PHYSIOTHERAPY IN UROSURGERIES

PRESENTED BY: DR.SHILPA PRAJAPATI (1ST YEAR MPT)

Anatomy for Urology

COMMON DISEASES

• Nephritis• Renal stone• Renal tumors• Polycystic kidney

• Uteric stone• Duplex ureter• Rupture bladder• Prostate cancer• Neurological bladder

UROLOGY PROCEDURES

• Kidney Transplant

• Nephrectomy

• Cystectomy and utero-colic anastomosis

• Ureterostomy

• Bladder Augmentation

• Transurethral Bladder Resection

• Artificial Sphincter Insertion

• Needle Bladder Neck Suspension

• Prostatectomy

NEPHRECTOMY• One kidney may be removed

provided that the other is healthy.

• Reasons for removal are tumor, infection, pyonephrosis, tuberculosis, multiple calculi or hydronephrosis.

• Problems that may occur with long-term decreased kidney function include:– High blood pressure

(hypertension)– Chronic kidney disease

• Incision used- oblique lumbar incision

• Latissimus dorsi and external oblique mainly cuts and traverses, internal oblique and lumbar fascia also cuts.

CYSTOSTOMY AND URETERO-COLIC ANASTOMOSIS

• Reasons are malignant disease of

bladder.• After removal of the

bladder the ureters are transplanted into the sigmoid colon.

• The terminal part of the ureter is in an oblique tunnel in the bowel wall.

• Incision used- pfannentiel incision.

• requires partial or compete transaction of the rectus abdominis muscle.

URETEROSTOMY

• creation of a new outlet for a ureter.

• Indications : removal of the bladder, congenital defect or absence of portions of the urinary tract, and neurogenic bladder

TRANSURETHRAL BLADDER RESECTION

• This is used both to diagnose bladder cancer and to remove cancerous tissue from the bladder.

• Complication :– Urinary tract or bladder

infection – bladder cancer can come

back after this surgery– Difficulty passing urine

BLADDER AUGMENTATION• Known as augmentation

cystoplasty• Is reconstructive surgery to

increase the reservoir capacity of the bladder.

• Bladder augmentation is used to treat irreversible forms of incontinence and to protect the upper urinary tract (kidney function) from reflexia (urine back up to the kidneys).

• some patients recover spontaneous voiding function.

• During a bladder augmentation procedure, an incision is made in the abdomen to expose the intestines and bladder

• complications : cardiovascular, thrombo-embolic (blood clot), gastrointestinal, and respiratory complications

PROSTATECTOMY• After the age of fifty, it is

common for the prostate gland become enlarged.

• 42% in men 45 to 49 years of age and 18% in men 50 to 54 years of age.

• The main symptom is difficult micturition with frequency due to pressure on the urethra.

• Retention of the urine may occur, necessitating urgent operation.

• Incision used- midline incision.• requires partial or compete

transaction of the rectus abdominis muscle.

• this condition, by suprapubic operation involving the bladder, or by rectopubic operations, in which the prostate is enucleated from its capsule.

• Complications: phlebo-thrombosis

ARTIFICIAL SPHINCTER INSERTION

• The implantation of an artificial valve in the genitourinary tract, as "gatekeeper" control.

• Severe incontinence due to lack of muscle contraction by the urethral sphincter pelvic fracture; urethral reconstruction; prostate surgeries

• Men have incontinence rates that are much lower than women, with a range of 1.5–5%, compared to women with rates of 50%.

NEEDLE BLADDER NECK SUSPENSION

• Known as needle suspension, or paravaginal surgery

• This is performed to support the hypermobile, or moveable urethra using sutures to attach it to tissues covering the pelvic floor.

• According to a recent report, a study of the effects of needle suspension found only a 67% cure, with delayed failures of sutures in a very high percentage (33-80%) of cases

• passage of a needle from the suprapubic area to the vagina with multiple sutures through looping

PRE-OPERATIVE PHYSIOTHERAPY

• Postural drainage: If there are lung secretion should be cleared, postural drainage should be use several times a day.– The sputum should be measured carefully and the surgeon

informed when the amount is minimal, as the patient will ready for operation.

• Breathing exercises• Coughing: which can bring up mucus• Arm exercises: the prayer position is best, the palm being

held, flat together, finger pointing upwards, then straightened until the upper arm are against the ear.

