidocaine jelly into urethra
Introduce catheter into urethral meatus
Follow the anticipated course of the urethra and pass approximately 3 inches into the bladder
The balloon should only be inflated after urine is observed flowing through the catheter
Gently pull catheter outward until balloon resting against bladder neck

Question 20

When it is time to remove the Foley catheter, remember to

Answer 20

deflate the balloon first!!!

Question 21

Catheterization of the Bladder- long term use

Answer 21

Chronic retention
Neurogenic bladder with retention
Unable to self cath
Incontinent  with complicated skin breakdown or infection
Comfort measure for terminally ill

Question 22

Suprapubic Catheterization indications

Answer 22

Bladder neck stricture, contracture or obstruction
Inability to pass urethral catheter
Urethral trauma
Recent urethra or bladder neck surgery
Inability to tolerate or unwilling to self cath
Presence of urethral or prostate infection
Severe phimosis
Collect urine sample - analyze, culture
Relief of urinary retention

Question 23

Suprapubic Catheterization contraindications and complications

Answer 23

Contraindications
Uncooperative patient
Blood dyscrasia or anti coagulation treatment
Infection or cellulitis of the suprapubic area

Complications
Peri-vesicular bleeding
Gross hematuria
Infection-skin, subcutaneous, intra-abdominal, bladder
Intestinal perforation

Question 24

Bladder Scan

Answer 24

Portable 3-D ultrasound device which provides quick and non-invasive measurements of the bladder volume and post void residual volume

only gives volumes, not evaluation of bladder structure itself

Question 25

Flow Cystometry

Answer 25

Two catheters are inserted into the bladder. One fills the bladder while the other measures pressures. Used for evaluation of urinary incontinence, an overactive bladder and urinary retention

Question 26

Cystoscopy indications and contraindications

Answer 26

``` Indications Urinary incontinence Known or suspected malignancy Recurrent UTI’s Pelvic pain symptoms Pelvic trauma Intra-operative assessment of bladder or urethral trauma ``` Contraindications: Relative -UTI or pyelonephritis-Can cause sepsis so patient is usually treated with antibiotics before procedure

Question 27

Intravenous Pyelogram(IVP)

Answer 27

An x-ray of the kidneys, ureters, and bladder which uses contrast material (usually iodine based) injected into the vein To detect problems in these areas including kidney stones, cancer, enlarged prostate Can be done using plain films or a CT scan Size of stones and tumors are difficult to measure

Question 28

Computed Tomography

Answer 28

Non-contrast helical CT scan is the gold standard for the radiologic diagnosis of renal stone disease. ***

Question 29

Extracorporeal Lithotripsy

Answer 29

Extracorporeal shock wave lithotripsy (ESWL) is a procedure used to shatter simple stones in the kidney or upper urinary tract. Ultrasonic waves are passed through the body focused to strike the stones. Pulses of the waves pulverize them into smaller fragments, which are easier to pass through the ureter and into the bladder.

Question 30

Intracorporeal Lithotripsy

Answer 30

Patient undergoes cystoscopy Laser is introduced through the cystoscope into the ureter and stones are broken into small pieces that will pass Procedure works well on stones in the ureter.

Question 31

Infant Circumcision- Indications

Answer 31

Parental desire based on religious, ethnic, and cultural preferences May decrease UTI’s and STI’s May decrease penile cancer rate AAP recently stated that the benefits outweigh the risks

Question 32

Infant Circumcision- contraindications

Answer 32

``` Hypospadius or epispadius Atypical genitalia Undetermined phenotype (ambiguous genitalia) Less than 12 hours postpartum Illness Prematurity (Relative) Familial bleeding disorder Maternal thrombocytopenia ```

Question 33

Infant Circumcision- Risks/complications

Answer 33

``` Bleeding Infection Trauma to glans or urethra Poor cosmetic result Paraphimosis Degloving of the penile shaft Meatal stenosis - rare ```

Question 34

Infant Circumcision procedure

Answer 34

Generally less complications than adult Usually done before the newborn goes home Frequently done without anesthesia- that’s not very nice!!! Three Methods : GOMCO, MOGEN, PLASTIBELL

Question 35

circumcision procedures

Answer 35

foreskin clamped at 12 o'clock, doral slit created GOMCO- with bell, some oozing Mogen- very quick plastibell-

Question 36

Adult Circumcision indications

Answer 36

``` Phimosis Paraphimosis Penile hygiene Recurrent balantitis Neoplastic foreskin Excessive foreskin redundancy Frenular tears Patient or spouse preference ```

Question 37

Adult Circumcision - Contraindications | and complications

Answer 37

``` Contraindications Acute inflammation Infection Psychiatric disorder Bleeding disorder ``` ``` Complications Bleeding Hematoma Infection Pain with erection Stricture or scarring Wound disruption usually due to erection ```

Question 38

Vasectomy indications, contraindications

Answer 38

Indications Undesired fertility Contraindications: Infection Coagulation disorder Inability to palpate or elevate vas deferens Stress – divorce, financial Inappropriate reasons for wanting procedure Concern about ability to perform sexually after the procedure