Renal Transplantation

The kidneys have several important functions in the body.

• They filter wastes from your bloodstream and maintain the balance of electrolytes in your body.
• They remove chemical and drug by-products and toxins from your blood.
• They eliminate these substances and excess water as urine.
• They secrete hormones that regulate the absorption of calcium from your food (and thus bone strength), the production of red blood cells (thus preventing anemia), and the amount of fluid in your circulatory system (and thus blood pressure). 

 

When blood enters the kidneys, it is first filtered through structures called glomeruli. The second step is filtering through a series of tubules called nephrons.

• The tubules both remove unwanted substances and reabsorb useful substances back into the blood.
• Each of your kidneys contains several million nephrons, which cannot be restored if they are damaged.

Renal failure
Various conditions can damage your kidneys, including both primary kidney diseases and other conditions that affect the kidneys.

• If kidney damage becomes too severe, your kidneys lose their ability to function normally. This is called kidney failure.
• Kidney failure can happen rapidly (acute kidney failure), usually in response to a severe acute (sudden, short-term) illness in another body system or in the kidneys. It is a very common complication in patients hospitalized for other reasons. It is often completely reversible with resolution of the underlying condition.
• Kidney failure can also happen very slowly and gradually (chronic kidney failure), usually in response to a chronic (ongoing, long-term) disease such as diabetes or high blood pressure.
• Both types of kidney failure can occur in response to primary kidney disease as well. In some cases this kidney disease is hereditary.
• Infections and substances such as drugs and toxins can permanently scar the kidneys and lead to their failure.

People with the following conditions are at greater-than-normal risk of developing kidney failure and end-stage renal disease:

• Diabetes (type 1 or type 2)
• High blood pressure - Especially if severe or uncontrolled
• Glomerular diseases - Conditions that damage the glomeruli, such as glomerulonephritis
• Hemolytic uremic syndrome
• Systemic lupus erythematosus
• Sickle cell anemia
• Severe injury or burns
• Major surgery
• Heart disease or heart attack
• Liver disease or liver failure
• Vascular diseases - Conditions that block blood flow to different parts of your body, including progressive systemic sclerosis, renal artery thrombosis (blood clot), scleroderma
• Inherited kidney diseases - Polycystic kidney disease, congenital obstructive uropathy, cystinosis, prune belly syndrome
• Diseases affecting the tubules and other structures in the kidneys - Acquired obstructive nephropathy, acute tubular necrosis, acute interstitial nephritis
• Amyloidosis
• Taking antibiotics, cyclosporin, heroin, chemotherapy - Can cause inflammation of kidney structures
• Gout
• Certain cancers - Incidental carcinoma, lymphoma, multiple myeloma, renal cell carcinoma, Wilms tumor
• HIV infection
• Vesicoureteral reflux - A urinary tract problem
• Past kidney transplant (graft failure)
• Rheumatoid arthritis

Chronic kidney failure is associated with complications that can be debilitating or have a negative effect on quality of life.

• Anemia
• Fluid retention
• Pulmonary edema - Fluid retention in the lungs that can cause breathing problems
• High blood pressure - From chemical imbalances and fluid retention
• Renal osteodystrophy - Weakening of the bones from calcium depletion, can fracture easily
• Amyloidosis - Deposition of abnormal proteins in the joints, causes arthritislike symptoms
• Stomach ulcers
• Bleeding problems
• Neurological damage
• Sleeping problems - Related to dialysis

Kidney Transplant Symptoms

The symptoms of kidney failure vary widely by cause of the kidney failure, severity of the condition, and the other body systems that are affected.

• Most people have no symptoms at all in the early stages of the disease, because the kidneys are able to compensate so well for the early impairments in the their function. Others have symptoms that are mild, subtle, or vague.
• Generally, obvious symptoms appear only when the condition has become severe or even critical.
• Kidney failure is not painful, even when severe, although there may be pain from damage to other systems.
• Some types of kidney failure cause fluid retention. However, severe dehydration (fluid deficiency) can also cause kidney failure.
• Fluid retention - Puffiness, swelling of arms and legs, shortness of breath (due to fluid collection in the lungs, called pulmonary edema)
• Dehydration - Thirst, rapid heart rate (tachycardia), dry mucous membranes (such as inside the mouth and nose), feeling weak or lethargic

Other common symptoms of kidney failure and end-stage renal disease include the following:

• Urinating less than usual
• Urinary problems - Frequency, urgency
• Bleeding - Due to impaired clotting, from any site
• Easy bruising
• Fatigue
• Confusion
• Nausea, vomiting
• Loss of appetite
• Pain - In the muscles, joints, flanks, chest
• Bone pain or fractures
• Itching
• Pale skin (from anemia)

End-stage renal disease cannot be prevented in some cases. You may be able to prevent your kidneys from failing, or slow the progression of the failure, by controlling your underlying conditions.

• Kidney failure has usually progressed fairly significantly by the time symptoms appear. If you are at high risk of developing chronic kidney failure, see your health care provider as recommended for screening tests.
• If you have a chronic condition such as diabetes, high blood pressure, or high cholesterol, follow the treatment recommendations of your health care provider. See your health care provider regularly for monitoring. Aggressive treatment of these diseases is essential to preserving kidney function and preventing complications.
• Avoid exposure to alcohol, drugs, chemicals, and other toxic substances as much as possible.

To learn more about kidney failure, click here.

Kidney Transplantation

When your health care provider makes the diagnosis of end-stage renal disease, he or she will discuss your treatment options. Whether kidney transplantation is an option for you depends on your specific situation. If your health care provider thinks you may be eligible for a transplant, you will learn about the pros and cons of this treatment. If you are a potential candidate, you will undergo a thorough medical evaluation. In the meantime, you will be treated with dialysis.
Kidney transplantation is replacement of nonworking kidneys with a healthy kidney from another person (the donor). The healthy kidney (the "graft") takes over the functions of your nonworking kidneys. You can live normally with only one kidney as long as it functions properly.
The transplantation itself is a surgical operation. The surgeon places the new kidney in your abdomen and attaches it to the artery that supplied blood to one of your kidneys and to the vein that carries blood away from the kidney. The kidney is also attached to the ureter, which carries urine from the kidney to the bladder. Your own kidneys are usually left in place unless they are causing you problems, such as infection.
Every operation has risks, but kidney transplantation is not a particularly difficult or complicated operation. It is the period after the surgery that is most critical. Your medical team will watch very carefully to make sure that your new kidney is functioning properly and that your body is not rejecting the kidney.
Are you eligible for a transplant?
Before you can receive a kidney transplant, you must undergo a very detailed medical evaluation.

• This evaluation may take weeks or months and require several visits to the transplant center for tests and examinations.
• The purpose of this thorough evaluation is to test whether you would benefit from a transplant and can withstand the rigors of the surgery and antirejection medications and the adjustment to a new organ.

Your medical team, which includes a nephrologist, a transplant surgeon, a transplant coordinator, a social worker, and others, will conduct a series of interviews with you and your family members.

• You will be asked many questions about your medical and surgical history, the medications you take and have taken in the past, and your habits and lifestyle.
• It will seem like they ask every imaginable question at least twice! It is important that they know every detail about you that could bear on a future transplant.
• They also want to make sure you are mentally prepared for following the necessary medication regimen.

You will also have a complete physical examination. Lab tests and imaging studies complete the evaluation.

• Your blood and tissue will be typed so that you can be matched to a donor kidney. This significantly lessens the chance of rejection.
• You will have blood and urine tests to monitor your creatinine level, other organ functions, and electrolyte levels.
• You will have x-rays, ultrasounds, CT/MRI scans, and other imaging tests as needed to make sure your other organs are healthy and functioning.

Any of the following conditions significantly increase your chance of rejecting the new kidney and may make you ineligible for transplant:

• Active cancer
• HIV infection
• Serious heart or lung disease
• Positive results for hepatitis C
• Severe infection

Potential kidney donors also must be in good health and undergo a thorough medical evaluation.
If you are considered eligible for a transplant, every effort will be made to find a donor among your family members (who are most likely to match) and friends. If no suitable donor can be found, your name will be added to the waiting list for a donor kidney.

• This list is administered by the Organ Procurement and Transplantation Network, which maintains a centralized database of everyone waiting for a transplant and of living donors.
• OPTC is run by the United Network for Organ Sharing, a private nonprofit organization.
• Every new kidney that becomes available is tested and checked against this list to find the most perfect match.

       

Kidney Transplant Medical Treatment

The most critical part of kidney transplantation is preventing rejection of the graft kidney.

