Care of the Patient With Renal and Urinary Disorders -

HandoutNursing IV - Medical Surgical

Component

Classroom Objectives

• Discuss the pathophysiology and clinical manifestations of renal failure

• Interpret the results of laboratory data & diagnostic tests associated with renal failure.

• Discuss three treatment modalities used in the collaborative management of chronic renal failure.

Classroom Objectives Cont.

• Describe the kidney donor selection process.

• Discuss the drug therapy used to prevent transplant rejection.

Continued

• Use Maslow’s hierarchy to prioritize assessments in the patient with CRF undergoing various treatment modalities.

• State four nursing diagnoses (NANDA)commonly associated with a patient in end-stage renal disease.

Classroom Objectives Cont.

• List four corresponding nursing outcomes (NOC) associated with the diagnoses generated for the patient in end-stage renal disease.

• Discuss appropriate NIC based nursing interventions for the patient undergoing dialysis or renal transplant.

•

Continued

• Discuss the nursing management of the end-stage renal patient at home and the use of community resources

Slide 72.1

Anatomic Location of the Organs of the Renal/Urinary System

Bisection of the Kidney Showing Major Structures of the Kidney

Slide 72.4

Anatomy of the Nephron

Sodium and Water Reabsorbtion by the Tubules of a Cortical Nephron

Renal Function• Excretory function- urine

formation• Regulatory functions -

acid base balance• Renal related endocrine

functions

Excretory Function/urine Formation*

• Glomerular filtration• Tubular Reabsorption - proximal

convoluted tubule• Tubular secretion• Active and passive reabsorption

Regulatory Functions*

• Partial control of acid-base balance• Renal regulation of water• Renal regulation of electrolytes- Na+ & K+

Renal Related Endocrine Functions*

• Renin• Erythropoietin• Prostaglandins• Vitamin D/Calcium• Insulin

The Juxtaglomerular Complex-Renin

Slide 72.10

Renal Hormone Production and Hormones Influencing Renal

Function* Hormones influencingRenal function• Antidiuretic hormone

(ADH)

• Aldosterone• Released from

posterior pituitary

• Released from adrenal cortex

• Makes DCT and CD permeable to water to maximize reabsorption and produce a concentrated urine

• Promotes sodium reabsorption and potassium secretion in DCT and CD; water and chloride follow sodium movement

DCT = distal convoluted tubule; CD = collecting ducts.Slide 72.3

Renal Hormone Production and Hormones Influencing Renal

Function

Renal hormoneProduction• Erythropoietin

• Activated vitamin D

• Renin

• Prostaglandins

• Renal parenchyma

• Renal parenchyma

• Juxtaglomerular cells of the afferent and efferent arterioles

• Renal tissues

Stimulates bone marrow to make red blood cells

• Promotes absorption of calcium in the gastrointestinal tract

• Raises blood pressure as result of angiotensin (vasoconstriction) and aldosterone (volume expansion) secretion

• Regulate intrarenal blood flow by vasodilation or constrictionSlide 72.2

Assessment of Renal/urinary Problems

• Secondary Prevention: Early Detection

• history• physical signs & symptoms• renal system lab tests

Interview Your New Patient

Very ill new admission - Suspect CRF, 7 lb weight gain in 3 wks, Hx

diabetes and HTN• What questions should you ask regarding

symptoms?• What risk factors for development of CRF

does the new admission have?• What cardiac and respiratory

manifestations might you find on physical exam?

History/diseases RT. Renal

• HTN, D.M., SLE• Infectious diseases - Strep. UTI• Drugs• Congenital abnormalities, ie polycystic

kidney disease• Diet - ca++, higher mineral• Immobility

Commonly Used Renal and Urinary Terms*

• Oliguria — decreased urinary output; Total urinary output between 100 and 400 ml in 24 hr.

• Polyuria — increased urinary output; Total urinary output usually greater than 2000 ml in 24 hr.

• Azotemia — increased BUN and serum creatinine levels- suggestive of renal impair. but without outward symp.of renal failure.

• Uremia — full-blown signs and symptoms of renal failure; Sometimes referred to as the uremic syndrome, especially if cause unknown. Slide 72.6

Physical Signs & Symptoms of Renal Disease*

• Fatigue• Change in mentation• Headache• HTN• Change in body weight• Pain –sharp or dull, localized or diffuse

Clinical Manifestations of CRF*• Cardiovascular• Respiratory-sleep apnea,

jittery• Hematologic• Genitourinary• Reproductive• Gastrointestinal• Musculoskeletal- renal

osteodystrophy – 90%• Neurological

• Integumentary• Nutritional• Electrolyte Imbalances• Metabolic

Blood Chemistries*

• BUN -greater than 20mg/dl - renal insufficiency normal =10-20mg/dl. Elderly sl. Higher

• Creatinine - 0.8 - 1.5 mg/dl• Creatinine clearance - best indication of

overall renal function- ave. 108- 120ml/min• BUN/ Creatinine ratio: 10:1 to 20:1

Acute Renal Failure

• Prerenal causes• Renal causes• Postrenal causes

Medical Management During ARF*

• Dialysis• Manage secondary infections &

Pericarditis• Careful fluid replacement• Electrolyte replacement• High calorie, low protein diet• Symptomatic relief - seizures, anemia,

bleeding tendencies

Chronic Renal Failure*

• Progressive reduction of functioning renal tissue. Remaining kidney can no longer maintain body environment.

