Kidneys are injured more often than any of the organs along the urinary tract from external trauma. If serious blunt or penetrating kidney injuries are not treated, complications, such as kidney failure or kidney loss, delayed bleeding, infection, and high blood pressure may result.

1. INJURIES TO THE
KIDNEY

2. ANATOMY OF URINARY
TRACT

3. INJURIES TO THE KIDNEY
 Trauma to abdomen, flank, or back may produce renal injury.
Suspicion is high in a patient with multiple injuries.

4.  Pathophysiology and Etiology
 Blunt trauma (falls, sporting accidents, motor vehicle accidents) can suddenly
move the kidney out of position and in contact with a rib or lumbar vertebral
transverse process, resulting in injury.
 Penetrating trauma (gunshot and stab wounds) can injure the kidney if it lies in
the path of the wound.
 Renal trauma is classified according to severity of injury
• Minor injuries—contusion, minor lacerations, hematomas
• Major injuries—major lacerations and rupture of kidney capsule (by
expanding hematoma)
• Critical injuries—multiple and severe lacerations and renal pedicle injury
(renal artery and vein are torn away from the kidney)
 Eighty percent of patients with renal trauma will have injuries to other organ
systems also necessitating treatment

5. Clinical Manifestations
 Hematuria is common but not indicative of severity of injury.
 Flank pain; perirenal hematoma.
 Nausea, vomiting, abdominal rigidity—from ileus (seen when there is retroperitoneal
bleeding).
 Shock—from severe or multiple injuries.
Diagnostic Evaluation
 History of injury—determine if injury was caused by blunt or penetrating trauma.
 IVU with nephrotomograms—to define extent of injury to involved kidney and the
function of contralateral kidney.
 CT scan—differentiates between major and minor injuries.
 Arteriography—if necessary to evaluate the renal artery.

6. Management
 Contusions and minor lacerations are managed conservatively with bed
rest, I.V. fluids, and monitoring of serial urines for clearing of hematuria.
 Major lacerations are surgically repaired.
 Ruptures are surgically repaired, usually by partial nephrectomy.
 Renal pedicle injury—this hemorrhagic emergency requires immediate
surgical repair and possible nephrectomy.

7.  Complications
 Shock with cardiovascular collapse
 Hematoma or urinoma formation, abscess formation
 Hypertension
 Pyelonephritis
 Nephrolithiasis

8.  INJURIES TO THE BLADDER AND URETHRA
Injuries to the bladder and urethra commonly occur along with pelvic
trauma or may be due to surgical interventions.

9.  Pathophysiology and Etiology
 Bladder injuries are classified as follows:
• Contusion of bladder
• Intraperitoneal rupture
• Extraperitoneal rupture
• Combination intraperitoneal and extraperitoneal bladder rupture
 Urethral injuries (occurring almost exclusively in men) are classified as
follows:
• Partial or complete rupture
• Anterior or posterior urethral rupture
 Injuries to the bladder and urethra are commonly associated with
pelvic fractures and multiple trauma

10.  Certain surgical procedures (endoscopic urologic procedures, gynecologic surgery, surgery
of the lower colon and rectum) also carry a risk of trauma to the bladder and urethra.
 Intraperitoneal bladder rupture occurs when the bladder is full of urine and the lower
abdomen sustains blunt trauma. The bladder ruptures at its weakest point, the dome. Urine and
blood extravasate into the peritoneal cavity.
 Extraperitoneal bladder rupture occurs when the lower bladder is perforated by a bony
fragment during pelvic fracture or with a sharp instrument during surgery. Urine and blood
extravasate into the pelvic cavity.
 Urethral rupture occurs during pelvic fracture (posterior) or when the urethra or penis is
manipulated accidentally during surgery or injury (anterior).

11. Clinical Manifestations
 Inability to void
 Hematuria; presence of blood at urinary meatus
 Shock and hemorrhage—pallor, rapid and increasing pulse rate
 Suprapubic pain and tenderness
 Rigid abdomen—indicates intraperitoneal rupture
 Absence of prostate on rectal examination in posterior urethral rupture
 Swelling or discoloration of penis, scrotum, and anterior perineum in anterior
urethral rupture

12. Diagnostic Evaluation
 Retrograde urethrogram—to detect rupture of urethra
 Cystogram—to detect and localize perforation/rupture of
bladder
 Plain film of abdomen—may show associated pelvic fracture
 Excretory urogram—to survey the kidneys for injury

