Definition
Retrograde pyelography is usually performed
Hydronephrosis is the swelling of the kidneys when urine flow is
obstructed in any of part of the urinary tract. Swelling of the ureter, which extracorporeal shock-wave lithotripsy or in patients with urologic
always accompanies hydronephrosis, is called hydroureter.
Hydronephrosis implies that a ureter and the renal pelvis (the connection
of the ureter to the kidney) are overfilled with urine.
Description
The kidneys filter urine out of the blood as a waste product. It collects in
the renal pelvis and flows down the ureters into the bladder. The ureters
are not simple tubes, but muscular passages that actively propel urine
into the bladder. At their lower end is a valve (the ureterovesical junction)
that prevents urine from flowing backward into the ureter. The bladder
stores urine. The prostate gland surrounds the bladder outlet in males.
Urine then flows through the urethra and out of the body as a waste
product.
Because the urinary tract is closed save for the one opening at the
bottom, urine cannot escape. Instead, the parts distend. Rupture is rare
unless there is violent trauma like an automobile accident.
Obstructed flow anywhere along the drainage route can cause swelling of
the upper urinary tract, but if the obstruction is below the bladder, the
ureterovesical valve will protect the upper tract to a certain extent. Even
then, with no place to go, the urine will back up all the way to its source.
Eventually, the back pressure causes kidney function to deteriorate.
Obstruction need not be complete for problems to arise. Intermittent or
partial obstruction is far more common than complete blockage, allowing
time for the parts to enlarge gradually. Furthermore, if a ureterovesical
valve is absent or incompetent, the pressure generated by bladder
emptying will force urine backward into the ureter and kidney, causing
dilation even without mechanical obstruction.
Strictures of the Ureter
Some patients are born with a narrowing of the ureter where it leaves the
kidney or where it enters the bladder. Scar tissue from previous surgery
or stones in the ureter can also cause narrowing of the ureter with
blockage of the flow of urine from the kidney. These abnormalities can be
treated using the ureteroscope to examine the area of narrowing and use
a device through the ureteroscope to incise, or cut, the area of stricture
or scar tissue. After this procedure, a stent (a small tube that passes from
the kidney, down the ureter to the bladder) is left inside the body for 1-4
weeks. This stent helps to keep the kidney drained, and can usually be
easily removed in the office.
Retrograde Pyelography
In retrograde pyelography, catheters are advanced through the
ureters into the renal pelvis by means of cystoscopy. A contrast
agent is then injected.
if intravenous urography provides inadequate visualization
of the collecting systems. It may also be used before
cancer who need follow-up and are allergic to intravenous contrast
agents. Possible complications include infection, hematuria, and
perforation of the ureter. Retrograde pyelography is used infrequently
because of improved techniques in excretory urography.
Each kidney contains about 1 million nephrons, the functional
units of the kidney. Each kidney is capable of providing adequate
renal function if the opposite kidney is damaged or
becomes nonfunctional. The nephron consists of a glomerulus
containing afferent and efferent arterioles, Bowman’s capsule,
proximal tubule, loop of Henle, distal tubule, and collecting ducts
(Fig. 43-2). Collecting ducts converge into papillae, which empty Signs and symptoms Why
into the minor calices, which drain into three major calices that Signs and symptoms
open directly into the renal pelvis. Acute: extreme flank plain on affected Buildup of pressure in the kidney
Nephrons are structurally divided into two types: cortical and or
juxtamedullary. Cortical nephrons are found in the cortex of the side; pain may radiate to groin ureter due to backflow of urine
kidney, and juxtamedullary nephrons sit adjacent to the medulla. Chronic: mild discomfort over affected Kidney shifts downward, causing
The juxtamedullary nephrons are distinguished by their long side (sometimes described as dull overfilling of the renal pelvis or
loops of Henle and the vasa recta, long capillary loops that dip and aching) blockage of the ureters
into the medulla of the kidney. Anuria, oliguria, hematuria, polyuria Blockage of the urethra or ureters
The glomerulus is composed of three filtering layers: the capillary Urinary tract infection Backflow or stasis of the urine
endothelium, the basement membrane, and the epithelium. encourages bacterial growth
The glomerular membrane normally allows filtration of fluid and Nausea, vomiting, abdominal pain Body’s immune response
small molecules yet limits passage of larger molecules, such as Asymptomatic If progression of hydronephrosis is
blood cells and albumin. Kidney function begins to decrease at a slow there may be no symptoms for
rate of approximately 1% each year beginning at approximately awhile
Palpable mass over flank area Seen only in extreme cases; due to
age 30. enlargement of obstructed area
related to the collection of urine
Hydronephrosis
What is it?
When urine outflow is obstructed, a large fluctuating collection—or
mass—of urine forms in the kidney. This mass subsides as retained urine What can harm my client?