• Different transplant centers use different drug combinations to fight rejection of a transplanted kidney.
• The drugs work by suppressing your immune system, which is programmed to reject anything "foreign," such as a new organ.
• Like any medication, these drugs can have unpleasant side effects.
• Some of the most common immune-suppressing drugs used in transplantation are described here.
  • Cyclosporine: This drug interferes with communication between the T cells of the immune system. It is started immediately after the transplant to suppress your immune system and continued indefinitely. Common side effects include tremor, high blood pressure, and kidney damage. These side effects are usually related to the dose and can often be reversed with proper dosing.
  • Corticosteroids: These drugs block T-cell communication as well. They are usually given at high doses for a short period immediately after the transplant and again if rejection is suspected. Corticosteroids have many different side effects, including easy bruising of the skin, osteoporosis, avascular necrosis (bone death), high blood pressure, high blood sugar, stomach ulcers, weight gain, acne, mood swings, and a round face. Because of these side effects, many transplant centers are trying to reduce the maintenance dose of the drug as much as possible or even to replace it with other drugs.
  • Azathioprine: This drug slows the production of T cells in the immune system.Azathioprine isusually used for long-term maintenance of immunosuppression. The most common side effects of this drug are suppression of the bone marrow, which produces blood cells, and liver damage. Many transplant centers are now using a newer drug called mycophenolate mofetil instead of azathioprine.
  • Newer antirejection drugs include tacrolimus, sirolimus, and mizoribin, among others. These drugs are now being used to try to reduce side effects and to replace drugs after episodes of rejection.
  • Other costly and experimental treatments include using antibodies to attack specific parts of the immune system to decrease its response.

Outlook After Kidney Transplantation

Self-care at home The period immediately following your transplant can be very stressful. You will not only be recovering from major surgery, you will also be anxious about organ rejection.

• You, your family, and the transplant coordinators must keep in contact and close follow-up with the transplant team.
• Before leaving the hospital, you will be given instructions on proper doses of and schedule for antirejection medication. Keeping track of these medications is extremely important, because they can actually harm your transplanted kidney if the doses are not appropriate.
• You will be taught how to measure your blood pressure, temperature, and urine output at home, and you should keep a log of these readings.
• Your social worker and dietitian will counsel you before you leave the hospital.

In the first few weeks after leaving the hospital, you will meet with members of your team frequently to monitor your recovery, review the logs, undergo blood tests, and adjust medication doses.
The outcome for kidney transplants continues to improve with advances in immune-suppressing medications.

• In the United States, the 3-year graft survival rate after transplantation is almost 80%.
• The earlier you can detect rejection, the better the chance it can be reversed and the new kidney's function preserved.

Complications

• Rejection
• Infection
• Cancer: Certain cancers, such as basal cell carcinoma, Kaposi sarcoma, carcinoma of the vulva and perineum, non-Hodgkin lymphoma, squamous cell carcinoma, hepatobiliary carcinoma, and carcinoma in situ of the uterine cervix, occur more frequently in people who have undergone kidney transplantation.
• Relapse: A small number of people who undergo transplantation for certain kidney disease experience a return of the original disease after the transplant.
• High blood cholesterol level
• Liver disease
• Weakening of the bones

Women who wish to become pregnant are usually told to wait for 2 years after the operation. Many women have taken their pregnancies to term after transplantation, but there is an increased risk of kidney rejection and fetal complications.
Signs of kidney rejection
One of your greatest concerns as a transplant recipient will be that your body's immune system will reject and attack the transplanted kidney. If not reversed, rejection will destroy the transplanted organ. For this reason, you and your family must keep aware of warning signs and symptoms of rejection. You must contact the transplant team immediately if any of these symptoms develop.

• Hypertension (high blood pressure) - An ominous sign that the kidney is not functioning properly
• Swelling or puffiness - A sign of fluid retention, usually in the arms, legs, or face
• Decreased urine output

If you are a kidney transplant recipient, any of the following symptoms warrant immediate care at a hospital emergency department, preferably the hospital where the transplant was done.

• Fever - A sign of infection
• Abdominal pain
• Tenderness, redness, or swelling at the surgical site
• Shortness of breath - A sign of fluid retention in the lungs

Follow-up

You must keep follow-up appointments with your transplant team to monitor for signs of rejection.

• You will have regular blood and urine tests to detect any signs of organ failure. One or more ultrasounds of the graft kidney may be done to see if there are structural abnormalities suggesting rejection.
• An arteriogram or nuclear medicine scan may be needed to confirm that blood is flowing to the transplanted kidney.

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Torsion of testis or testicular torsion

   It is a condition in which the testicle rotates on the spermatic cord which supplies blood for the testicles. This result in block of blood supply to testicles causing sever pain and swelling. It is common in males of age group under 25.
                                
     In the fetus the testicle develops within the abdomen and migrates down into the scrotum, trailing its blood supply behind it like a leash. In the scrotum the testicle resides within a smooth sack called the tunica vaginalis. The testicle can spin and move about within the sack. As males grow and age the testicle develops connections with the sack making it harder for the testicle to spin or twist. This is why torsion is usually seen in younger men, adolescents, and children.
It can occur during fetal development leading to neonatal torsion or vanishing testis and is one of the main cause for monarchism (single testicle).
It needs emergency treatment to save the testicles. Other wise it can lead to permanent damage to the testicles leading  to necrosis of testis and atrophy of testis. It can lead to sterility

Signs and symptoms of testicular torsion

• Severe sudden pain in the scrotum.
• Swelling of the scrotum.
• Redness of skin of the scrotum.
• Lower abdominal pain.
• Fever.
• Testicle is positioned at an higher level than normal or at an odd angle.

Tests and diagnosis

• Physical examaintion.
• Urine analysis.
• Testicular ultrasound.
• Nuclear scan of the testicles.
• Surgical exploration.

Treatment of testicular torsion

• Manual detorsion of the torsed testis can be attempted. It is difficult since it is very painful and may not be successful.
• Testicular torsion is an medical emergency requiring immediate treatment. It is called orchidopexy. If treated with in 6 hours 100% chance are there for saving the testicle. During surgery the testicle on other side is also anchored as a preventive measure.

Medical Treatment

If your doctor suspects torsion, a urologist will be notified. Depending on your history and physical, you may either be brought to the operating room or you may have imaging done. Occasionally a testicular torsion may be manually detorsed (untwisted by hand) by a physician.

Medications

In the emergency room, the patient with testicular torsion will probably receive a narcotic such as morphine for pain relief.
Surgery
The goal of surgery is to salvage the testicle. If the testicle cannot be salvaged, the testicle is removed (a procedure known as orchiectomy). If the testicle is detorsed successfully, it will be sutured within the scrotum so that it can no longer twist (called orchiopexy). The other testicle will also undergo the same fixation to the scrotum.
Other Therapy
Patients who have a nonviable testicle may return for the insertion of a prosthetic testicle. This will be done only after the urologists feels that healing from the surgery is complete.

Next Steps

After surgery, the patient will learn if the testicle was able to be salvaged.

Follow-up

The surgeon will inform the patient as to when follow-up is needed.

Prevention

The orchiopexy should prevent further episodes of torsion.

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Prostatectomy

        Open prostatectomy is surgery to remove an enlarged prostate that's causing urinary symptoms. With open prostatectomy, your doctor will remove your entire prostate through a cut (incision) beneath your navel. For most men, open prostatectomy generally requires a hospital stay of a few days, and a few weeks of recovery.
Open prostatectomy is one of several alternatives for treating an enlarged prostate, a condition also known as benign prostatic hyperplasia (BPH). Other treatments include medications, transurethral resection of the prostate (TURP), transurethral microwave therapy (TUMT), transurethral needle ablation (TUNA), and laser surgery. Open prostatectomy is the most invasive of all treatments for enlarged prostate.
                                       
Indication
Open prostatectomy is a procedure to treat urinary symptoms caused by an enlarged prostate. These symptoms include:

• · Frequent need to urinate
• · Increased frequency of urination at night (nocturia)
• · Stopping and starting again while urinating
• · Feeling like you can't completely empty your bladder

Open prostatectomy works well at relieving urinary symptoms, but it has a higher risk of complications than do most other enlarged prostate procedures. Although it's more involved than other treatments, open prostatectomy can be the best option for certain men. It's generally reserved for men who have a very enlarged prostate.
Risks
Open prostatectomy can cause temporary problems right after surgery and can also cause long-term problems. Risks of open prostatectomy include:

· Urinary incontinence. In some men, open prostatectomy causes loss of bladder control and an urgent need to urinate. In most cases, this gets better after several weeks to several months.
· Dry orgasm. After prostatectomy, you can still have an orgasm during sex, but you'll ejaculate very little or no semen.
· Urinary tract infection. A urinary tract infection is more likely to occur the longer you have a catheter in place, and may require antibiotics or other treatment.
· Erectile dysfunction. In some cases, open prostatectomy causes erectile dysfunction — the inability to maintain an erection firm enough to have sex. In some men it can improve over time, but in many men it's permanent.
· Narrowing (stricture) of the urethra or bladder neck. This condition blocks the urethra, the tube that carries urine from your bladder, making urination difficult. It may require additional treatment to correct.
· Heavy bleeding. If you lose too much blood during surgery, you may require a blood transfusion. You may store your own blood ahead of time in case this occurs, or you may be given donor blood if needed. In some cases, the surgery area continues to bleed after the procedure and requires further treatment.