13. Management
 Bladder Injury
 Treatment instituted for shock and hemorrhage.
 Surgical intervention carried out for intraperitoneal bladder rupture. Extravasated blood and urine
will first be drained and urine diverted with suprapubic cystostomy or indwelling catheter.
 Small extraperitoneal bladder ruptures will heal spontaneously with indwelling suprapubic or
urethral catheter drainage.
 Large extraperitoneal bladder ruptures are repaired surgically. Urethral Injury Management Is
Controversial
 Immediate repair—urethra is manipulated into its correct anatomical position with reanastomosis
after evacuation of hematoma.
 Delayed repair—suprapubic cystostomy drainage for 6 to 12 weeks allows the urethra to realign
itself while hematoma and edema resolve; then surgical reanastomosis.
 Two-stage urethroplasty—reconstruction of the urethra occurs in two separate surgeries with
urinary elimination diverted until final procedure

14. Complications
 Shock, hemorrhage, peritonitis
 UTI
 Urethral stricture disease

15. CANCER OF THE BLADDER
 Cancer of the bladder is the second most common urologic
malignancy. Approximately 90% of all bladder cancers are transitional
cell carcinomas, which arise from the epithelial lining of the urinary
tract; transitional cell tumors can also occur in the ureters, renal
pelvis, and urethra. The remaining 10% of bladder cancers are
adenocarcinoma, squamous cell carcinoma, or sarcoma.

16.  Pathophysiology and Etiology
 Many bladder tumors are diagnosed when the lesions are superficial, papillary
tumors that are easily resected.
 One fourth of patients with bladder cancer present with nonpapillary, muscle-
invasive disease.
 Bladder tumors tend to be either low-grade superficial tumors or high-grade
invasive cancers.
 Metastasis occurs in the bladder wall and pelvis; para-aortic or supraclavicular
nodes; in liver, lungs, and bone.
 Although the specific etiology is unknown, it appears that multiple agents are
linked to the development of cancer of the bladder, including:

17. • Cigarette smoking—the risk of developing bladder cancer is up to four times
higher in smokers.
• Prolonged exposure to aromatic amines or their metabolites—generally dyes
manufactured by the chemical industry and used by other industries.
• Exposure to cyclophosphamide (Cytoxan), radiation therapy to the pelvis,
chronic irritation of the bladder (as in long-term indwelling catheterization),
and excessive use of the analgesic drug phenacetin, which has been taken off
the market.
 Bladder cancer is the fourth most common cancer in men; it occurs four times
more frequently in men; peak incidence occurs in the 6th to 8th decades.

18. Clinical Manifestations
 Painless hematuria, either gross or microscopic—most
characteristic sign
 Dysuria, frequency, urgency—bladder irritability
 Pelvic or flank pain—obstruction or distant metastases
 Leg edema—from invasion of pelvic lymph nodes

19.  Diagnostic Evaluation
 Cystoscopy for visualization of number, location, and appearance of tumors; for
biopsy
 Urine and bladder washing for cytologic study
 Urine for flow cytometry—uses a computer-controlled fluorescence microscope to
scan and image the nucleus of each cell on a slide; based on the fact that cancer cells
contain abnormally large amounts of deoxyribonucleic acid
 IVU—may reveal filling defect indicative of bladder tumor, also to determine status
of upper tracts
 To evaluate for metastatic disease:
• CT scan or MRI—to evaluate extent of disease and tumor responsiveness
• Chest X-ray—to evaluate for pulmonary metastases
• Pelvic lymphadenectomy (during cystectomy)—most accurate for staging

20.  Management, Surgery
 Transurethral resection and fulguration—endoscopic resection for superficial tumors.
• May be followed by intravesical chemotherapy to prevent tumor recurrence.
• Complications include hemorrhage, infection, bladder perforation, and temporary irritative voiding.
• Laser irradiation of bladder tumors is also used to destroy tumors; however, it does not allow for
tumor specimen collection for pathologic analysis.
 Partial cystectomy when lesions are located only in the dome of the bladder, away from the
ureteral orifices.
 Radical cystectomy (removal of bladder) for invasive or poorly differentiated tumors.
• Requires diversion of the urinary stream (see page 766).
• In men, includes removal of bladder, prostate and seminal vesicles, proximal vas deferens, and part
of proximal urethra.
• P.793
•
• In women, consists of anterior exenteration with removal of bladder, urethra, uterus, fallopian tubes,
ovaries, and segment of anterior wall of the vagina.
• May be combined with chemotherapy and radiation.

21. Systemic Chemotherapy
 Metastatic bladder cancer is a chemotherapeutically responsive disease;
MVAC combination is widely used (methotrexate [Mexate], vinblastine
[Velban], doxorubicin [Adriamycin], and cisplatin [Platinol]).
Radiation Therapy
 External beam radiation therapy is commonly used in combination
with chemotherapy.

