UROLITHIASIS ON SURGERY AND SURGICAL NURSING

Surgery and surgical nursing notes

1. UROLITHIASIS DESCRIPTION OF THE SYSTEM Urolithiasis is a condition involving the formation of stones (calculi) within the urinary system, which includes the kidneys, ureters (tubes connecting the kidneys to the bladder), bladder, and urethra (tube that carries urine out of the body). The primary function of this system is to filter waste products from the blood and excrete them as urine. DESCRIPTION OF THE CONDITION Urolithiasis : Formation of stones (calculi) in the urinary tract. Stones can form in the kidney (nephrolithiasis), ureter (ureterolithiasis), or bladder (cystolithiasis).

2. PATHOPHYSIOLOGY OF UROLITHIASIS Urolithiasis is caused by the supersaturation of urine with stone-forming salts. This occurs due to: 1. High concentration of stone-forming solutes (e.g., calcium, oxalate, uric acid) in the urine. 2. Low urine volume (due to dehydration). 3. Abnormal urinary pH (e.g., acidic urine favors uric acid stones, alkaline urine favors calcium phosphate/ struvite stones). This supersaturation leads to crystallization, nucleation (formation of crystal seed), and subsequent aggregation and growth of the crystals into stones. When a stone moves or obstructs the flow of urine, it causes symptoms like renal colic and can lead to hydronephrosis (swelling of the kidney due to urine backup).

3. CAUSES OF UROLITHIASIS Dehydration/Low Fluid Intake: The most common cause, leading to concentrated urine. • Dietary Factors: High intake of sodium, animal protein, and oxalate-rich foods; low intake of calcium (paradoxically). • Metabolic Disorders: Hyperparathyroidism (leading to hypercalciuria ), renal tubular acidosis, gout (leading to hyperuricosuria), and genetic disorders like cystinuria . • Urinary Tract Infections (UTIs): Specifically with urea-splitting organisms (e.g., Proteus), which cause struvite (infection) stones. • Anatomic Abnormalities: Conditions causing urinary stasis.

4. SIGNS AND SYMPTOMS Renal Colic: Sudden, severe, cramping pain in the flank or side that often radiates to the lower abdomen, groin, or inner thigh. The pain is typically intermittent and excruciating. • Hematuria: Blood in the urine (may be visible or microscopic). • Nausea and Vomiting: Due to the severity of pain and a shared nerve pathway (T10-L2) between the kidney and the stomach. • Urinary Urgency, Frequency, and Dysuria (Painful Urination): If the stone is near the bladder ( ureterovesical junction). • Fever and Chills: Indicate an associated UTI or urosepsis (a medical emergency).

5. SURGICAL MANAGEMENT Surgical and interventional procedures are used for stones too large to pass or those causing persistent obstruction, infection, or uncontrolled pain. Extracorporeal Shock Wave Lithotripsy (ESWL): Uses shock waves outside the body to break the stones into smaller fragments that can be passed naturally. Ureteroscopy (URS): A rigid or flexible scope is passed through the urethra and bladder into the ureter to visualize the stone, break it with a laser (laser lithotripsy), and remove the fragments with a basket. Percutaneous Nephrolithotomy (PCNL): For very large stones (e.g., staghorn calculi) or those in the kidney; involves a small incision in the back to pass a tube directly into the kidney to break and remove the stone. Open/laparoscopic surgery (rare)

6. NURSING MANAGEMENT • Pain Management: Administering prescribed opioid and non-steroidal anti-inflammatory drugs (NSAIDs) for renal colic. • Fluid Management: Encourage liberal oral fluid intake (unless contraindicated) and administer IV fluids to promote stone passage and prevent dehydration. • Strain All Urine: Collect any passed stone fragments for laboratory analysis to determine composition, which guides prevention. • Monitor for Complications: Watch for signs of obstruction (decreased urine output), infection (fever, chills), and hematuria. • Patient Education: Teach the patient about the condition, prescribed medications, signs of infection/obstruction, and specific dietary changes/fluid intake requirements based on stone composition.

7. COMPLICATION PREVENTION Urinary Tract Obstruction(leading to hydronephresis ) Timely intervention (URS,ESWL,PCNL) Urinary Tract Infection/ Urosepsis Prompt treatment of existing stones, sometimes with prophylactic antibiotics. Renal Damage Relief of obstruction Stone Recurrence High fluid intake(aiming for more than 2.5L of urine per day) specific dietary modifications ( e.g , low sodium, controlled oxalate, reduced animal protein) and medication therapy( e.g , thiazide diuretics for calcium stones, allopurinol for uric acid.