PRE-OPERATIVE PHYSIOTHERAPY

• Leg exercises: toe and ankle movements are taught in full range, also static contraction of quadriceps and glutei. All these movement should be done rhythmically and repeated at frequent intervals, e.g. for five minute in every hour.– Also be shown how to flex hip and knee, keeping heel on the floor,

so that the minimum of lifting strain is put on the abdominal muscle.

• Posture correction: the patient should be taught to sit equally on both buttocks, arms hanging to sides, lie equally outside hips, shoulder should be in level.

• Static abdominals: 10 repetitions, 5sec hold each• Pelvic floor exercises:

POST-OPERATIVE PHYSIOTHERAPY

• Immediately after surgery, watch blood pressure, electrolytes and fluid balance. These body functions are controlled in part by the kidneys. most likely have a urinary catheter (tube to drain urine) in bladder for a short time during recovery.discomfort and numbness (caused by severed nerves) near the incision area.

• Encourage for plenty of fluid intake.• Strenuous activity and heavy lifting should be

avoided for 6 weeks.

POST-OPERATIVE PHYSIOTHERAPY• Bed cradler: should be used to release tight or heavy bed cloths and

facilitate leg movement.• Breathing: dressings are kept to minimum to avoid restriction,

Elastoplast being use to secure dressing.– It is frequently easier to get maximum thoracic excursion and air

interchange by lateral costal breathing.– Emphasis will be usually be placed on those part of the lungs needing

specific attention.– Bilateral breathing exercise are best:– With a right side incision, because of the right arm will be painful to

move, the right basal expansion must be encouraged.– Left side basal expansion may also be limited by patient have had a long

term operation and patient may lying on that side to relieve pressure on right.

POST-OPERATIVE PHYSIOTHERAPYby B. SHOTTON

– The best way to be sure that lung tissue is expanding satisfactory is by X-ray,

– More simply findings : breath sounds are normal, percussion to detect collapse of lung tissue.

– Another method is to ask the patient to hold his breath, he will find difficult if there is some collapse.

– The pulse is taken at frequent intervals.– Frequently, rapid rise in pulse rate could indicate early collapse of lung, it

can be detected before rise patient’s temperature.

• Coughing : this can be aided by firm pressure over the wound by the therapist or by patient him self.– Relaxant drugs are now in frequent use because, normal muscle tone

dose note always reappear until several days after operation, so it is difficult for the patient to produce a strong cough.

POST-OPERATIVE PHYSIOTHERAPYby B. SHOTTON

• Leg exercise : test for Homan’s sign– Foot exercise and static quadriceps and glutei are safe in

upper abdominal operations.– In lower abdominal operations, start exercise when

surgeon allow for movements, start with hip and knee flexion and heel on the floor, Progressed by lifting the heel, then straight leg raising.

– Early ambulation being allow 1 or 2 days after operation.

– Prolong sitting in chair should be avoided, this position causes pressure on the veins of the leg.

POST-OPERATIVE PHYSIOTHERAPYby B. SHOTTON

• Posture :– back needs firm support,– Best taught for flatten the lumbar hollow, at the same time

drawing his pubic symphysis and his sternum closer together.– Trunk movement usually be started on the forth day, before that

they were use trunk movement for bed mobility and toilet purposes.

• WARD CLASSSES– Once out of bed and ambulant, exercise can be continued in

small groups.– Except in specific cases, physiotherapy should no longer be

needed after the 10th day.

COMPLICATIONS

IMMEDIATE COMPLICATIONS• Postoperative shock• Respiratory complication• Acute dilatation of stomach

DELAYED COMPLICATIONS:• Thrombo-embolic (blood clot),• Unhealed wound and incisional hernia• Retention of urine• Uremia• paralytic ileus• Post operative cough• Infection and septicemia• Postural deformities

SURGERY ON THE BLADDER

To increase bladder capacity: Augmentation

Continent diversionTo increase outlet resistance: Injection therapy External compressive procedures Artificial urinary sphincter To decrease outlet resistance: Sphincterotomy Urinary diversion

References

• Physical and medical rehabilitation, 3rd edition, by RANDALL BRADDOM.

• Physiotherapy in general surgery, by B. Shotton.

• Thank you