Renal Calculi and Genitourinary Cancers

Definitions:
* Nephrolithiasis: The formation of stones within the kidneys (kidney stones).
* Urolithiasis: The formation of stones within the bladder (bladder stones).
Epidemiology and Statistics:
    * Affects approximately $1$ to $2 imes 10^6$ people each year.
    * Incidence is more common in men than in women.
    * Caucasian populations are at a higher risk.
    * Prevalence increases during summer months, often linked to warm climates and dehydration.
Risk Factors:
    * Dietary Factors: High protein intake, decreased fluid intake, excess tea consumption, and consumption of dark colas.
    * Metabolic and Physical Factors: Immobilization and hypercalcemia.
    * Infections and Medical Devices: Urinary Tract Infections (UTI) and prolonged catheterization.
    * Structural and Functional Issues: Urinary stasis and obstruction.

Clinical Manifestations:
    * Pain: Significantly severe pain.
    * Gastrointestinal Symptoms: Nausea and vomiting (N/V).
    * The "Kidney Stone Dance": A characteristic behavior where the patient is unable to get comfortable and is constantly moving to find a position that relieves pain.
    * Urinary Issues: Signs of obstruction and general UTI symptoms.
Diagnostics:
    * Urinalysis: Used to confirm the diagnosis by assessing for hematuria (blood in the urine) and crystalluria (crystals in the urine).
    * Ultrasound (US): Useful for identifying masses or cysts.
    * Non-contrast CT Scan: Utilized to identify the location and size of the stone without the need for contrast dye.

General Nursing Care:
    * Pain Management: Priority intervention due to high pain levels.
    * Fluid Management: Increase fluid intake and strictly monitor Intake and Output (I & O).
        * The goal is an intake of $3\,dm^3/day$ to achieve a Urinary Output (UOP) of at least $2\,dm^3/day$ .
    * Urine Straining: All urine must be strained to capture the stone. This provides confirmation that the stone has passed.
    * Ambulation: Encouraged to help facilitate the passage of the stone.
Surgical Interventions (Lithotripsy):
    * Laser Lithotripsy:
        * Requires general anesthesia.
        * Uses a ureteroscope to reach the stones.
        * Typically indicated for large stones.
    * Extracorporeal Shock-Wave Lithotripsy (ESWL):
        * A non-invasive procedure.
        * Requires spinal or general anesthesia.
        * Uses ultrasound guidance to target larger stones and break them into smaller pieces.

General Characteristics:
* Predominantly occurs as adenocarcinoma.
* More common in men than women.
Risk Factors:
* Smoking is the major risk factor for developing kidney cancer.
Metastasis:
* Approximately $30\%\,$ of patients have metastasis at the time of diagnosis because the condition is often asymptomatic in early stages.

Clinical Manifestations:
    * Painless Hematuria: Often the primary symptom that brings patients in for evaluation.
    * Flank Pain: Localized pain in the side/back area.
    * Palpable Mass: A mass that can be felt upon physical examination.
    * Systemic Symptoms: Hypertension (HTN), weight loss, fever, and anemia.
Diagnostics:
* Ultrasound (US): Can differentiate between a solid mass tumor and a fluid-filled cyst.
* CT Scan: Capable of detecting even small kidney tumors.
Staging:
    * Stage 1: Tumor is confined within the kidney.
    * Stage 2: Tumor is larger but still confined to the kidney.
    * Stage 3: Tumor extends to the vena cava or nearby lymph nodes.
    * Stage 4: Tumor has metastasized to other organs.

Surgical Options (Nephrectomy):
    * Partial Nephrectomy: Removal of only the mass or tumor.
    * Total Nephrectomy: Removal of the entire kidney.
    * Radical Nephrectomy: Removal of the kidney, adrenal gland, surrounding fascia, and draining lymph nodes.
Post-operative Nursing Care:
    * Intake and Output (I & O): Must be monitored hourly; expected UOP is $30$ to $50\,cm^3/hr$ .
    * Drain Tubes: Monitor volume, color, and consistency of output, and inspect the skin around tube insertion sites.
    * Laboratory Monitoring: Continuous assessment of relevant lab values.
    * Bleeding Monitoring: Assess vital signs (VS), the surgical site, and check for abdominal distention.
    * Respiratory Status: Monitor Oxygen saturation (O2 sat) and Respiratory Rate (RR).
    * Pain Management: Implementation of appropriate pain relief strategies.

Epidemiology:
    * Approximately $84,000$ new diagnoses each year.
    * Approximately $17,000$ annual deaths.
    * Most common in individuals over the age of $50$ years.
Risk Factors:
* Smoking (associated with $\frac{1}{2}$ of all cases).
* Recurrent renal calculi (chronic irritation).
Clinical Manifestations:
* Painless Hematuria: The most common sign.
* Bladder Irritability: Includes dysuria (painful urination), frequency, and urgency.
Diagnostics:
    * Urinalysis: Checks for the presence of blood and epithelial cells.
    * CT Scan: To visualize the bladder structure.
    * Cystoscopy with Biopsy: The definitive method to confirm a mass in the bladder.

Surgical Options:
    * Transurethral Resection of Bladder Tumor (TURBT): Indicated for small tumors.
    * Cystectomy: Partial or total removal of the bladder.
    * Radical Cystectomy:
        * In Men: Removal of the bladder, prostate, and seminal vesicles.
        * In Women: Removal of the bladder, uterus, cervix, anterior vagina, and ovaries.
        * Requirement: Requires the creation of a urinary diversion to allow urine to leave the body.
Post-operative Nursing Care (Cystectomy):
    * Output Monitoring: Requires catheter placement.
    * Bleeding Assessment: Pink-tinged urine is normal for several days post-op. After $7$ to $10$ days, flecks of rust or red may appear. The urine should NOT contain clots or appear thick.
    * Fluid Intake: Increase fluids to $2$ to $3\,dm^3$ daily for the first week post-op.
    * Pain Management: Continuous assessment and relief.
    * Gastrointestinal Health: Monitor for constipation risk.

Incontinent Urinary Diversion (Ileal Conduit/Ileal Loop):
    * Uses a $6$ to $8$ inch segment of the ileum to create a diversion.
    * Requires an external pouch device for drainage.
    * Care concerns include skin integrity and body image.
Continent Urinary Diversion (Kock Pouch):
    * An internal reservoir created using the ileum and ascending colon.
    * Features a stoma (open hole) but no external bag.
    * The patient must self-catheterize the reservoir every $4$ to $6$ hours to empty it.