Retropubic prostatectomy
Advantages of the retropubic technique over the suprapubic approach include the following:

• Superb anatomic prostatic exposure
• Direct visualization of the adenoma during enucleation to ensure complete removal
• Precise division of the prostatic urethra optimizing preservation of urinary continence
• Direct visualization of the prostatic fossa after enucleation for hemorrhage control
• Minimal to no surgical trauma to the bladder

Suprapubic prostatectomy
The major advantage of the suprapubic approach over the retropubic approach is that it permits better visualization of the bladder neck and ureteral orifices and is therefore better suited for patients with the following conditions:

• Enlarged, protuberant, median prostatic lobe
• Concomitant symptomatic bladder diverticulum
• Large bladder calculus
• Obesity (to a degree that makes access to the retropubic space more difficult)

Simple perineal prostatectomy
Advantages of the perineal prostatectomy approach include the following:

• Ability to avoid the retropubic space (Prior retropubic surgery would make retropubic or suprapubic surgery more difficult.)
• Ability to treat clinically significant prostatic abscess and prostatic cysts
• Less postoperative pain

Contraindications

Disadvantages of retropubic prostatectomy relate largely to the limited access to the bladder, which is an important consideration if a bladder diverticulum requiring excision coexists or when a large bladder calculus must be directly removed. Additionally, if cystoscopy findings indicate that the obstructing adenoma primarily involves the median lobe, the suprapubic approach may be preferred because this technique optimizes anatomic exposure.
The disadvantage of the suprapubic approach relates to reduced visualization of the apical prostatic adenoma and the potential complication of postoperative urinary incontinence and intraoperative bleeding.
The main contraindication and disadvantage to perineal enucleation prostatectomy is performing the procedure in patients for whom sexual potency remains important. This approach invades the perineal neurovascular anatomy more extensively than other available open techniques.

Workup

Laboratory Studies

• Exclude prostate cancer before performing a prostatectomy in patients with symptomatic bladder outlet obstruction. All men should undergo preoperative prostate-specific antigen (PSA) determination and routine digital rectal examination (DRE). Suspicions evoked by either screening modality should prompt a transrectal ultrasound-guided needle biopsy of the prostate to exclude the presence of carcinoma before open (simple) prostatectomy is performed.
• A urinalysis and urine culture, electrolyte study, complete blood cell count, coagulation studies, and at least a type and screen should be obtained in all patients prior to proceeding with an open (simple) prostatectomy.

Imaging Studies

• Although transrectal ultrasonography may help document prostatic size, it is not indicated preoperatively and does not assist in the preoperative screening for prostatic malignancy.
• Imagery of the upper urinary tract is not performed routinely in patients with outlet obstruction unless it is indicated for other reasons (eg, evaluation of hematuria).
• Chest radiography is indicated to investigate potential complications of possible preexisting conditions in patients older than 60 years.

Other Tests

• ECG is indicated to investigate potential complications of possible preexisting conditions in patients older than 60 years.

Diagnostic Procedures

• Cystoscopy is useful for identifying the presence of urethral stricture disease, bladder calculi, diverticula, and a large median lobe. This information is useful in deciding whether to perform a suprapubic versus a retropubic prostatectomy.
• Preoperative lower urinary tract studies may include a urinary flow rate with documentation of postvoid residual and, possibly, a cystometrogram and pressure or flow evaluation in patients with more complex conditions who may have coexisting bladder instability or detrusor function abnormalities.

Treatment

Medical Therapy

A number of treatment options exist for benign prostatic hyperplasia (BPH). Consider medications that act at the level of the prostate and bladder neck. These include alpha-blockers, such as tamsulosin (Flomax), terazosin (Hytrin), doxazosin (Cardura), and alfuzosin (Uroxatral), which relax prostatic and bladder neck smooth muscle. In addition, the 5-alpha-reductase inhibitors, finasteride (Proscar) and dutasteride (Avodart), decrease the size of the prostate. These medications have been shown to improve symptoms of lower urinary tract obstruction.
In patients with outlet obstruction that is recalcitrant (does not respond to medical treatment) or more advanced, minimally invasive procedures are available, including visual laser prostatic ablation, TUIP, and thermotherapy procedures, such as TUMT, TUEVP, and TUNA.

Surgical Therapy

The advantages of open (simple) prostatectomy over TURP include the complete removal of the prostatic adenoma under direct visualization in the suprapubic or retropubic approaches. These procedures do not obviate the need for further prostate cancer surveillance because the posterior zone of the prostate remains as a potential source of carcinoma formation.
The transurethral resection (TUR) syndrome of dilution hyponatremia is unique to TURP and does not occur with open (simple) prostatectomy. The incidence of TUR syndrome during a TURP is roughly 2%. Thus, in patients with a greater risk of congestive heart failure caused by underlying cardiopulmonary disease, open prostatectomy has a much smaller risk of intraoperative fluid challenge.
Open (simple) prostatectomy does have disadvantages when compared to TURP, however, and include the morbidity and longer hospitalization associated with the open procedure and the potential for greater intraoperative hemorrhage.

Preoperative Details

• Exclude prostate cancer before performing prostatectomy in patients with symptomatic bladder outlet obstruction. All men should undergo preoperative PSA determination and routine DRE. Suspicions evoked by either screening modality should prompt a transrectal ultrasound-guided needle biopsy of the prostate before open (simple) prostatectomy is performed. Additionally, preoperative lower urinary tract studies likely include a urinary flow rate with documentation of postvoid residual and, possibly, a cystometrogram and pressure or flow evaluation in patients with more complex conditions who may have coexisting bladder instability or detrusor function abnormalities.
• Patients who present for open (simple) prostatectomy are typically aged 60 years or older. The comorbidities common to this patient population involve not only routine preoperative history, physical examination, and standard serum chemistries but also chest radiography and ECG to investigate potential complications of these potential preexisting conditions.
• If anticoagulants (eg, aspirin, other nonsteroidal anti-inflammatory drugs [NSAIDs], warfarin [Coumadin]) are required preoperatively, coordinate their discontinuation with the ordering physician and correct any significant coagulopathy before surgery.
• Discuss potential risks of open (simple) prostatectomy with the patient preoperatively, including urinary incontinence, erectile dysfunction, retrograde ejaculation, urinary tract infection, and the need for a blood transfusion. Additionally, as with all open pelvic procedures, the risk of deep vein thrombosis and pulmonary embolus always exists.

Laparoscopic and robotic simple prostatectomy
In 2002, Moreno was the first to describe a laparoscopic simple prostatectomy for BPH. Since then, several others have described extraperitoneal laparoscopic prostatectomies for obstructing BPH. Both the transvesical and transcapsular (Millin) techniques have been performed laparoscopically. Most investigators have found laparoscopic simple prostatectomy to be a feasible alternative to the open (simple) technique. However, this technique has a steep learning curve and requires significant laparoscopic expertise.
In 2008, Sotelo et al published their initial experience with a robotic suprapubic simple prostatectomy.^{[5 ]}As with other laparoscopic cases, robotic assistance may prove to be very valuable and may increase the popularity of this minimally invasive approach.

Postoperative Details

Postoperative care of patients who have had an open (simple) prostatectomy parallels care following most major open surgical procedures. Because the need for postoperative blood transfusions is minimized through improvements in understanding of the relevant surgical anatomy and advancements in operative technique, most patients are discharged comfortably on the second day following surgery. For the surgeon, the most significant concern is to observe drain output and fluid status immediately after surgery, as patients generally ambulate and tolerate a regular advancement of their diet by the first day following surgery.

Follow-up

Monitor the patient in the clinic after surgery. If the Foley catheter was not removed during the hospitalization, a voiding trial can be performed on an outpatient basis. Review pathology and schedule follow-up examinations to exclude carcinoma.
For excellent patient education resources, visit eMedicine's Prostate Health Center and Men's Health Center. Also, see eMedicine's patient education articles Understanding the Male Anatomy and Enlarged Prostate.

Complications

• Postoperative complications following both suprapubic and retropubic prostatectomy include hemorrhage, urinary extravasation, and associated urinoma.
• Infectious processes, including cystitis and epididymo-orchitis, may also occur, but only rarely when prophylactic antibiotics are administered.
• Because the risk of injury to the external urinary sphincter is minimal with these procedures, stress urinary incontinence and total urinary incontinence are rare.
• Coincident erectile dysfunction and bladder neck contracture have also been reported postoperatively in approximately 2%-3% of patients following suprapubic prostatectomy.
• Depending on the degree of preoperative urge incontinence, postoperative urge incontinence may be present for weeks to months.
• Retrograde ejaculation has been reported in up to 80%-90% of patients after surgery and is a common phenomenon after these procedures.
• Finally, as with any significant pelvic surgery, the risk of non-urologic complications exists, including deep vein thrombosis, pulmonary embolus, myocardial infarction, and cerebral vascular accident. The incidence of these complications, however, is low and reflects the comorbidities of the patient population being treated.

