Urological procedures Flashcards
Take a moment to be amazed:
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).
Urinalysis purpose and methods
Purpose: Routine screen Assess systemic disorders Metabolic Endocrine Evaluate renal or urinary tract disease Prenatal evaluation
Methods:
Physical appearance
Dipstick evaluation
Microscopic evaluation
Obtaining a Voided Sample
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
Situations where a voided sample is not adequate
Vaginitis
Menses
Extremes in age
Morbid obesity
If the patient cannot void
urine can be obtained by catheterization.
Urethral, Suprapubic, Nephrostomy
Pediatrics usually obtained with a bag frequently called a “Puck” Pediatric Urine Collection Kit
Urinalysis Physical appearance
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
Dipstick evaluation
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
urinalysis- microscopic evaluation
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
microscopic eval: test results
Rare/trace - under 2 Occasional/1+ 3-5 Frequent/2+ 5-9 Many/3+ Large amt TNTC/4+ Packed field
Blood in the urine
RBC’s: Glomerulonephritis Cancer Clotting disorders Exercise Stones
WBC’s:
Infection
Inflammation
Injury
Casts
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
Crystal formation can be caused:
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.
most common crystals and their causes
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
Bacteria
Almost always caused by infection in the urinary tract. E. Coli is the most common organism.
24 hour urine collection
Total protein
Calcium, sodium, potassium
Creatinine (Cr)and creatinine clearance (CrCl)
Clearance = Urine Cr (x) Total volume/Plasma Cr (x) Time
Urine protein electrophoresis
Measures the levels of both major types of protein in the urine (albumins and globulins).
Catheterization of the Bladder indications
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
Catheterization of the Bladder contraindication and complications
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
Catheterization of the Bladder
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
When it is time to remove the Foley catheter, remember to
deflate the balloon first!!!
Catheterization of the Bladder- long term use
Chronic retention Neurogenic bladder with retention Unable to self cath Incontinent with complicated skin breakdown or infection Comfort measure for terminally ill
Suprapubic Catheterization indications
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
Suprapubic Catheterization contraindications and complications
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
Bladder Scan
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
Flow Cystometry
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
Cystoscopy indications and contraindications
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
Intravenous Pyelogram(IVP)
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
Computed Tomography
Non-contrast helical CT scan is the gold standard for the radiologic diagnosis of renal stone disease.
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Extracorporeal Lithotripsy
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.
Intracorporeal Lithotripsy
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.
Infant Circumcision- Indications
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
Infant Circumcision- contraindications
Hypospadius or epispadius Atypical genitalia Undetermined phenotype (ambiguous genitalia) Less than 12 hours postpartum Illness Prematurity (Relative) Familial bleeding disorder Maternal thrombocytopenia
Infant Circumcision- Risks/complications
Bleeding Infection Trauma to glans or urethra Poor cosmetic result Paraphimosis Degloving of the penile shaft Meatal stenosis - rare
Infant Circumcision procedure
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
circumcision procedures
foreskin clamped at 12 o’clock, doral slit created
GOMCO- with bell, some oozing
Mogen- very quick
plastibell-
Adult Circumcision indications
Phimosis Paraphimosis Penile hygiene Recurrent balantitis Neoplastic foreskin Excessive foreskin redundancy Frenular tears Patient or spouse preference
Adult Circumcision - Contraindications
and complications
Contraindications Acute inflammation Infection Psychiatric disorder Bleeding disorder
Complications Bleeding Hematoma Infection Pain with erection Stricture or scarring Wound disruption usually due to erection
Vasectomy indications, contraindications
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