8. GENITOURINARY TUMORS Description of the Systems The Genitourinary (GU) System encompasses the Urinary System (kidneys, ureters, bladder, urethra) and the Male Reproductive System (testes, prostate, seminal vesicles, penis). Genitourinary tumors include cancers of the kidney, bladder, prostate (in males), and testis (in males), among others. Description of the Conditions Genitourinary tumors are abnormal masses of tissue arising in any organ of the GU system. These can be benign (non-cancerous) or malignant (cancerous). Malignant GU tumors are collectively referred to as Genitourinary Cancers (e.g., Renal Cell Carcinoma, Prostate Cancer, Bladder Cancer).

9. PATHOPHYSIOLOGY GU cancers arise from uncontrolled cell growth due to mutations in cellular DNA. These mutations lead to a loss of the normal regulation of cell division and apoptosis (programmed cell death), resulting in the formation of a tumor. The tumor can invade adjacent tissues and may metastasize (spread) to distant sites via the bloodstream or lymphatic system. Specific types of cancer are named after the cell of origin (e.g., Urothelial Carcinoma in the bladder lining, Renal Cell Carcinoma in the kidney tubules).

10. CAUSES OF GU Causes are often multifactorial, involving a combination of genetic and environmental factors. • Age: Risk for most GU cancers (especially Prostate and Bladder) increases significantly with age. • Chemical Exposure: Occupational exposure to certain dyes, rubber, leather, and chemicals (linked to Bladder Cancer). • Genetic Factors/Family History: A significant risk for Prostate, Kidney, and Testicular cancers. • Chronic Inflammation: Chronic bladder irritation/infection can lead to specific types of bladder cancer. • Obesity and Hypertension: Risk factors for Kidney Cancer.

11. SIGNS AND SYMPTOMS Symptoms vary greatly depending on the tumor's location: • Kidney Cancer: Often asymptomatic until advanced. May cause flank pain, a palpable abdominal mass, and gross hematuria (blood in urine). • Bladder Cancer: The most common symptom is painless gross hematuria. May also cause urinary urgency, frequency, and dysuria. • Prostate Cancer (Males): Often asymptomatic in early stages. May cause difficulty urinating (hesitancy, weak stream, frequency), nocturia (waking to urinate), or blood in the semen. • Testicular Cancer (Males): A painless lump or swelling in the testicle, a feeling of heaviness in the scrotum, or a dull ache in the abdomen/groin.

12. SURGICAL MANAGEMENT Surgery is often the primary treatment for localized GU tumors. • Nephrectomy (Kidney): Partial or radical removal of the affected kidney for kidney cancer. • Cystectomy (Bladder): Removal of the bladder (radical cystectomy) for invasive bladder cancer, requiring urinary diversion (e.g., ileal conduit).. • Transurethral Resection of Bladder Tumor (TURBT): For non-muscle invasive bladder cancer, removes the tumor through the urethra. • Prostatectomy (Prostate): Radical prostatectomy (removal of the entire prostate gland) for localized prostate cancer. • Orchiectomy (Testis): Removal of the affected testicle for testicular cancer.

13. NURSING MANAGEMENT • Pre- and Post-operative Care: Managing pain, monitoring vital signs, assessing incision sites for infection, and managing drains/catheters. • Urinary Diversion Care (Post-Cystectomy): Teaching stoma care, appliance changes, and monitoring for complications in patients with ileal conduits or continent diversions. • Symptom Management: Managing side effects of chemotherapy or radiation (nausea, fatigue, skin reactions). • Emotional/Psychological Support: Counseling on body image changes, sexual dysfunction (common after prostate or bladder surgery), and coping with a cancer diagnosis.

14. COMPLICATIONS PREVENTIONS Metastasis/recurrence Adjuvant or neo-adjuvant therapy (chemo/radiation), regular follow-up/surveillance. Urinary incontinence/erectile dysfunction(post-prostatectomy) Pre – and post- operative pelvic floor exercises( kegels ), penile rehabilitation. Stoma /Diversion isssues (post cystectomy) Careful stoma site selection, meticulous stoma and skin care, patient education. Developing cancer Cessation of smoking, reducing occupational chemical exposure, maintain a healthy weight and diet, and routine screenings.