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HYDROCELE

Hydrocele is an abnormal collection of serous fluid in the tunica vaginalis covering the testicles

or within some part of processus vaginalis.

Hydrocele is the commonest cause of swelling in the scrotum in the elderly. About 5% of the

patients attending the geriatric outpatient department are hydrocele patients. Very large hydrocele in

the elderly can cause problems like embarrassment, heaviness and difficulty in walking normally.

Simple surgical correction like eversion or excision of sac can cure the problem and improve the

quality of life of the elders. It is important to examine the patients completely including the hernial

orifices, back and the perineal region and to refer them to the surgeons for surgical correction.

1. · Primary hydrocele cause not known (common)
2. · Secondary hydrocele secondary to a disease in testis or epididymis

Etiology

· Defective absorption of fluid by the tunica vaginalis
· Excessive production of fluid within the sac
· Lymphatic obstruction
· Communication with peritoneal cavity

Symptoms

In majority – swelling of the scrotum may be the only complaint. Occasionally patient may
complain of pain (due to heaviness or complications)

Examination

· Swelling confined to scrotum (can get above the swelling, cf. inguinal hernia)
· Fluctuation test positive( cystic swelling)
· Transillumination test positive (except in thickened, fibrosed and calcified sac)
· Irreducible
· Testis not felt separately (not in secondary hydrocele)

Complications

· Infection = Rupture
· Haematocele = Hernia of the hydrocele sac
· In long standing hydrocele (calcification of the sac, atrophy of the testis may be present)
· Skin excoriation due to in drawing of the penis and dribbling of urine.
· Decubitus ulcer in the scrotum.

Treatment 

Jaboulay’s method of eversion of sac;
In this procedure the hydrocele fluid is let out after opening the sac through scrotal
incision and then eversion of sac is done so that the secreting surface of the tunica
vaginalis turned outside

Lord’s procedure; 
In case of small hydrocele and thin sac, plication of the sac is done.

Excision of the sac done in case of massive hydrocele with thickened sac

In cases of secondary hydrocele due to testicular malignancy, the management protocol
for malignancy should be followed in tertiary care hospital

Postoperative complication

· Hematoma – drain aseptically
· Infection – treat conservatively/antibiotics after culture and sensitivity.if required

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Urinary Reconstruction and Diversion

              When the urinary bladder is removed (due to cancer, other medical condition, or because the organ no longer works), another method must be devised for urine to exit the body. Urinary reconstruction and diversion is a surgical method to create a new way for you to pass urine.

Urinary diversion options

There are three main types of urinary diversion surgeries

• Ileal Conduit Urinary Diversion
• Indiana Pouch Reservoir
• Neobladder to Urethra Diversion

For all of these procedures, a portion of the small and/or large bowel is disconnected from the fecal stream and used for reconstruction.

Ileal Conduit Urinary Diversion

With this procedure, the ureters drain freely into part of the ileum (the last segment of the small intestine). The end of the ileum into which the ureters drain is then brought out through an opening in the abdominal wall. This opening, called a stoma, is covered with a bag that gathers the urine as it drains from the ileal conduit.

Advantages:

The advantages of the Ileal Conduit Urinary Diversion surgery are:

• It is a relatively simple surgery.
• It requires less surgical time (compared with other surgical methods).
• There is no need for occasional catheterization (use of a tube to drain the urine)

Disadvantages:

The disadvantages of the Ileal Conduit Urinary Diversion are:

• There is a change in body image.
• It uses an external bag to collect urine, which might leak or have odors.
• Urine could back up into the kidneys, causing infections, stone formation in some patients, and organ damage over time.

Indiana Pouch Reservoir

With this type of surgery, a reservoir or pouch is made out of a portion of the large intestine (the ascending colon on the right side of the abdomen) and a portion of the ileum (the last segment of the small intestine). The ureters are repositioned to drain into this pouch. The urine flows freely in a downward direction from the kidneys into the pouch. This positioning prevents urine from backing up into the kidneys, which protects the kidneys from infection. A short piece of small intestine is then brought out through a small opening in the abdominal wall (a stoma). Unlike the Ileal Conduit, no external bag is needed, and the stoma is very small and can be covered with an adhesive bandage. Instead, a one-way valve is surgically created to keep the urine inside the pouch. Several times a day, usually every four to six hours, a small, thin catheter must be passed through the stoma and into the pouch to empty the urine. An adhesive bandage is worn over the stoma at all other times (when not actively emptying the pouch). Catheters are washed with soap and water after each use. The catheters do not have to be sterilized. They can be taken on trips or social events and simply stored in a zip lock bag.

Advantages:

The advantages of the Indiana Pouch Reservoir surgery are:

• Urine is kept inside the body, in the reservoir, until it is ready to be emptied.
• No external bag is necessary.
• There is no odor.
• The risk of urine leaking is minimal.
• The small stoma can be covered with an adhesive bandage.
• The risk of reflux (back up) of urine into the kidneys is lessened, lowering the risk of infection.

Disadvantages:

The disadvantages of the Indiana Pouch are:

• The surgical time is longer compared with the Ileal Conduit.
• There is the need for occasional catheterization (the passing of tubing into the stoma to empty the pouch), every four to six hours.

Neobladder to Urethra Diversion

This procedure most closely mimics the storage function of a urinary bladder. With this procedure, a small part of the small intestine is made into a reservoir or pouch, which is connected to the urethra. The ureters are repositioned to drain into this pouch. As with the Indiana Pouch, this downward flow of urine from the kidneys into the pouch helps prevent urine back up, which helps protect the kidneys from infection. Urine is able to pass from the kidney, to the ureters, to the pouch, and through the urethra in a manner similar to the normal passing of urine. To be a candidate for this surgical procedure, there must be a low risk of cancer recurrence in the urethra, and patients must be able to pass a catheter into the urethra to empty the pouch if necessary.

Advantages:

The advantages of the Neobladder to Urethra Diversion are:

• The process of urination most closely matches normal urination.
• No stoma is needed.
• The kidneys are protected from urine back up and infection.

Disadvantages:

The disadvantages of the Neobladder to Urethra Diversion are:

• Surgery time is slightly longer than the Ileal Conduit Urinary Diversion procedure.
• Urinary incontinence (leakage of urine) is normal after surgery — while regaining control of urination — but might last up to six months. Also, about 20 percent of patients during the night and 5 percent to 10 percent of patients during the day are incontinent, requiring the wearing of a pad.
• Despite the surgery, some patients might not be able to empty their bladder well and will need to perform occasional catheterization (passing tubing through the urethra into the pouch every four to six hours) for a prolonged period of time after surgery and perhaps permanently.

A Look at the Three Surgical Procedures

Ileal Conduit Urinary Diversion: A segment of the intestine directs urine through a stoma into an external collecting bag.

Indiana Pouch Reservoir: A pouch made out of portions of intestines stores urine until it is drained via a catheter inserted through the stoma.

Neobladder to Urethra Diversion: Intestine is made into a reservoir and connected to the urethra

Immediate post-op period

It takes one to two months on average to feel well again and to regain your strength. Also, it is not unusual to feel a little depressed or discouraged after surgery. Discussing your feeling with friends, family, and even other members of a support group (ask your health care team member about support groups in your area) can help you deal with your emotions. As with any life change, an adjustment period is normal. Don't hesitate to call your doctor or other health care team members for assistance or if you have questions. Their goal for you is to get you back to your lifestyle as soon as possible.
People with urinary diversions are usually able to return to the life, work, and hobbies they previously enjoyed.

• Work — Most people can return to their jobs in one or two months on average. If you have concerns about your line of work or other job hazards, be sure to ask your doctor.
• Activities — After the post-operative period, exercising and participation in sports and other activities is encouraged. Check with your doctor or health care team member.
• Diet — There are no eating restrictions, but if you have special dietary concerns, check with your doctor or health care team member.
• Travel — There are no travel restrictions. Just a word to the wise — travel fully prepared with necessary supplies, as you might not be able to purchase all supplies at your destination.

Most people can return to their jobs in one or two months on average. If you have concerns about your line of work or other job hazards, be sure to ask your doctor.

NURSING CARE PLAN
Incontinent urinary diversions: These ostomies require permanent stoma care and external collecting devices.
Ileal conduit: Ureters are anastomosed to a segment of ileum, resected with the blood supply intact (usually 15–20 cm long). The proximal section is closed, and the distal end brought to skin opening to form a stoma (a passageway, not a storage reservoir).
Colonic conduit: This is a similar procedure using a segment of colon.
Ureterostomy: The ureter(s) is brought directly through the abdominal wall to form its own stoma.
Continent urinary diversions: Continent urinary reservoirs (CURs) have become one of the major options for patients to improve their quality of life regarding stoma care and the ability to sleep and travel.
Kock reservoir or Indiana (ileocecal) pouch: A section of intestine is used to form a pouch inside the patient’s abdomen, creating a reservoir that the patient periodically drains by inserting a catheter through the stoma, thus negating the need for an external collecting device.
 
