1. Lithotripsy. Extracorporeal shock wave - a noninvasive mechanical procedure used to break up renal calculi so they can pass spontaneously, in most cases. The trunk of the patient is submerged in distilled water. In addition to being strapped to a frame, the patient may also receive sedation and analgesia for pain from sound waves. The procedure takes 30-45 min, and remaining still is important. An underwater electrode generates shock waves that fragment the stone so it can be excreted in the urine a few days after the procedure. A degree of renal colic O may occur, requiring narcotics for up to 3 days. Nursing measures should encourage ambulation and promote diuresis through forcing fluids. Percutaneous lithotripsy - nephrostomy tract above kidney region; nephroscope used to retrieve calculi. Urinary drainage from incision for 3-4 days is normal. May be required for large fragments remaining after extracorporeal lithotripsy. Nursing measures include: dressing changes to prevent infection and prevent skin breakdown, and administration of antibiotics and narcotics for pain.

  2. Benign prostatic hyperplasia (BPH): bladder outlet obstruction resulting from an enlargement of the prostate gland.
    1. Pathophysiology: prostate enlarges, bulges upward, blocks flow of urine from bladder into urethra —> obstruction —> hydroureter, hydronephrosis.
    2. Risk factors:
      1. Changes in estrogen and androgen levels.
      2. Men >50.
    3. Assessment:
      1. Subjective data - urination:
        1. Difficulty starting stream.
        2. Smaller, less forceful.
        3. Dribbling.
        4. Frequency.
        5. Urgency.
        6. Nocturia.
        7. Retention (incomplete emptying).
        8. Inability to void after ingestion of alcohol or exposure to cold.
      2. Objective data:
        1. Catheterization for residual urine: 25-50 mL after voiding.
        2. Enlarged prostate on rectal exam.
        3. Lab data:
          1. Urine - increased RBC, WBC.
          2. Blood - increased creatinine, PSA.
    4. Analysis/nursing diagnosis:
      1. Urinary retention related to incomplete emptying.
      2. Altered urinary elimination related to obstruction.
      3. Urinary incontinence related to urgency, pressure.
      4. Anxiety related to potential surgery.
      5. Body image disturbance related to threat to male identity.
    5. Nursing care plan/implementation:
      1. Goal: relieve urinary retention.
        1. Catheterization: release maximum of 1000 mL initially; avoid bladder decompression, which results in hypotension, bladder spasms, ruptured blood vessels in bladder; empty 200 mL every 5 min.
        2. Patency: irrigate intermittently or continually, as ordered.
        3. Fluids: minimum 2000 mL/24 hr.
      2. Goal: health teaching.
        1. Preparation for surgery (cystostomy, prostatectomy):
          1. Expectations - indwelling   catheter (will feel urge to void).
          2. Avoid pulling on catheter (this increases bleeding and clots).
          3. Bladder spasms common 24 - 48 hr after surgery, particularly with transurethral resection and suprapubic approaches.
          4. Threatening nature of procedure (possibility of impotence with perineal prostatectomy).

  3. Prostatectomy: surgical procedure to relieve urinary retention and frequency caused by benign prostatic hyperplasia or cancer of the prostate.
    1. Types
      1. Transurethral resection (TUR) - removal of obstructive prostatic tissue surrounding urethra by an electric wire (resectoscope) introduced through the urethra; hypertrophy may recur, and TUR repeated; little risk of impotence. Laser also being used.
      2. Suprapubic - low midline incision is made directly over the bladder; bladder is opened and large mass of prostatic tissue is removed through incision in urethral mucosa.
      3. Retropubic - removal of hypertrophied prostatic tissue high in pelvic area through a low abdominal incision; bladder is not opened; patient may remain potent.
      4. Perineal - removal of prostatic tissue low in pelvic area is accomplished through an incision made between the scrotum and the rectum; usually results in impotency and incontinence.
    2. Nursing care plan/implementation:
      1. Preoperative: see X. Prostatic hyperplasia.
      2. Postoperative:
        1. Goal: promote optimal bladder function and comfort.
          1. Urinary drainage: sterile closedgravity system - maintain external traction as ordered.
          2. Reinforce purposes, sensations to expect.
          3. Bladder irrigation to control bleeding, keep clots from forming.
          4. Suprapubic catheter care (suprapubic prostatectomy) - closed-gravity drainage system; observe character, amount, flow of drainage.
