Page 146 - Critical Care Notes

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GU

Cystectomy
Radical cystectomy is the removal of the bladder, prostate, and seminal vesicles
in men and the bladder, ureters, cervix, urethra, and ovaries in women. The
ureters are diverted into collection reservoirs → urinary diversion (ileal conduit,
continent pouch, bladder reconstruction [neobladder], ureterosigmoidostomy).
Pathophysiology
Primary indication is for treatment of carcinoma of the bladder (transitional cell,
squamous cell, or adenocarcinoma). Once the cancer spreads beyond the tran-
sitional cell layer, the risk of metastasis ↑ greatly.
Secondary indication is as part of pelvic exenteration for sarcomas or tumors
of the GI tract or gynecological system.
Clinical Presentation
■ Gross painless hematuria (chronic or intermittent)
■ Bladder irritability with dysuria, urgency, and frequency
■ Urine cytology positive for neoplastic or atypical cells
■ Urine tests positive for bladder tumor antigens
■ Incidental or symptomatic obstructive hydroureteronephrosis
Diagnostic Tests
■ Urine cytology
■ Urine for bladder tumor antigens
■ IV pyelogram or retrograde ureteropyelography of bladder
■ Ultrasound of bladder, kidneys, and ureters
■ CT of abdomen and pelvis
■ MRI of abdomen and pelvis
■ Cystoscopy and biopsy (confirmation of bladder carcinoma)
■ Bladder barbotage (bladder washings) for cytology
Postoperative Management
■ Provide routine postoperative care.
■ Monitor vital signs per hospital policy immediately postoperatively.
■ Encourage patient to cough and deep breathe and to use incentive spirom-
eter every hour.
■ Monitor and record amount of bleeding from incision and in urine.
■ Monitor and record intake and output.
■ If patient has a cutaneous urinary diversion, assess stoma for warmth and
color every 8 hr in early postop period (ostomy appliance will collect urine).
■ Collaborate with enteral stoma nurse regarding stoma, skin, and urinary drainage.
■ If Penrose drain or plastic catheters in place, monitor and record drainage.
■ Monitor hemoglobin and hematocrit levels.
■ Provide pain management.
■ Encourage early ambulation.
■ Provide patient and family support.
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