_ End-stage renal failure.
finally passes into the ureters and bladder. Stagnation of urine in the
kidneys leads to infection. Hydronephrosis is distension of the kidney _ Infection.
_ Improper catheter irrigation technique. For example, using too much
with urine that leads to progressive atrophy and eventual destruction of
the kidney. The kidney ends up looking like a thin-walled shell filled with force can cause fluid and bacteria to travel back up into the kidney,
which can cause hydronephrosis.
fluid. The causative factor, obstruction, has several different types.
If I were your teacher, I would test you on . . .
_ What is it?
_ What causes it and why.
_ Signs and symptoms and why.
_ Care of the client undergoing stent placement.
_ Care of the client undergoing surgery.
_ Patient education regarding side effects of hormone therapy.
Quickie tests and treatments
Tests:
_ Physical exam: distended kidney is palpable.
_ Bladder catheterization: detects site of the obstruction.
_ Urinalysis: increased white blood cells and presence of red blood
cells.
_ Ultrasound: detects cause of the obstruction.
_ Intravenous urography: detects flow of urine through the kidneys.
Treatments:
_ Immediate drainage of urine via needle directly into the kidney
through the skin.
_ Surgery: remove obstruction.
_ Urethral stent: bypasses obstruction (this is used in chronic
hydronephrosis).
_ Hormone therapy for prostate cancer.
_ Prevent and treat infection and/or kidney failure promptly.
Open Reduction and Internal Fixation
of Fractures of the Tibial Shaft
Definition
Realignment and fixation of a tibial shaft fracture.
Discussion
The type of fixation device is determined by the anatomic considerations
of the fracture (e.g., comminuted, spiral, or “open”). Severely
comminuted fractures may have to be treated with prolonged traction
rather than fixation.
Procedure
Open Reduction and Internal Fixation of Fractures of the Tibial
Shaft is described. The fracture is exposed.Transverse bone screws or
plates (including compression plates) may be applied to reduce fracture
fragments. In addition, after the fragments have been reduced, an
intramedullary nail or rod may be employed (e.g., Ender nail or Rush
rod) to fix a fractured tibia and provide improved rotational stability.An
Ender nail is slightly curved and semi-elastic. An incision about the tibial
tuberosity is made.A drill reamer penetrates the medullary canal.The
measured nail is inserted and aligned to avoid malrotation or shattering
the shaft of the tibia. Loose fragments and debris may be pulse lavaged
or irrigated with saline or an antibiotic solution.The Ender nail is then
driven past the fracture site into the distal portion until the threaded end
remains exposed (for later extraction). A counter incision over the Pulsed lavage suction irrigator and tip, e.g., Impulse, Simpulse,
fracture MicroAire (optional)
site may be needed to effect reduction. Again, care is taken during Supplies
the driving of the nail to avoid injury to the shaft. Use of multiple Ender Antiembolitic stocking, optional
nails can improve rotational stability; fanning of the proximal end helps Webril
control rotation. Small bones or fractures at the insertion site may Tube stockinette
complicate Esmarch bandage
use of Ender nails. X-rays are taken to visualize and document the Blades, (2) #10
repair. Hemostasis is assured before the wound is closed. Electrosurgical pencil and cord with holder and scraper
Basin set
Preparation of the Patient Needle magnet or counter
An antiembolitic stocking may be placed on the unaffected extremity, Suction tubing (2) or cojoined suction and irrigation tubing for
as requested. General anesthesia or regional block anesthetic may be pulsed lavage
employed.The patient is supine; arms may be extended on padded Irrigation solution in bags (for pulsed lavage), or graduated
armboards. pitcher, bulb syringes (2), antibiotic solutio
The safety strap is secured over the blanket-covered unaffected
extremity. Sheet wadding and a tourniquet are placed high on the thigh
of the operative leg. An electrosurgical dispersive pad is applied.
Skin Preparation
Care is taken to support the extremity to avoid further injury. Begin at
the fracture site; prep the entire extremity. Include the leg, thigh (up
to the tourniquet), and foot.
Draping
The supported leg is abducted and elevated; the foot is grasped and
covered
by a tube stockinette. A large sheet is draped over the end of the
table.The stockinette is brought up (unrolled) to the level of the
tourniquet.
A folded towel (thirds, lengthwise) is wrapped around the top of
the stockinette and secured. A split sheet is draped under the leg, or the
leg may be passed through a sheet with a rubberized fenestration.A large
drape (or split) sheet is draped cephalad, over the thigh, and secured
underneath. The leg is passed through a fenestrated sheet (e.g.,
transverse
or laparotomy), or additional drape sheets complete the draping.
Equipment
Suction
ESU
Tourniquet and insufflator (tank of compressed air) with microprocessor
regulator
Power sources for drill and saw (unless power equipment is selfcontained)
Instrumentation
Basic orthopedic procedures tray
Bone-holding instruments trayFixation device and insertion
instrumentation
High-speed power drill, cord, chuck, key, and drill bits