22. KIDNEY
SURGERY

23. KIDNEY SURGERY
 Kidney Surgery
A patient may undergo surgery to remove obstructions that affect
the kidney (tumors or calculi), to insert a tube for draining the
kidney (nephrostomy, ureterostomy), or to remove the kidney
involved in unilateral kidney disease, renal carcinoma, or kidney
transplantation

24.  PREOPERATIVE CONSIDERATIONS
 Surgery is performed only after a thorough evaluation of renal function. Patient preparation to
ensure that optimal renal function is maintained is mandatory. Fluids are encouraged to promote
increased excretion of waste products before surgery, unless contraindicated because of preexisting
renal or cardiac dysfunction. If kidney infection is present preoperatively, wide-spectrum antimicrobial
agents may be prescribed to prevent bacteremia. Antibiotic agents must be given with extreme care
because many are toxic to the kidneys. Coagulation studies (prothrombin time, partial thromboplastin
time, platelet count) may be indicated if the patient has a history of bruising and bleeding. The general
preoperative preparation is similar to that described in Chapter 18. Because many patients facing
kidney surgery are apprehensive, the nurse encourages the patient to recognize and express anyfeelings
of anxiety. Confidence is reinforced by establishing a relationship of trust and by providing expert
care. Patients faced with the prospect of losing a kidney may think that they will be dependent on
dialysis for the rest of their life. It is important to teach the patient and family that normal function
may be maintained by a single healthy kidney.

25.  PERIOPERATIVE CONCERNS
 Renal surgery requires various patient positions to expose the surgical
 site adequately. Three surgical approaches are common: flank,
 lumbar, and thoracoabdominal (Fig. 44-10). During surgery, plans
 are carried out for managing altered urinary drainage and drainage
 systems. Plans may include inserting a nephrostomy or other
 drainage tube or using ureteral stents.

26.  POSTOPERATIVE MANAGEMENT
 Because the kidney is a highly vascular organ, hemorrhage and
 shock are the chief complications of renal surgery. Fluid and
 blood component replacement is frequently necessary in the immediate
 postoperative period to treat intraoperative blood loss.
 Abdominal distention and paralytic ileus are fairly common
 after renal and ureter surgery and are thought to be due to a reflex
 paralysis of intestinal peristalsis and manipulation of the
 colon or duodenum during surgery. Abdominal distention is relieved
 by decompression through a nasogastric tube (see Chap. 38
 for treatment of paralytic ileus). Oral fluids are permitted when
 the passage of flatus is noted.
 If infection occurs, antibiotic agents are prescribed after a culture
 reveals the causative organism. The toxic effects that antibiotic
 agents have on the kidneys (nephrotoxicity) must be kept
 in mind when assessing the patient. Low-dose heparin therapy
 may be initiated postoperatively to prevent thromboembolism in
 patients who had any type of urologic surgery.

27. Drainage Tubes
 Almost all patients undergoing kidney and urologic surgery, as
 well as patients with other kidney and urologic disturbances, have
 drains, tubes, or catheters in place. All catheters and tubes must
 be kept patent (eg, draining) to prevent obstruction by blood
 clots, which can cause infection, kidney damage, or severe pain
 (similar to renal colic) when they pass along the ureter.

28.  Nephrostomy Drainage
 A nephrostomy tube is inserted directly into the kidney for temporary
 or permanent urinary diversion. It can be inserted either
 percutaneously or through a surgical incision. A single tube or a
 self-retaining U loop or circular nephrostomy tube may be used
 and is attached to a closed drainage system or to a urostomy
 appliance. Nephrostomy drainage may be required to provide
 drainage from the kidney after surgery or to bypass an obstruction
 in the ureter or lower urinary tract. Permanent nephrostomy
 tubes are usually changed every 3 months.
 Percutaneous nephrostomy is the insertion of a tube through
 the skin into the renal pelvis. This procedure is performed to provide
 external drainage of urine from an obstructed ureter, to create
 a route for inserting a ureteral stent (see following discussion), to
 dilate strictures, to close fistulas, to administer medications, to
 allow insertion of a brush biopsy instrument and nephroscope, or
 to perform selected surgical procedures.
 The skin site is prepared and anesthetized, and the patient is
 asked to inhale and hold his or her breath while a spinal needle is
 advanced into the renal pelvis. Urine is aspirated for culture, and a
 contrast agent may be injected into the pyelocalyceal system. An
 angiographic catheter guide wire is introduced through the needle
 to the kidney. The needle is withdrawn and the tract dilated
 by the passage of tubes or guide wires. The nephrostomy tube is
 introduced and positioned within the kidney or ureter, fixed by
 skin sutures, and connected to a closed drainage system.