CARE SETTING
Inpatient acute surgical unit.
 
Surgical intervention
Patient Assessment Database
Data depend on underlying problem, duration, and severity, e.g., malignant bladder tumor, congenital malformations, trauma, chronic infections, or intractable incontinence due to injury/disease of other body systems (e.g., multiple sclerosis). (Refer to appropriate CP.)
 
TEACHING/LEARNING
Discharge plan
DRG projected mean length of inpatient stay: 5.5 days
May require assistance with management of ostomy and acquisition of supplies.
Refer to section at end of plan for postdischarge considerations.
 
DIAGNOSTIC STUDIES
Intravenous pyelogram (IVP): Visualizes size/location of kidneys and ureters and rules out presence of tumors elsewhere in urinary tract.
Cystoscopy with biopsy: Determines tumor location/stage of malignancy. Ultraviolet cystoscopy outlines bladder lesion.
Bone scan: Determines presence of metastatic disease.
Bilateral pedal lymphangiogram: Determines involvement of pelvic nodes, where bladder tumor easily seeds because of close proximity.
CT scan: Defines size of tumor mass, degree of pelvic spread.
Urine cystoscopy: Detects tumor cells in urine (for determining presence and type of tumor).
Endoscopy: Evaluates intestines for use as conduit.
Conduitogram: Assesses length and emptying ability of the conduit and presence of stricture, obstruction, reflux, angulation, calculi, or tumor (may complicate or contraindicate use as a urinary diversion).
 
NURSING PRIORITIES
1. Prevent complications.
2. Assist patient/SO in physical and psychosocial adjustment.
3. Support independence in self-care.
4. Provide information about procedure/prognosis, treatment needs, potential complications, and resources.
 
DISCHARGE GOALS 1. Complications prevented/minimized.
2. Adjusting to perceived/actual changes.
3. Self-care needs met by self/with assistance as necessary.
4. Procedure/prognosis, therapeutic regimen, potential complications understood and sources of support   identified.
5. Plan in place to meet needs after discharge.

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Cancer of the Bladder

     The bladder is a hollow organ that stores urine as it is filtered from the kidneys. The flexible bladder wall is made up of three layers, allowing the bladder to expand and contract as needed. 90% of bladder cancers are found in the epithelial lining, the innermost layer of the wall.

 

 

Bladder cancer is the sixth leading cause of new cancer cases in Canada each year. It is diagnosed two to three times more often in men than in women, and it is seen in Caucasians twice as often as those of African descent. It's the fourth most common cancer among American men, the ninth most common in women.
Because of early diagnosis and better treatments, the mortality rates for this disease have been falling significantly over the last 25 years.

Causes of Cancer of the Bladder

The actual cause of bladder cancer is unknown, but there are some proven risk factors. They include:

• smoking - smokers are twice as likely to develop bladder cancer than non-smokers
• chemical exposure - certain chemicals, such as those used in the following professions, can become concentrated in the urine, creating a risk factor for cancer:
  • hairdressers
  • painters
  • textile workers
  • dye, leather, and rubber workers
• race - Caucasians have twice as high a risk of developing this cancer as people of African descent; Asians have the lowest risk
• gender - men have a two to three times higher risk than women of developing bladder cancer
• age - most cases of bladder cancer are diagnosed in people over the age of 40 years
• previous use of certain chemotherapy medications, such as cyclophosphamide* (often used in breast cancer and lymphoma treatment), can significantly increase the risk of later developing bladder cancer
• previous radiation to the pelvic area
• family or personal history of bladder cancer

Symptoms and Complications of Cancer of the Bladder

The symptoms of bladder cancer are easily confused with those of a bladder or urinary tract infection, kidney stones, or prostate problems. They are:

• blood in the urine (most common)
• pain or burning sensation while urinating
• a feeling of urgency or needing to urinate immediately
• the feeling of not having emptied the bladder completely after urinating
• pain in the lower back

If any of these symptoms are present, it's important to get them checked by your doctor to get a diagnosis of what's causing the symptoms.
It is important to catch bladder cancer early. This increases the chance that treatment will be successful. Complications from bladder cancer occur more from the treatment (such as surgery) rather than the cancer itself. However, if the cancer is left untreated and allowed to grow, it will eventually cause even greater complications. Cancer that has spread from the bladder is more difficult to treat.
Complications from surgery depend on the type of surgery. If a partial cystectomy (removal of part of the bladder) takes place, the bladder can still collect urine, but will be quite a bit smaller. This means the person will have to urinate much more often. As well, cancer can return, and frequent checkups are necessary so that any cancerous cells can be found as early as possible.
After a full cystectomy (removal of the entire bladder), there's no bladder to hold the urine, so another way to hold and eliminate urine must be made. In some cases, a new bladder can be created by using a small section of bowel tissue. This new bladder has to be regularly emptied manually, usually by using a tube or a catheter (a thin, flexible tube inserted into the body that permits the introduction or withdrawal of fluids).
Or, a urostomy may be necessary, in which a surgeon connects the ureters (tubes that drain the urine from the kidneys to the bladder) to the abdominal wall to create a stoma (opening). A plastic bag is externally attached to the stoma, acting like a bladder to collect urine. The bag must be emptied regularly.
Other complications from bladder cancer surgery may include infertility for women (if the uterus is removed), menopause (if the ovaries are removed), and possibly some sexual dysfunction if the vagina has been made smaller or shorter.
Men can also experience sexual dysfunction and infertility due to the removal of the prostate and the seminal vesicles (the glands that make semen).

Diagnosing Cancer of the Bladder

To diagnose bladder cancer, your doctor will review your medical history, including information about past employment, possible exposure to chemicals, and lifestyle habits such as smoking. Your doctor will then do a physical exam and will probably perform a vaginal and/or rectal examination to rule out other possible causes of the symptoms.
Blood tests are done to check for kidney function, and urine is checked for blood or cancer cells. Next, a cystoscopy is performed. A doctor inserts a thin tube called a cystoscope through the urethra (the tube that carries urine from the bladder to outside the body during urination) and into the bladder.
The cystoscope allows the doctor to look inside the bladder for any abnormalities, and to take a tiny sample of tissue (a biopsy), which will be checked for cancer cells. If you have a cystoscopy, your doctor may give you either a local or general anesthetic.
Once a diagnosis of cancer is made, the stage of the cancer (how far it has advanced) is determined. Some of the following tests might be done:

• CT or CAT scans (computed tomography) show any tumours or abnormalities in the urinary tract area (this includes the bladder, kidneys, urethra, and ureters).
• MRIs (magnetic resonance imaging), more sophisticated than CT scans, show any irregularities in the bladder or urinary tract area.
• IVP (intravenous pyelogram or intravenous pyelography) involves injection of dye into the bloodstream (which becomes concentrated in the urine), at which point X-rays are taken. The X-rays follow the urinary path and show any obstructions or abnormalities.
• Bone scans determine if the cancer has spread to the bones.
• Chest X-rays show if the cancer has spread to the lungs.

Treating and Preventing Cancer of the Bladder

Like most cancers, bladder cancer can be treated by surgery, radiotherapy, chemotherapy, or a combination of therapies. The choice of treatment depends on the location and the staging of the cancer.

Surgery

When bladder cancer is caught early, a transurethral resection (TUR) can be done. Using a cystoscope, the doctor uses a special tool to burn away the cancerous cells inside the bladder. The advantage of this treatment is that the bladder stays intact and people can still urinate normally after the procedure.
Surgery to remove the bladder is called a cystectomy. If the cancer has invaded through the bladder wall, or if it covers a large portion of the bladder, surgeons generally choose this surgery over TUR.
In women, removing the bladder usually involves also removing the uterus (hysterectomy), fallopian tubes, ovaries, and part of the vagina. If the woman is young, the ovaries might be left intact so that she won't have early menopause. For men, the prostate and the seminal vesicles (the glands that produce semen) must usually be removed along with the bladder.
Occasionally, an operation called a segmental cystectomy may be performed if the cancer is limited to a small part of the bladder wall. This surgery doesn't remove the entire bladder, so people can still urinate normally afterward.

