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GENITOURINARY SYSTEM

595

Clinical Tip

• Pulmonary hygiene treatments can be performed during

dialysis; however, this depends on the hemodynamic stability of the patient and is at the discretion of the nurse or physician. Extreme caution should be taken with the

access site to prevent accidental disruption.

• The dialysis nurse is generally nearby to monitor the

procedure and is a valuable source of information regarding the patient's hemodynamic stability.

• Activity tolerance can be altered when fluid and electrolyte

levels are unbalanced. Patients will demonstrate variable levels

of fatigue; some are more fatigued before a dialysis session,

whereas others are more fatigued after a dialysis session.

• Fluid and electrolyte imbalance can also alter the hemodynamic responses to activity; therefore, careful vital sign and symptom monitoring should always be performed.

Surgical Interventions

Surgical interventions for genitourinary system disorders can be categorized broadly as procedures that remove diseased portions of the genitourinary tract or procedures that restore urinary flow. These

interventions are briefly discussed in the following sections. Refer to

Appendix V for general postoperative considerations.

Nephrectomy

There are three types of nephrectomy. The primary indications for

removing a part or all of the kidney include renal tumor, polycystic kidney disease, severe traumatic injury to the kidney, and organ donation, as well as removing a failing transplanted organ.47•48 Nephrectomy can be

performed as an open or laparoscopic procedure. Open nephrectomy is

the conventional method that requires an incision of approximately 7 in.

Laparoscopic nephrectomy involves five access sites, ranging from less

than 0.5 in. to 3 in. Laparoscopic nephrectomy is gaining acceptance as a

viable alternative to open nephrectomy, as there have been fewer postoperative complications associated with the procedure.47-so The types of nephrectomy and their definitions follow:

Radical nephrectomy-removal of the entire kidney, a section of the

ureter, the adrenal gland, and the fatty tissue surrounding the kidney.

596

AClTrE CARE HANDBOOK FOR I)HYSICAL TIIERAPISTS

Simple nephrectomy removal of rhe entire kidney wirh a secrion

-

of the ureter. Generally performed when harvesting donor organs for

kidney transplantation.

Partial Ilephrectomy-only the infected or diseased portion of the

kidney is removed.

Open Prostatectomy

Open prostatectomy is the surgical removal of a prostate gland

with or without irs capsule and is primarily indicated for parienrs

with prostare cancer. Five types of surgical approaches can be used:

( 1) transcoccygeal, (2) perineal, (3) retropubic, (4) transvesical, and

(5) suprapubic. This procedure is contraindicated if the prostate is

small and fibrou . The suprapubic and retropubic approaches of this

procedure are contraindicated in the presence of cancer.42

Transurethral Resection

Transurethral resectioll refers to the surgica I approach performed

when managing bladder tumors, bladder neck fibrosis, and prostatic hyperplasia. The most common type of transurethral resection is a TURP, which this section focuses on. TURP is indicated for obstructive BPH. Involved tissues arc resected with a resectoscope that is inserted through the urethra. Excision and coagulation of tissue are accompanied by continuous irrigation. Conrra-indications for TURP include the presence of urinary tract infection and a prostate gland weighing more than 40 g. TURP is also contraindicated with conditions that interfere with operative positioning for the procedure, such as irreversible scrotal hernia or ankylosis

of the hip."

Percutaneous Ncph.roscopic Stone Removal

Percutaneous nephroscopic stone removal involvcs rhe removal of

stones formed in the urinary tract with a perclltaneous nephrostomy

tube that is placed under fluoroscopic monitoring. Depending on the

size of the stone, stones may need to be broken up, thcn removed with

a basket. Small fragments can be flushed through the system mechanically or physiologically. Considerations for this procedure include controlling septicemia before removal of the stones.42

Open Urologic Surgery

Open urologic surgery is a large category of surgical procedures that

is beyond the scope of this chapter but includes the following";

•

Nephrolithotomy (renal incisions for kidney stone removal)

GENrrQURINARY SYSTEM

597

• Pyelolithotomy (removal of the kidney stone from the pelvis of the

kidney)

• Ureterolithotomy (removal of a urinary srone from the ureter)

• Cystectomy (bladder removal)

Bladder Neck Suspension

Bladder neck suspension is a procedure used in women ro help resrore

urinary continence by suturing the urethra to the pubic bones, which

increases urethral resistance. It is indicated for women with stress

incontinence as a result of pelvic relaxation. This procedure may also

be called the Marshall-Marchetti-Krantz procedure or retropubic 5115-

pension. Bladder neck suspension is contraindicated in cases of urethral sphincter damage leading to stress inconrinence.42,51.52

Urinary Diversion

Obstructed urinary flow can be resolved by diverting urine with any

of rhcse four procedures: (I) supravesical diversion, (2) incontinent

urinary diversion, (3) continent urinary diversion and, (4) orthotopic

bladder substitution"'"

5upravesical Diversion

A supravesical diversion is one in which the urine is diverted at the level

of the kidney by nephrostomy. Nephrostomy involves placing a catheter

through the renal pelvis and into the renal calyces to temporarily drain

urine into an external collection device (Figure 9-7). Complications, such

as stone formation, infection, hemorrhage, and hematuria, can be associated with long-term ncphrostomy tube placement."'"