Surgery - GU / Renal

What is the minium post-op urine output goal

At least 0.5 ml/kg/hour

Ideally, when do we remove urine caths post-op

POD 1

What timeframe is given to assess if patient can properly void without a cath

6-8 hours post-op or post-cath removal

How does post-op low urine output typically occur

Kidneys have decreased blood flow

Activates the renin-angiotensin system

Preserve water

What are important questions to ask if a patient has low post-op urine output

Was the patient appropriately volume resuscitated?

Is the patient NPO?

What maintenance fluids? Rate?

Weight of the patient?

Fever / Increased metabolic issue?

What is the blood pressure / mean arterial pressure?

Treatment for Low Urine Output Post-OP

Assess for volume overload/heart failure issues

no signs of volume overload → bolus – 500-1,000 mL NSS

ncrease the maintenance fluid rate

Watch for signs of fluid overload

Signs of volume overload → Lasix

Risk Factors for POUR

Age over 40 years

Male gender

History of DM

Preexisting urinary retention

Neurologic disease

Type of surgery

Types of anesthesia

Prolonged surgical procedures

Certain medications

What neuro diseases have risk of causing POUR

cerebral palsy

neuropathy

MS

What anthesia types have risk for causing POUR

Epidural and spinal

POUR

Post-op urine retention

What medications can induce POUR

opioids

anticholingerics

beta-blockers

At what volume is post-void residual indicative for retention

Post-void residual >100 mL

Signs of Urine Retention / POUR

Inability to void despite feeling of full bladder

Suprapubic discomfort

Agitation

Palpable

Treatment for POUR

Encourage fluid intake

Intermittent catheterization to relieve bladder pressure

Temporary indwelling bladder catheter may be needed

alpha-adrenergic blocker → Tamsulosin

home performing clean intermittent catheterization (CIC)

What surgery types tend to cause POUR

Pelvic

Anorectal

Hernia repairs

Incontinence Surgery

What region of the prostate is affected by BPH

transitional zone of the prostate

Presentation of BPH

Nocturia,

frequency,

dysuria,

weak stream,

urinary retention

Treatment of BPH

Medical therapy - Alpha blockers + 5-alpha-reductase inhibitors

Surgery

Most procedures for BPH are performed

Transurethral

How long does a cath remain post-op TURP

1-7 days

Most Common Complication of TURP

UTI

Complications from TURP

UTIs

Reterograde ejaculation

Presentation of Nephrolithiasis

Severe colicky, flank (back) pain,

restlessness,

N/V

dx for Nephrolithiasis

Urinalysis demonstrates blood and/or stones

Abdominal CT (generally non-contrast)

Treatment for Nephrolithiasis

IV fluids,

analgesics,

watchful waiting

Surgery

Indications for Surgical Treatment of Nephrolithiasis

Intractable pain or infection

Progressive obstruction

Progressive renal damage

Solitary kidney

Stones with low probability of passing (size)

At what size are renal stones determined not to pass on own

6mm or more

Procedures for Nephrolithiasis

Extracorporeal shock wave lithotripsy (ESWL)

Ureteroscopy with stone extraction

Percutaneous nephrolithotomy (PCNL)

Open nephrolithotomy

Placement of stent past obstruction

Contraindications for ESWL

Pregnany

Bleeding diathesis

Stones several cm in size

Complications from ESWL

Bleeding

Infections

Most Common Complications from Ureteroscopy with stone extraction

Ureteral injury

Ureteral stricture

Percutaneous nephrolithotomy (PCNL)

removal of stone through skin

Complications from Percutaneous nephrolithotomy (PCNL)

Bleeding

kidney damage

Risks of Open nephrolithotomy

infection

longer recovery time

Complications from Ureter Stents

pain

infection

Most common type of bladder cancer

transitional cell carcinoma

Presentation of bladder cancer

painless hematuria

Pain usually with locally advanced or metastatic disease

Risk Factors for Bladder Cancer

Smoking

aniline dyes

Cyclophosphamide

dx for bladder cancer

Cystoscopy → initial procedure for diagnosis and management

Urinalysis

Treatment for Bladder Cancer

T1 tumor (No detrusor involvement) → Intravesical (BCG) or (TURBT)

If muscle wall invaded (T2 or higher) – need cystectomy with ileal conduit + chemotherapy + XRT

Complications of Bladder Surgery

Infection of the bladder

Bleeding

Lymphedema (legs) if lymphadenectomy done

Changes in urinary function

Types of Urinary Diversion

Ileal Conduit

Continent Cutanous Reservior

Orthotopic Neobladder

Most common tumor of the kidney

Renal cell carcinoma

hypernephroma

Renal cell carcinoma

Risk Factors for Renal cell carcinoma

smoking,

obesity,

hypertension,

chronic kidney disease

, genetic

What genetic syndrome is associated with renal cell carcinoma

(von Hippel-Lindau disease)

Presentation of renal cell carcinoma

flank pain,

mass,

hematuria,

unexplained weight loss,

fatigue,

night sweats,

persistent fever

with paraneoplastic syndromes

Test of Choice for renal cell carcinoma

CT

Most Common Mets Site for Renal Cell Carcinoma

Lung

How can renal cell carcinoma effect labs

HTN and elevated RBC due to high EPO

Treatment for renal cell carcinoma

radical nephrectomy with regional nodes, radiation, and chemotherapy

If less than 4cm → partial nephrectomy may be offered

renal cell carcinoma