Radiotherapy

There are two types of radiotherapy used to treat bladder cancer: internal and external.
External radiotherapy aims radiation directly at the cancer cells in the bladder. It may be done prior to surgery to shrink the size of the tumour, or after the surgery along with chemotherapy.
Internal radiotherapy is done by inserting radiation implants directly into the bladder. This treatment requires a hospital stay. Visitors might not be allowed - this is to avoid exposing them to the radiation coming from the person being treated. Once the implants are removed, no more radiation is released and the person can return home from the hospital.
Some people receive both internal and external radiation.
The side effects of radiotherapy are usually temporary, and they include:

• fatigue
• red, dry skin at the radiation site
• nausea
• decreased appetite
• diarrhea
• vaginal dryness (for women)
• difficulty having erection (for men)

Chemotherapy

Chemotherapy can be used alone or in combination with surgery and/or radiotherapy. It's available as a general treatment (usually given intravenously) or a local one.
Local chemotherapy (intravesical therapy) involves putting chemotherapy medications directly into the bladder for several hours at a time. The greatest advantage to intravesical treatment is that there are fewer side effects since the medications are not given systemically (throughout the body). This approach is usually reserved for superficial tumours removed during a cystoscopy, both to treat tiny amounts of tumour left behind or to prevent recurrence after successful removal.
General, or systemic, chemotherapy circulates throughout the body, so more of the body systems are affected by the treatment. This approach is used if the cancer has spread and can't be reached by the local (intravesical) approach.
Side effects from chemotherapy include:

• nausea and vomiting
• hair loss
• fatigue
• diarrhea
• mouth sores
• increased risk of infection

Nursing Interventions: Bladder Cancer

• Encourage the patient to express feelings and concerns about the extent of the cancer.
• To relieve discomfort administer ordered analgesics for pain as necessary.
• Implement comfort measures and provide distractions that will enable the patient to relax.
• As appropriate, implement measures to prevent or alleviate complications of treatment.
• Monitor the patient’s intake and output. Question him regularly about changes in his urine elimination pattern to detect changes in his condition.
• Observe the patient’s urine for signs of hematuria (reddish tint to gross bloodiness).
• Monitor the patient’s laboratory tests, such as changes in white blood cell differential, indicating possible bone marrow suppression from chemotherapy.
• If the patient is being given intravesical chemotherapy, watch closely for myelosuppression, chemical cystitis, and skin rash.
• Instruct the patient and the family about the types of treatment that are being planned for him.
• Teach the patient and family to recognize and to manage adverse effects of chemotherapy.
• Stress the importance of notifying the doctor if the patient develops signs and symptoms of urinary tract infection or other sudden changes in his condition.

The prognosis (outlook) for bladder cancer is good. The sooner the cancer is discovered, the better the chances of survival. The five-year survival rate can be as high as 94% if the cancer is detected early. However, this drops dramatically once the cancer has spread to other areas of the body.
If bladder cancer does return, it most often happens within the first year or two after treatment, so good follow-up is essential. This involves cystoscopies and urine tests at least every three months for a couple of years, then less frequent ongoing monitoring.
While some of the risk factors for bladder cancer can't be avoided (age and gender, for example), there are some precautions that can be taken to help avoid developing it. For those who work with high-risk chemicals, it's important to have urine tests as part of general annual physical examinations. Any unusual bladder symptoms should be checked by a doctor immediately.
Since smoking is a known risk factor for getting bladder cancer, smokers should try to quit or ask their doctor about ways to quit.

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Nephrectomy

 Definition

A nephrectomy is a surgical procedure for the removal of a kidney or section of a kidney.

Purpose

Nephrectomy, or kidney removal, is performed on patients with severe kidney damage from disease, injury, or congenital conditions. These include cancer of the kidney (renal cell carcinoma); polycystic kidney disease (a disease in which cysts, or sac-like structures, displace healthy kidney tissue); and serious kidney infections. It is also used to remove a healthy kidney from a donor for the purposes of kidney transplantation .

  According to the United Network for Organ Sharing (UNOS), 5,974 people underwent nephrectomy to become living kidney donors in 2001. The majority of these donors—43.9%—were between the ages of 35 and 49, and 58.8% were female. Related donors were more common than non-related donors, with full siblings being the most common relationship between living donor and kidney recipients (28.5% of living donors).

Description

Nephrectomy may involve removing a small portion of the kidney or the entire organ and surrounding tissues. In partial nephrectomy, only the diseased or infected portion of the kidney is removed. Radical nephrectomy involves removing the entire kidney, a section of the tube leading to the bladder (ureter), the gland that sits atop the kidney (adrenal gland), and the fatty tissue surrounding the kidney. A simple nephrectomy performed for living donor transplant purposes requires removal of the kidney and a section of the attached ureter.

Open nephrectomy

In a traditional, open nephrectomy, the kidney donor is administered general anesthesia and a 6–10 in (15.2–25.4 cm) incision through several layers of muscle is made on the side or front of the abdomen. The blood vessels connecting the kidney to the donor are cut and clamped, and the ureter is also cut between the bladder and kidney and clamped. Depending on the type of nephrectomy procedure being performed, the ureter, adrenal gland, and/or surrounding tissue may also be cut. The kidney is removed and the vessels and ureter are then tied off and the incision is sutured (sewn up). The surgical procedure can take up to three hours, depending on the type of nephrectomy being performed.

Laparoscopic nephrectomy

Laparoscopic nephrectomy is a form of minimally invasive surgery that utilizes instruments on long, narrow rods to view, cut, and remove the kidney. The surgeon views the kidney and surrounding tissue with a flexible videoscope. The videoscope and surgical instruments are maneuvered through four small incisions in the abdomen, and carbon dioxide is pumped into the abdominal cavity to inflate it and improve visualization of the kidney. Once the kidney is isolated, it is secured in a bag and pulled through a fifth incision, approximately 3 in (7.6 cm) wide, in the front of the abdominal wall below the navel. Although this surgical technique takes slightly longer than a traditional nephrectomy, preliminary studies have shown that it promotes a faster recovery time, shorter hospital stays, and less post-operative pain.
A modified laparoscopic technique called hand-assisted laparoscopic nephrectomy may also be used to remove the kidney. In the hand-assisted surgery, a small incision of 3–5 in (7.6–12.7 cm) is made in the patient's abdomen. The incision allows the surgeon to place his hand in the abdominal cavity using a special surgical glove that also maintains a seal for the inflation of the abdominal cavity with carbon dioxide. This technique gives the surgeon the benefit of using his hands to feel the kidney and related structures. The kidney is then removed by hand through the incision instead of with a bag.

Diagnosis/Preparation

Prior to surgery, blood samples will be taken from the patient to type and crossmatch in case transfusion is required during surgery. A catheter will also be inserted into the patient's bladder. The surgical procedure will be described to the patient, along with the possible risks.

Aftercare

Nephrectomy patients may experience considerable discomfort in the area of the incision. Patients may also experience numbness, caused by severed nerves, near or on the incision. Pain relievers are administered following the surgical procedure and during the recovery period on an as-needed basis. Although deep breathing and coughing may be painful due to the proximity of the incision to the diaphragm, breathing exercises are encouraged to prevent pneumonia. Patients should not drive an automobile for a minimum of two weeks.

Risks

Possible complications of a nephrectomy procedure include infection, bleeding (hemorrhage), and post-operative pneumonia. There is also the risk of kidney failure in a patient with impaired function or disease in the remaining kidney.

Normal results

Normal results of a nephrectomy are dependent on the purpose of the procedure and the type of nephrectomy performed. Immediately following the procedure, it is normal for patients to experience pain near the incision site, particularly when coughing or breathing deeply. Renal function of the patient is monitored carefully after surgery. If the remaining kidney is healthy, it will increase its functioning over time to compensate for the loss of the removed kidney.
Length of hospitalization depends on the type of nephrectomy procedure. Patients who have undergone a laparoscopic radical nephrectomy may be discharged two to four days after surgery. Traditional open nephrectomy patients are typically hospitalized for about a week. Recovery time will also vary, on average from three to six weeks.

Alternatives

Because the kidney is responsible for filtering wastes and fluid from the bloodstream, kidney function is critical to life. Nephrectomy candidates diagnosed with serious kidney disease, cancer, or infection usually have few treatment choices aside from this procedure. However, if kidney function is lost in the remaining kidney, the patient will require chronic dialysis treatments or transplantation of a healthy kidney to sustain life.

 NURSING CARE  OF CLIENT HAVING A NEPHRECTOMY

Perioperative Nursing Considerations

• The surgeon or anesthesiologist may request hypothermia measured during the procedure.
• Have all X-rays in the room.
• Verify with the blood bank the number of available units.
• Chest tube and drainage unit will be needed for a transthoracic approach.
• A suprapubic catheter and drainage unit may be used if nephroureterectomy is performed.
• When two incisions are used, the patient is repositioned. Additional instrument tray is necessary.
  •Discuss operative and postoperative expectations as indicated, including the location of the incision  and anticipated tubes, stents, and drains. Preoperative teaching about postoperative expectations reduces anxiety for the client and family during the early postoperative period

POSTOPERATIVE CARE

• Provide routine postoperative care •Frequently assess urine color, amount, and character, noting any hematuria, pyuria, or sediment. Promptly report oliguria or anuria, as well as changes in urine color or clarity.Preserving function of the remaining kidney is critical; frequent assessment allows early intervention for potential problems.

• Note the placement, status, and drainage from ureteral catheters, stents, nephrostomy  tubes, or drains. Label each  clearly. Maintain gravity drainage; irrigate only as ordered. Maintaining drainage tube patency is vital to prevent potential hydronephrosis. Bright bleeding or unexpected drainage may indicate a surgical complication. 
• Support the grieving process and adjustment to the loss of a kidney. Loss of a major organ leads to a body image change and grief response. When renal cancer is the underlying diagnosis,the client may also grieve the loss of health and potential loss of life. 