          5. After removal:
            1. Observe for urinary drainage q4h for 24 hr.
            2. Skin care.
            3. Report excessive drainage to physician.
          6. Dressings: keep dry, clean; reinforce if necessary (may need to change suprapubic dressing if urinary drainage); notify physician of excessive bleeding.
          7. Observe for signs of:
            1. Bladder distention - distinct mound over pubis, slow drip incollecting bottle; irrigate catheter as ordered.
            2. Increased bleeding - expect and report frank bleeding (if venous bleeding, increase traction on catheter); if bright red drainage, and clots (arterial bleeding), may need surgical control; cool, clammy, pale skin and increased pulse rate indicate shock.
        2. Goal: assist in rehabilitation. Emotional support: fears of incontinence, loss of male identity, impotence.
        3. Goal: health teaching.
          1. Expectations: mild incontinence, dribbling for a while (several months) after surgery; need to void as soon as urge is felt; push fluids.
          2. Exercises: perineal (Kegel) 1-2 days after surgery - buttocks are tightened for a count of ten, 20-50 times daily.
          3. Avoid:
            1. Long auto trips, vigorous exercise, heavy lifting (anything heavier than 10 lb), and sexual intercourse for about 3 wk or until medical permission, because they may increase tendency to bleed.
            2. Alcoholic beverages for 1 mo, because this may cause burning on urination; caffeine, because it causes diuresis.
            3. Tub baths, because they increase chance of infection.
          4. Medications: stool softeners or mild cathartics to decrease straining.
    3. Evaluation/outcome criteria:
      1. Relief of symptoms.
      2. No complications (e.g., hemorrhage, impotence).
  4. Urinary diversion. Incontinent - ileal conduit: anastomosis of ureters to a small portion of the ileum; stoma is called urostomy; urine flow is constant; requires external collection device. Continent - Kock pouch, Indiana pouch: segment of small bowel or colon is used to create a pouch; holds urine without leakage; requires self-catheterization.
    1. Indications:
      1. Congenital anomalies of bladder.
      2. Neurogenic bladder.
      3. Mechanical obstruction to urine flow (e.g., bladder cancer).
      4. Chronic progressive pyelonephritis.
      5. Trauma to lower urinary tract.
    2. Analysis/nursing diagnosis:
      1. Altered urinary elimination related to surgical diversion.
      2. Risk for impaired skin integrity related to leakage of urine.
      3. Risk for infection related to contamination of stoma.
      4. Constipation related to absence of peristalsis.
      5. Body image disturbance related to stoma.
    3. Nursing care plan/implementation:
      1. Preoperative: optimal bowel and stoma site preparation.
        1. Diet: low-residue 2 days followed by clear liquids for 24 hr.
        2. Medications:
          1. Neomycin (for bowel sterilization).
          2. Cathartics (GoLYTELY), enemas.
        3. Site selection: appliance faceplate (incontinent diversion) must bond securely; avoid areas of pressure from clothing (waistline); usual site is right or left lower abdominal quadrant.
      2. Postoperative:
        1. Goal: prevent complications and promote comfort.
          1. Observe for signs of:
            1. Paralytic ileus (common complication) - keep NG tube patent.
            2. Stoma necrosis - dusky or cyanotic color (emergency situation).
          2. Skin care: check for leakage around ostomy bag.
          3. Urinary drainage - stents or catheter in stoma; blood in urine in immediate postoperative period; mucus normal.
        2. Goal: health teaching.
          1. Self-care activities:
            1. Peristomal skin care - prevent irritation, breakdown; proper cleansing - soap and water; adhesive remover, if needed.
            2. Appliance application and emptying; pouch opening 2-3 mm larger than stoma; do not remove each day; change appliance every 3-5 days or when leaking.
            3. Odor control - dilute urine, acid®||ash diet, hygiene; avoid asparagus, tomatoes.
            4. Use of night drainage system if necessary for uninterrupted sleep.
          2. Signs of complications: change in urine color, clarity, quantity, smell; stomal color change (normal is bright pink or red).
    4. Evaluation/outcome criteria:
      1. Acceptance of new body image.
      2. Regains independence.
      3. Demonstrates confidence in management of self-care activities.