Synonym/Acronym
Retrograde pyelography.
Rationale
To assess the urinary tract for trauma, obstruction, stones, infection, and abscess that can interfere with genitourinary function.
Patient Preparation
There are no activity restrictions unless by medical direction. Instruct the patient to fast and restrict fluids for 8 hr, or as ordered, prior to the procedure. Fasting may be ordered as a precaution against aspiration related to possible nausea and vomiting. The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org.
Regarding the patient’s risk for bleeding, the patient should be instructed to avoid taking natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered, prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Note the last time and dose of medication taken. Protocols may vary among facilities.
Normal Findings
- Normal outline and opacification of renal pelvis and calyces
- Normal size and uniform filling of the ureters
- Symmetrical and bilateral outline of structures
Study type: X-ray, contrast/special; related body system: Urinary system.
Retrograde ureteropyelography uses a contrast medium introduced through a ureteral catheter during cystography and radiographic visualization to view the renal collecting system (calyces, renal pelvis, and urethra). During a cystoscopic examination, a catheter is advanced through the ureters and into the kidney, and contrast medium is injected through the catheter into the kidney. This procedure is primarily used in patients who are known to be hypersensitive to IV-injected iodine-based contrast medium and when excretory ureterography does not adequately reveal the renal collecting system. The incidence of allergic reaction to the contrast medium is reduced because there is less systemic absorption of the contrast medium when injected into the kidney than when injected IV. Retrograde ureteropyelography sometimes provides more information about the anatomy of the different parts of the collecting system than can be obtained by excretory ureteropyelography. Computed tomography (CT) and ultrasound studies are replacing retrograde pyelography because they are less invasive and the quality of the technology has significantly improved.
Contraindications
Pregnancy is a general contraindication to procedures involving radiation.
Patients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.
Patients with bleeding disorders, because the puncture site may not stop bleeding.
Factors That May Alter the Results of the Study
- Gas or feces in the gastrointestinal tract resulting from inadequate cleansing or failure to restrict food intake before the study.
- Retained barium from a previous radiological procedure.
- Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.
- Inability of the patient to cooperate or remain still during the procedure, because movement can produce blurred or otherwise unclear images.
Abnormal Findings Related to
Potential Nursing Problems: Assessment & Nursing Diagnosis
| Problems | Signs and Symptoms |
|---|
| Infection (risk—related to stones, urinary stasis, invasive procedure, postoperative change in skin condition [incision]) | Fever; chills; changes in laboratory studies (WBC count, CRP, urine culture); diaphoresis; increased heart rate; urine frequency and burning; cloudy, foul-smelling urine; red-tinged urine; red indurated incision; urinary frequency and urgency | | Pain (related to stones, obstruction and/or anomalies, spasm) | Self-report of pain in flank area, facial grimace, moaning, crying, abdominal guarding, diaphoresis, restlessness, nausea, vomiting, sleeplessness |
|
Before the Study: Planning and Implementation
Teaching the Patient What to Expect
- Discuss how this procedure can assist in assessing the urinary tract.
- Explain that the procedure takes about 30 to 60 min and is performed in a special cystoscopy suite near or in the surgery department.
- Review the procedure with the patient.
- Review the type of anesthesia to be administered (local or general anesthesia).
- Explain that pregnancy testing may be required.
- Explain that prior to the procedure, laboratory testing may be required to determine the possibility of bleeding risk (coagulation testing).
- Discuss how there may be moments of discomfort or pain when the IV line or catheter is inserted, allowing for infusion of fluids such as saline, anesthetics, sedatives, medications used in the procedure, or emergency medications.
- Advise that contrast medium will be injected into the ureter by catheter.
- Explain that a burning and flushing sensation may be felt throughout the body during injection of the contrast medium and that the patient may experience an urge to cough, flushing, nausea, or a salty or metallic taste.
- Explain that if a local anesthetic is used, some pressure may be felt in the kidney area as the catheter is introduced and contrast medium injected with urgency to void.
Procedural Information
- Baseline vital signs are recorded and monitored throughout the procedure.
- Electrocardiographic electrodes are placed for cardiac monitoring to establish a baseline rhythm and identify any ventricular dysrhythmias.
- Positioning for this procedure is supine on the examination table in the lithotomy position.
- A kidney, ureter, and bladder (KUB) or plain image is taken to ensure that no barium or stool will obscure visualization of the urinary system. The patient may be asked to hold the breath to facilitate visualization.
- After the anesthetic is given, a cystoscopic examination is performed and the bladder is inspected.
- A catheter is inserted, and the renal pelvis is emptied by gravity.
- X-ray images are taken and the results processed; additional images may be necessary to visualize the area in question.
- More contrast medium is injected through the catheter to outline the ureters as the catheter is withdrawn.
- The catheter may be kept in place and attached to a gravity drainage unit until urinary flow has returned or is corrected.
- Urinary stasis is evaluated by taking additional x-ray images 10 to 15 min after catheter removal and noting retention of contrast medium.
- Once the study is completed, the needle or catheter is removed, and a pressure dressing is applied over the IV puncture site.
Potential Nursing Actions
- Follow the facility’s guidelines regarding the administration of prophylactic antibiotics, by medical direction, prior to a procedure that involves manipulation of the ureters.
Safety Considerations
- Anticoagulants, aspirin, and other salicylates should be discontinued by medical direction for the appropriate number of days prior to a procedure in which bleeding is a potential complication.
After the Study: Implementation & Evaluation Potential Nursing Actions
Avoiding Complications
- Monitor the patient for complications related to the procedure.
- Potential procedure-related complications include hematuria (related to insertion of cystoscope), sepsis (related to bacterial contamination from infected urine), or urinary tract infection (related to insertion of cystoscope or catheter).
- Administer ordered antihistamines or prophylactic steroids if the patient has an allergic reaction.
Treatment Considerations
- Follow postprocedure vital sign and assessment protocol.
Infection
- Encourage intake of acidic fluids such as juice to decrease pathogenic bacteria growth.
- Encourage intake of 2 to 3 liters of fluid per day to decrease urinary stasis risk, unless contraindicated.
- Administer ordered antibiotics.
- Monitor and trend laboratory studies: blood urea nitrogen, Ca, Cr, electrolytes, uric acid, and WBC count.
- Monitor and trend vital signs, surgical site for redness, induration, drainage, and urine characteristics (color, odor, blood).
Pain
- Discuss use of medication, diversion, and realization techniques to manage pain.
- Assess pain character, location, duration, and intensity using an easily understood pain rating scale.
- Collaborate to identify what works and what does not work. Administer ordered analgesics and narcotics.
- Encourage position changes and walking as a strategy to move the kidney stone, if present.
- Place in a position of comfort (knee to chest).
- Encourage drinking fluids including fruit juices to acidify urine to decrease stone formation risk; administer ordered parenteral fluid; strain urine.
- Explain the use of any ordered medications and the importance of adhering to the therapy regimen.
- Instruct the patient in the care and assessment of the site.
- Explain the importance of applying cold compresses to the puncture site as needed to reduce discomfort or edema.
- Provide information on significant adverse effects associated with the prescribed medication. Encourage a review of corresponding literature provided by a pharmacist.
Clinical Judgement
- Consider the best way to manage pain while stressing therapeutic management and prevention strategies.
Follow-Up and Desired Outcomes
- Correctly identifies symptoms of delayed allergic reaction or infection and whom to contact should they occur.