cystoureterography

Cystoscopy

Common use

Area of application

Contrast

Description

This procedure is contraindicated for

• high alertPatients who are pregnant or suspected of being pregnant, unless the potential benefits of a procedure using radiation far outweigh the risk of radiation exposure to the fetus and mother.
• high alertPatients with bleeding disorders because instrumentation may lead to excessive bleeding from the lower urinary tract.
• high alertPatients with acute cystitis or urethritis because instrumentation could allow bacteria to enter the bloodstream, resulting in septicemia.

Indications

• Coagulate bleeding areas
• Determine the possible source of persistent urinary tract infections
• Determine the source of hematuria of unknown cause
• Differentiate, through tissue biopsy, between benign and cancerous lesions involving the bladder
• Dilate the urethra and ureters
• Evacuate blood clots and perform fulguration of bleeding sites within the lower urinary tract
• Evaluate changes in urinary elimination patterns
• Evaluate the extent of prostatic hyperplasia and degree of obstruction
• Evaluate the function of each kidney by obtaining urine samples via ureteral catheters
• Evaluate urinary tract abnormalities such as dysuria, frequency, retention, inadequate stream, urgency, and incontinence
• Identify and remove polyps and small tumors (including by fulguration) from the bladder
• Identify congenital anomalies, such as duplicate ureters, ureteroceles, urethral or ureteral strictures, diverticula, and areas of inflammation or ulceration
• Implant radioactive seeds
• Place ureteral catheters to drain urine from the renal pelvis or for retrograde pyelography
• Place ureteral stents and resect prostate gland tissue (transurethral resection of the prostate)
• Remove renal calculi from the bladder or ureters
• Resect small tumors

Potential diagnosis

Normal findings

• Normal ureter, bladder, and urethral structure

Abnormal findings related to

• Diverticulum of the bladder, fistula, stones, and strictures
• Inflammation or infection
• Obstruction
• Polyps
• Prostatic hypertrophy or hyperplasia
• Renal calculi
• Tumors
• Ureteral or urethral stricture
• Urinary tract malformation and congenital anomalies

Critical findings

N/A

Interfering factors

• Other considerations

  • Failure to follow dietary restrictions before the procedure may cause the procedure to be canceled or repeated.
  • Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status.

Nursing Implications and Procedure

Pretest

• Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
• Patient Teaching: Inform the patient this procedure can assist in assessing the urinary tract.
• Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to latex, contrast medium, anesthetics, and dyes.
• Obtain a history of results of the patient’s genitourinary system, symptoms, and previously performed laboratory tests and diagnostic and surgical procedures.
• Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
• Obtain a list of the patient’s current medications, including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus). Such products should be discontinued by medical direction for the appropriate number of days prior to a surgical procedure. Note the last time and dose of medication taken.
• Review the procedure with the patient. Address concerns about pain and explain that there may be moments of discomfort and some pain experienced during the test. Inform the patient that the procedure is usually performed in a special cystoscopy suite near or in the surgery department by a health-care provider (HCP), with support staff, and takes approximately 30 to 60 min.
• Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
• Explain that an IV line may be inserted to allow infusion of IV fluids such as normal saline, anesthetics, sedatives, or emergency medications.
• Instruct the patient that to reduce the risk of nausea and vomiting, solid food and milk or milk products have been restricted for at least 8 hr, and clear liquids have been restricted for at least 2 hr prior to general anesthesia, regional anesthesia, or sedation/analgesia (monitored anesthesia). The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org. Patients on beta blockers before the surgical procedure should be instructed to take their medication as ordered during the perioperative period. Protocols may vary among facilities.
• Obtain and record the patient’s vital signs.
• Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

• Potential complications:

• Infection related to the use of the endoscope or bleeding

• Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate specimen container with the corresponding patient demographics, initials of the person collecting the specimen, date, and time of collection.
• Ensure that the patient has complied with dietary restrictions; ensure that food has been restricted for at least 8 hr depending on the anesthetic chosen for the procedure.
• Administer ordered prophylactic steroids or antihistamines before the procedure if the patient has a history of allergic reactions to any substance or drug.
• Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
• Have emergency equipment readily available.
• Establish an IV fluid line for the injection of saline, anesthetics, sedatives, or emergency medications.
• Administer ordered preoperative sedation.
• Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings provided.
• Position patient on the examination table, draped and with legs in stirrups. If general or spinal anesthesia is to be used, it is administered before positioning the patient on the table.
• Cleanse external genitalia with antiseptic solution. If local anesthetic is used, it is instilled into the urethra and retained for 5 to 10 min. A penile clamp may be used for male patients to aid in retention of anesthetic.
• The HCP inserts a cystoscope or a urethroscope to examine the urethra before cystoscopy. The urethroscope has a sheath that may be left in place, and the cystoscope is inserted through it, avoiding multiple instrumentations.
• After insertion of the cystoscope, a sample of residual urine may be obtained for culture or other analysis.
• The bladder is irrigated via an irrigation system attached to the scope. The irrigation fluid aids in bladder visualization.
• If a prostatic tumor is found, a biopsy specimen may be obtained by means of a cytology brush or biopsy forceps inserted through the scope. If the tumor is small and localized, it can be excised and fulgurated. This procedure is termed transurethral resection of the bladder. Polyps can also be identified and excised.
• Ulcers or bleeding sites can be fulgurated using electrocautery.
• Renal calculi can be crushed and removed from the ureters and bladder.
• Ureteral catheters can be inserted via the scope to obtain urine samples from each kidney for comparative analysis and radiographic studies.
• Ureteral and urethral strictures can also be dilated during this procedure.
• Upon completion of the examination and related procedures, the cystoscope is withdrawn.
• Place obtained specimens in proper containers, label them properly, and immediately transport them to the laboratory.

Post-Test

• Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
• Instruct the patient to resume his or her usual diet and medications, as directed by the HCP.
• Encourage the patient to drink increased amounts of fluids (125 mL/hr for 24 hr) after the procedure.
• Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and then as ordered by the HCP. Take the temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Protocols may vary among facilities.
• Instruct the patient to immediately report symptoms such as fast heart rate, difficulty breathing, skin rash, itching, chest pain, persistent right shoulder pain, or abdominal pain. Immediately report symptoms to the appropriate HCP.
• Inform the patient that burning or discomfort on urination can be experienced for a few voidings after the procedure and that the urine may be blood-tinged for the first and second voidings after the procedure.
• Persistent flank or suprapubic pain, fever, chills, blood in the urine, difficulty urinating, or change in urinary pattern must be reported immediately to the HCP.
• Recognize anxiety related to test results. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate.
• Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
• Depending on the results of this procedure, additional testing may be needed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

• Related tests include biopsy kidney, biopsy prostate, calculus kidney stone panel, Chlamydia group antibody, CT pelvis, culture urine, cytology urine, IVP, MRI pelvis, PSA, US pelvis, and UA.
• Refer to the Genitourinary System table at the end of the book for related tests by body system.