Provide the following home care instructions for the client and family.

• Teach the importance of protecting the remaining kidney by preventing UTI, renal calculi, and trauma. 
• Maintain a fluid intake of 2000 to 2500 mL per day. This important measure helps prevent dehydration and maintain good urine flow. 
• Gradually increase exercise to tolerance, avoiding heavylifting for a year after surgery. Participation in contact sports is not recommended to reduce the risk of injury to the remaining kidney. Lifting is avoided to allow full tissue healing. Trauma to the remaining kidney could seriously jeopardize renal function. 
• Teach care of the incision and any remaining drainage tubes, catheters, or stents. This routine postoperative instruction is vital to prepare the client for self-care and prevent complications. 
• Instruct to report signs and symptoms to the physician, including manifestations of UTI (dysuria, frequency, urgency, nocturia, cloudy, malodorous urine) or systemic infection (fever, general malaise, fatigue), redness, swelling, pain, or drainage from the incision or any catheter or drain tube site. 
• Prompt treatment of postoperative infection is vital to allow continued healing and prevent compromise of the remaining kidney.

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Wilms tumor (Nephroblastoma)

Definition

Wilms tumor is a type of kidney cancer that occurs in children.

 

Causes, Incidence, And Risk Factors

Wilms tumor is the most common form of childhood kidney cancer. The exact cause of this tumor in most children is unknown.
A missing iris of the eye (aniridia) is a birth defect that is sometimes associated with Wilms tumor. Other birth defects linked to this type of kidney cancer include certain urinary tract problems and enlargement of one side of the body, a condition called hemihypertrophy.
It is more common among some siblings and twins, which suggests a possible genetic cause.
The disease occurs in about 1 out of 200,000 to 250,000 children. It usually strikes when a child is about 3 years old. It rarely develops after age 8.

Symptoms

• Abdominal pain
• Constipation
• Fever
• General discomfort or uneasiness (malaise)
• High blood pressure
• Increased growth on only one side of the body
• Loss of appetite
• Nausea
• Swelling in the abdomen (abdominal hernia or mass)
• Vomiting

Signs And Tests

Special emphasis is placed on the history and physical exam. The doctor may ask if you have a family history of cancer and look for associated birth defects in the child.
A physical examination reveals an abdominal mass. High blood pressure may also be present.
Blood in the urine occurs in less than 25% of children.
Tests include:

• Abdominal ultrasound
• Abdominal x-ray
• BUN
• Chest x-ray
• Complete blood count (may show anemia)
• Creatinine
• Creatinine clearance
• CT scan of the abdomen
• Intravenous pyelogram
• Urinalysis

Other tests may be required to determine if the tumor has spread.

Treatment

If your child is diagnosed with this condition, avoid prodding or pushing on the child's belly area, and use care during bathing and handling to avoid injury to the tumor site.
The first step in treatment is to stage the tumor. Staging helps doctors determine how far the cancer has spread and to plan for the best treatment. Surgery to remove the tumor is scheduled as soon as possible. Surrounding tissues and organs may also need to be removed if the tumor has spread.
Radiation therapy and chemotherapy will often be started after surgery, depending on the stage of the tumor.

Expectations (Prognosis)

Children whose tumor has not spread have a 90% cure rate with appropriate treatment.

Complications

The tumor may become quite large, but usually remains self-enclosed. Spread of the tumor to the lungs, liver, bone, or brain is the most worrisome complication.
High blood pressure and kidney damage may occur as the result of the tumor or its treatment.
Removal of Wilms tumor from both kidneys may affect kidney function.

Calling Your Health Care Provider

Call your health care provider if you discover a lump in your child's abdomen, blood in the urine, or other symptoms of Wilms tumor.
Call your health care provider if your child is being treated for this condition and symptoms get worse or new symptoms develop, particularly cough, chest pain, weight loss, or persistent fevers.

Prevention

For children with a known high risk of Wilms tumor, screening with ultrasound of the kidneys may be recommended.

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Stones in the Urinary Tract

Definition

Kidney stones are pieces of a stone or crystal-like material in the urine. These stones form inside the kidneys or other parts of the urinary tract. The kidneys remove waste (in the form of urine) from the body. They also balance the water and electrolyte content in the blood by filtering salt and water.
There are several types of kidney stones:

• The most common type has mostly calcium along with oxalate or phosphate.
• Others types contain uric acid, struvite, and/or cystine.

Kidney Stone

  

Causes

Some of the known causes include:

• Chemotherapy (ie, uric acid stone)
• Too much oxalate in urine (hyperoxaluria)
• Too little magnesium in urine (hypomagnesemia)
• Too much calcium in the urine (hypercalciuria)
• Too much calcium in the blood (hypercalcemia)
• Too little citrate in the urine (hypocitraturia)
• Tiny bacteria around which a stone can form
• Too much uric acid in the urine (hyperuricuria, gout)
• Bacteria that produce enzymes that increase the amount of ammonia and struvite in the urine
• Inherited abnormality in the way the body handles cystine
• Certain medications (such as indinavir)
• Foreign bodies in the urinary tract, such as stents or catheters
• Retention of urine

Risk

These factors increase your chance of developing kidney stones. Tell your doctor if you have any of these risk factors:

• Race: White
• Sex: male
• Age: 20 to 50 years old
• Geographic location (residents of the Southeast United States have an increased risk)
• Family members who have had kidney stones or gout
• Previous kidney stones
• Taking calcium supplements or vitamin C in excessive doses
• Pregnancy
• Fasting
• Other medical conditions, including:
  • Kidney disease
  • Overactive parathyroid
  • Chronic diarrhea
  • Ulcerative colitis
  • Crohn's disease
  • Leukemia
  • Lymphoma
  • Urinary tract infections
  • Sarcoidosis
• Immobility, paralysis, being bedridden
• Medications, including some AIDS medications, chemotherapy drugs, diuretics, antacids
• Previous intestinal bypass surgery
• Reduced fluid intake or increased fluid loss in hot weather ( dehydration)
• Urinary tract obstruction or failure to empty the bladder
• Foreign material in the urinary tract (eg, catheter)

Symptoms

Occasionally, kidney stones do not cause symptoms, and they leave the body in the urine. The condition, though, can cause severe pain.
Symptoms include:

• Sharp, stabbing pain in the mid-back that may occur every few minutes lasting from 20 minutes to one hour
• Pain in the lower abdomen and groin area, labia, or testicles
• Nausea, vomiting, or diarrhea
• Blood in the urine
• Frequent urge to urinate
• Burning pain during urination
• Fever
• Urinary tract infection

Diagnosis

The doctor will ask about your symptoms and medical history. A physical exam will be done.
Tests may include:

• Urinalysis—to look for blood, pus, bacteria, and crystals in the urine
• Blood tests—to check kidney function, calcium , and uric acid levels
• Urine culture —if infection suspected
• Spiral CT scan—a type of x-ray that uses a computer to make pictures of the inside of the kidney
• Ultrasound —a test that uses sound waves to examine the kidneys
• Intravenous pyelogram (IVP) —special x-ray that produces images of the urinary system (less commonly used today)
• 24-hour urine—a urine test to check levels of many factors, including calcium , phosphorus , uric acid, oxalate, and citrate

Treatment

Treatment depends on the size and location of the kidney stone. Treatment may include:
Water
For small kidney stones, drinking at least two or three quarts of water a day helps the body pass the stone in the urine. The doctor may provide a special cup to catch the stone when it passes so that it can be analyzed. If you are having a hard time keeping fluids down, you may need to be hospitalized to receive fluids in your vein.
Medications and Nerve Stimulation
Your doctor may recommend that you take pain medication. You may need medication that is given in the vein or in the muscles.
Certain medicine used to treat high blood pressure (eg, calcium channel blockers and alpha blockers) may help your body pass kidney stones. * ¹

Surgery

Surgery may be needed if the stone is:

• Very large or growing larger
• Causing bleeding or damage to the kidney
• Causing infection
• Blocking the flow of urine
• Unable to pass on its own

Types of surgery include:

• Stent placement—used to allow urine to pass
• Ureteroscopy and stone basketing or laser lithotripsy—a camera is used to locate the stone
  • Stone basketing—a tiny basket is used to remove the stone
  • Laser lithotripsy—the stone is broken into smaller pieces with a laser if it is too large to remove
• Extracorporeal shock wave lithotripsy (ESWL) —uses shock waves to break up stones that are too large to pass
• Percutaneous nephrolithotomy—uses a scope placed through a small tube in the back to remove a large stone
• Lithotomy—open surgery to remove a stone (rarely used now)

If you are diagnosed as having kidney stones, follow your doctor's instructions .