15. FEMALE GENITOURINARY TUMORS Description of the Systems This section focuses on tumors in the Female Genitourinary Tract, which includes the Urinary System (kidney, ureters, bladder, urethra) and the Female Reproductive System (vagina, cervix, uterus, ovaries, fallopian tubes, vulva). Description of the Conditions These are tumors arising in the female urinary or reproductive organs. Female Genitourinary Tumors often specifically refers to cancers of the kidney, bladder, and those considered Gynecologic Cancers (e.g., Cervical, Endometrial/Uterine, Ovarian, Vaginal, Vulvar).

16. PATHOPHYSILOGY The pathophysiology is similar to other cancers: DNA mutations leading to uncontrolled cellular proliferation and tumor formation. • Cervical Cancer: Nearly always caused by persistent infection with High-Risk Human Papillomavirus (HPV), leading to cellular dysplasia and malignancy. • Endometrial (Uterine) Cancer: Often linked to unopposed estrogen exposure (estrogen without sufficient progesterone), which stimulates endometrial cell growth. • Ovarian Cancer: The exact mechanism is unclear but involves epithelial or germ cell changes. Risk is increased by genetic mutations (e.g., BRCA)

17. CAUSES • Infection: HPV infection (Cervical, Vaginal, Vulvar Cancers). • Hormonal Factors: Unopposed estrogen (Endometrial Cancer). Early menarche, late menopause, never having been pregnant ( nulliparity ) increase risk for Ovarian/Endometrial. • Genetics: BRCA1/2 mutations (Ovarian, Fallopian Tube, Peritoneal Cancers), Lynch syndrome (Endometrial Cancer). • Lifestyle: Smoking, obesity, and age are common risk factors for many types.

18. S/S • Cervical/Vaginal/Vulvar Cancers: Abnormal vaginal bleeding (after intercourse, between periods, post-menopause), unusual vaginal discharge, or a persistent lump/sore on the vulva. • Endometrial (Uterine) Cancer: Abnormal vaginal bleeding (especially post-menopausal bleeding) is the most common symptom. • Ovarian Cancer: Often non-specific, leading to late diagnosis. Symptoms include abdominal bloating or swelling, pelvic or abdominal pain, feeling full quickly when eating, and urinary frequency/urgency • Urinary Tract Cancers (Bladder/Kidney): As described in Section 2.e (e.g., painless hematuria, flank pain).

19. SURGICAL MANAGEMENT Surgery is a cornerstone of treatment. • Hysterectomy: Removal of the uterus (often with fallopian tubes and ovaries) for Cervical, Endometrial, and sometimes Ovarian cancer • Oophorectomy/ Salpingo -Oophorectomy: Removal of ovaries and/or fallopian tubes (often with hysterectomy for Ovarian cancer). • Tumor Debulking : Removing as much of the tumor as possible (often for advanced Ovarian cancer). • Radical Trachelectomy : Removal of the cervix and surrounding tissue (spares the uterus) for early-stage cervical cancer in women who wish to preserve fertility. • TURBT/Cystectomy/Nephrectomy: For bladder and kidney tumors, as described in Section

20. NURSING MANAGEMENT Pre- and Post-operative Monitoring: Routine post-op care, especially monitoring for hemorrhage and infection. • Urinary/Bowel Function: Monitoring and managing changes post-surgery (especially with extensive pelvic surgery). • Sexual Health Counseling: Addressing potential changes in body image, sensation, and function due to surgery or radiation. • Symptom and Side Effect Management: Administering pain medication, anti-emetics for chemotherapy, and managing radiation-induced skin/bowel changes. • Emotional Support: Counseling related to fertility concerns (if pre-menopausal) and coping with a gynecologic cancer diagnosis

21. COMPLICATIONS PREVENTIONS Infection/Hemorrhage (post-surgery) Standard surgical infection control Lymphedema (post -pelvic lymph node dissection) Compression stockings, physical therapy Menopausal symptoms (post-oophorectomy) Hormone replacement therapy Developing cancer HPV vaccination (cervical, vulvar, vaginal cancers), routine pelvic exams and pap smears, management of obesity, and prophylactic surgery for high-risk genetic carriers.