29.  Before a percutaneous nephrostomy tube is inserted, several
 precautions should be taken. The patient should receive a broadspectrum
 antibiotic to prevent infection. Bleeding disorders and
 uncontrolled hypertension should be corrected. Also, anticoagulant
 agents and aspirin should be discontinued and bleeding
 study results (prothrombin time, partial thromboplastin time,
 platelet count) should be normal to decrease the chance of developing
 a perirenal hematoma or renal hemorrhage. Chart 44-12
 describes postsurgical nursing care of the patient with a nephrostomy
 tube

30.  Ureteral Stents
 A ureteral stent is a self-retaining tubular device that helps maintain
 the position and patency of the ureter. Stents are used to
 maintain urine flow in patients with ureteral obstruction (from
 edema, stricture, fibrosis, calculi, or tumors), to divert urine, to
 promote healing, and to maintain the caliber and patency of the
 ureter after surgery (Fig. 44-11). Stents are usually removed 4 to
 6 weeks after surgery in an outpatient setting without the need
 for general anesthesia or risk of ureteral injury.
 The stent, usually made of soft, flexible silicone, may be inserted
 through a cystoscope or nephrostomy tube or by open surgery.
 Complications include infection, inflammation secondary to a foreign
 body in the genitourinary tract, tube encrustation, bleeding
 or clot obstruction within the stent, and migration or displacement
 of the stent (Lehmann & Dietz, 2002).
 Several stents are designed to avoid some of these problems.
 The double-J ureteral stent has a J-shaped curve molded into each
 end that prevents upward or downward migration. This stent can
 be used in place of a nephrostomy for short- or long-term urinary
 drainage. The double-pigtail ureteral stent has a pigtail coil at
 each end; this permits placement of the upper coil (pigtail) in the
 renal pelvis, with the lower coil at the ureteral orifice. The coils
 prevent the stent from moving and allow free body movement.
 Nursing interventions related to the care of a patient with a
 ureteral stent include monitoring the patient for bleeding, assessing
 and measuring urine output, assessing the patient for signs ofurinary tract infection or retroperitoneal infection from leakage
 of urine, and monitoring the patient for stent displacement,
 which is evidenced by colicky pain and a decrease in urine output.
 An indwelling stent may produce a local ureteral reaction,
 including mucosal edema, which can cause temporary obstruction
 of the ureter and intense pain.

31.  NURSING PROCESS:
 THE PATIENT UNDERGOING
 KIDNEY SURGERY
 Assessment
 Immediate care of the patient who has undergone surgery of the
 kidney includes assessment of all body systems. Respiratory and
 circulatory status, pain level, fluid and electrolyte status, and patency
 and adequacy of urinary drainage systems are assessed.
 RESPIRATORY STATUS
 As with any surgery, the use of anesthesia increases the risk of respiratory
 complications. Noting the location of the surgical incision
 assists the nurse in anticipating respiratory problems and
 pain. Respiratory status is assessed by monitoring the rate, depth,
 and pattern of respirations. The location of the incision frequently
 causes pain on inspiration and coughing; therefore, the
 patient tends to splint the chest wall and take shallow respirations.
 Auscultation is performed to assess normal and adventitious
 breath sounds.
 CIRCULATORY STATUS AND BLOOD LOSS
 The vital signs and arterial or central venous pressure are monitored.
 Skin color and temperature and urine output provide information
 about circulatory status. The surgical incision and
 drainage tubes are observed frequently to help detect unexpected
 blood loss and hemorrhage.

32.  PAIN
 Postoperative pain is a major problem for the patient because of
 the location of the surgical incision and the position the patient
 assumed on the operating table to permit access to the kidney.
 The location and severity of pain are assessed before and after
 analgesic medications are administered. Abdominal distention,
 which increases discomfort, is also noted.
 URINARY DRAINAGE
 Urine output and drainage from tubes inserted during surgery are
 monitored for amount, color, and type or characteristics. Decreased
 or absent drainage is promptly reported to the physician
 because it may indicate obstruction that could cause pain, infection,
 and disruption of the suture lines.
 Diagnosis
 NURSING DIAGNOSES
 Based on the history and assessment data and the type of surgical
 procedure performed, some major nursing diagnoses for the patient
 include the following (additional diagnoses and interventions
 appear in the Plan of Nursing Care):
 • Ineffective airway clearance related to the location of the
 surgical incision
 • Ineffective breathing

33. NURSING DIAGNOSIS
 Acute pain related to the location of the surgical incision,
the position the patient assumed on the operating table during
surgery, and abdominal distention
 Urine retention related to pain, immobility, and anesthesia

35. THANK U