Prevention

Once you have formed a kidney stone, you are more likely to form another. Here are some steps to prevent this condition:

• Drink plenty of fluids, especially water.
• Talk to your doctor about what diet is right for you. Depending on the type of stone you have, you may be advised to:
  • Avoid apple and grapefruit juices.
  • Drink more cranberry juice.
  • Avoid foods high in oxalate, such as spinach.
  • Eat less meat, fish, and poultry. These foods increase urine acidity.
  • Decrease your sodium intake (especially if you have calcium stones).
  • Increase your intake of magnesium.
  • Drink lemonade daily.
  • Increase your fiber intake.
  • Lose weight.
• If you have an enlarged parathyroid gland, you may need to have it removed surgically.
• Medicines may include:
  • Drugs that control the amount of acid in the urine
  • Allopurinol or sodium cellulose phosphate—to treat urine high in calcium
  • Hydrochlorothiazide (a diuretic)—to treat urine high in calcium
  • Thiola—to reduce the amount of cystine in the urine

Removing a Stone With Sound Waves

Kidney stones can sometimes be broken up by sound waves produced by a lithotriptor in a procedure called extracorporeal shock wave lithotripsy. After an ultrasound device or fluoroscope is used to locate the stone, the lithotriptor is placed against the back, and the sound waves are focused on the stone, shattering it. Then the person drinks fluids to flush the stone fragments out of the kidney, to be eliminated in the urine. Sometimes blood appears in the urine or the abdomen is bruised after the procedure, but serious problems are rare.

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 Definition

Hydronephrosis is distention (dilation) of the kidney with urine, caused by backward pressure on the kidney when the flow of urine is obstructed.

 

Kidney stones are common causes of urinary tract obstruction.

When hydronephrosis occurs quickly, people may have excruciating pain, most often in the flank (the area between the ribs and the hips).
When hydronephrosis occurs more gradually, people may have no symptoms or experience attacks of dull, aching discomfort in the flank.
Doctors initially use bladder catheterization (or ultrasonography) to detect hydronephrosis, and they may use ultrasonography or another imaging test to determine the site of the blockage.
Treatment depends on the cause of the obstruction. 

Normally, urine flows out of the kidneys at extremely low pressure. If the flow of urine is obstructed, urine backs up behind the point of blockage, eventually reaching the small tubes of the kidney and its collecting area (renal pelvis), distending the kidney and increasing the pressure on its internal structures. The elevated pressure from obstruction may ultimately damage the kidney and can result in loss of its function. When the flow of urine is obstructed, urinary tract infections are fairly common and stones are more likely to form. If both kidneys are obstructed, kidney failure may result.

Long-standing distention of the renal pelvis and ureter can also inhibit the rhythmic muscular contractions that normally move urine down the ureter from the kidney to the bladder (peristalsis). Scar tissue may then replace the normal muscular tissue in the walls of the ureter, resulting in permanent damage

Causes

• 
  
  • Hydronephrosis commonly results from an obstruction located at the junction of the ureter and renal pelvis (ureteropelvic junction). Causes of this type of obstruction include the following:
  • Structural abnormalities—for example, a birth defect in which the insertion of the ureter into the renal pelvis is too high or there is inadequate development of the ureteral muscles (congenital ureteropelvic junction obstruction)
    
  • Kinking at the ureteropelvic junction resulting from a kidney shifting downward (ptosis of the kidney)
    
  • Stones (calculi) or a blood clot in the renal pelvis
    
  • Compression of the ureter by bands of fibrous tissue, an abnormally located artery or vein, or a tumor
    
  
  Hydronephrosis can also result from an obstruction below the ureteropelvic junction or from backflow (reflux) of urine from the bladder. Causes of this type of obstruction include the following:
  
  • Stones in the ureter
    
  • Blood clot in the ureter
    
  • Tumors in or near the ureter
    
  • Narrowing of the ureter resulting from a birth defect, an injury, an infection, radiation therapy, or surgery
    
  • Disorders of the muscles or nerves in the ureter or bladder
    
  • Formation of fibrous tissue in or around the ureter resulting from surgery, radiation therapy, or drugs (especially methysergide)
    
  • Bulging of the lower end of the ureter into the bladder (ureterocele)
    
  • Cancers of the bladder, cervix, uterus, prostate, or other pelvic organs
    
  • Obstruction that prevents urine flow from the bladder to the urethra, resulting from prostate enlargement (most often caused by a condition called benign prostatic hyperplasia—see Prostate Disorders: Benign Prostatic Hyperplasia (BPH)), or rectal impaction with feces
    
  • Abnormal contractions of the bladder resulting from a birth defect or a spinal cord or nerve injury
    
  
  Hydronephrosis of both kidneys can occur during pregnancy as the enlarging uterus compresses the ureters. Hormonal changes during pregnancy may aggravate the problem by reducing the muscular contractions that normally move urine down the ureters. This condition, commonly called hydronephrosis of pregnancy, usually ends when the pregnancy ends, although the renal pelvis and ureters may remain somewhat distended afterward.
  
  

  Symptoms

  
  Symptoms depend on the cause, location, and duration of the obstruction. When the obstruction begins quickly (acute hydronephrosis), it usually produces renal colic—an excruciating, intermittent pain in the flank (the area between the ribs and hip) on the affected side. Obstruction on one side does not reduce urine flow. Obstruction can stop or reduce urine flow if blockage affects the ureters from both kidneys or if it affects the urethra. Obstruction of the urethra or bladder outlet may produce pain, pressure, and distention of the bladder.
  
  People who have slowly progressive (chronic) hydronephrosis may have no symptoms, or they may have attacks of dull, aching discomfort in the flank on the affected side. Sometimes a kidney stone temporarily blocks the ureter and produces painful hydronephrosis that occurs intermittently.
  
  Hydronephrosis may cause vague intestinal symptoms, such as nausea, vomiting, and abdominal pain. These symptoms sometimes occur in children when hydronephrosis results from a birth defect in which the junction of the ureter and renal pelvis is too narrow (ureteropelvic junction obstruction).
  
  People who have urinary tract infections may have pus in the urine, fever, and discomfort in the area of the bladder or kidneys.
  
  

  Diagnosis

  
  Early diagnosis is important, because most cases of obstruction can be corrected and because a delay in treatment can lead to irreversible kidney damage. Doctors may suspect hydronephrosis because of a person's symptoms and sometimes because of findings discovered during a physical examination. A distended kidney can occasionally be felt in the flank, particularly if the kidney is greatly enlarged in an infant or a child or a thin adult. A distended bladder can sometimes be felt in the lower part of the abdomen just above the pubic bone.
  
  Doctors depend on testing to make the diagnosis. Bladder catheterization (insertion of a hollow, flexible tube through the urethra) is often the first diagnostic test done in people with renal colic, pelvic pressure, or distention. If the catheter drains a large amount of urine from the bladder, then either the bladder outlet or the urethra is obstructed. Many doctors do ultrasonography to determine whether the bladder is filled with a large amount of urine before doing bladder catheterization.
  
  If the presence or site of obstruction is in doubt, various imaging tests can be done to identify evidence of obstruction such as hydronephrosis or a site of blockage. For example, ultrasonography is a very useful test in most people (particularly children and pregnant women) because it is fairly accurate and does not expose the person to any radiation. Computed tomography (CT) scanning is an alternative. It is rapid and highly accurate, particularly at identifying stones. Other imaging tests, such as intravenous urography, may be performed to identify the site of obstruction, if it is not visible with ultrasonography or CT.
  
  An endoscope (a rigid or flexible telescope) is sometimes used to look at possible sites of obstruction as closely as possible. An endoscope can be used to examine the urinary tract.
  
  Blood and urine tests are done. Blood test results are usually normal, but tests may reveal high levels of urea nitrogen (sometimes called BUN), creatinine, or both, if obstruction affects both kidneys. Results from an analysis of urine (urinalysis) are usually normal but white blood cells and red blood cells may be present when a stone or a cancer is the cause of obstruction, or when the obstruction is complicated by an infection.
  
  

  Prognosis

  
  Permanent kidney damage is unlikely to result unless both kidneys are obstructed for at least a few weeks. The prognosis is less certain for chronic hydronephrosis.
  
  

  Treatment

  
  Treatment usually aims to relieve the cause of obstruction. For example, if the urethra is obstructed because of an enlarged or cancerous prostate, treatment can include drugs, such as hormone therapy for prostate cancer (see Prostate Disorders: Prostate Cancer), surgery, or enlargement of the urethra with dilators. Other treatments, such as lithotripsy or endoscopic surgery, may be needed for stones that block the flow of urine. If the cause of obstruction cannot be rapidly corrected, particularly if there is infection, kidney failure, or severe pain, the urinary tract is drained. In acute hydronephrosis, urine that has accumulated above the obstruction can be drained with a soft tube inserted through the skin into the kidney (nephrostomy tube) or by insertion of a soft plastic tube that connects the bladder with the kidney (ureteral stent). Complications of nephrostomy tubes or ureteral stents can include displacement of the tube, infection, and discomfort.
  
  Urgent relief of chronic hydronephrosis is usually not required. Complications of hydronephrosis, such as urinary tract infections and kidney failure, if present, are treated promptly.
  

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