• Insidiously or after ARF.• HTN and diabetes - most common causes.

Progression Toward Chronic Renal Failure

• Stage I

• Stage II

• Stage III

Slide 75.6

Stage I: Diminished Renal Reserve.*

• Renal function is reduced, but no accumulation of metabolic wastes occurs.

• The healthier kidney compensates for the diseased kidney.

• Ability to concentrate urine is decreased, resulting in nocturia and polyuria.

• A 24-hour urine for creatinine clearance is necessary to detect that renal reserve is less than normal.

Stage II: renal insufficiency.*

• Metabolic wastes begin to accumulate in the blood because the unaffected nephrons can no longer compensate.

• Responsiveness to diuretics is decreased = oliguria and edema.

• The degree of insufficiency is determined by decreasing GFR (glomerular filtration rate) and is classified as mild, moderate, or severe.

• Treatment is medical.

Stage III: Renal Failure - end-stage renal disease.*

• Excessive amounts of metabolic wastes such as urea and creatinine accumulate in the blood.

• The kidneys are unable to maintain homeostasis.

• Treatment is by dialysis or other renal replacement therapy.

Stage IV End Stage Renal Failure -Uremia

• Anuria• Marked azotemia• Severe electrolyte imbalances• Pul edema , uremic lung• Uremic frost,pruritus• Anemia• Proteinuria• CHF

GFR = Calculation of Age, Serum Creatinine, Race, Sex

• Stage 1 90 mL/min or more - Healthy kidneys or Kidney damage with normal or high GFR

• Stage 2 60 to 89 mL/min -Kidney damage and mild decrease in GFR

• Stage 3 30 to 59 mL/min - Moderate decrease in GFR

• Stage 4 15 to 29 mL/min Severe decrease in GFR

• Stage 5 Less than 15 mL/min or on dialysis -Kidney failure

Clinical Manifestations of CRF*• Cardiovascular• Respiratory-sleep apnea,

jittery• Hematologic• Genitourinary• Reproductive• Gastrointestinal• Musculoskeletal- renal

osteodystrophy – 90%• Neurological

• Integumentary• Nutritional• Electrolyte Imbalances• Metabolic

Clinical Manifestations Continued*

Key Features of Uremia- Excessive amounts of Urea & Nitrogenous

Wastes ( Azotemia)*• Metallic taste• Anorexia• Nausea• Vomiting• Muscle Cramps• Itching

Key Features of Uremia Continued*

• Fatigue & Lethargy• Hiccups• Edema• Dyspnea• Muscle Cramps• Parenthesis

Electrolyte Imbalances*N.B!

• K+ increases• Phosphate increases• Sodium - normal or decreased• Magnesium increases• Calcium decreases • Metabolic acidosis

The Effects of Renal Failure on Phosphate and Calcium Balance

Slide 75.1

Focused Assessment for Care Clients with Chronic Renal Failure (Acute Care Too)*

Assess renal status, including

• Amount, frequency, and appearance of urine (anuric clients)

• Presence of bone pain

• Presence of hyperglycemia secondary to diabetes

Slide 75.19

Focused Assessment for Care Clients with Chronic Renal Failure*

Assess cardiovascular and respiratory status, including

• Vital signs, with special attention to blood pressure

• Presence of S3 and/or pericardial friction rub

• Presence of chest pain

Slide 75.18

Assessment Continued*

• Presence of edema (periorbital, pretibial, sacral)

• Jugular vein distension• Presence of dyspnea• Presence of crackles, beginning at the

bases, and extending upward

Continued*

Assess hematologic status, including• Presence of petechiae, purpura,

ecchymoses• Presence of fatigue or shortness of breathAssess gastrointestinal status, including• Presence of stomatitis• Presence of melena

Assessment Continued*

Assess integumentary status, including• Skin integrity• Presence of pruritis• Presence of skin discoloration

Review - Focused Assessment for Clients with Chronic Renal Failure

Assess NEUROLOGIC status, including• Changes in mental status• Presence of seizure activity• Presence of sensory changes• Presence of lower extremity weakness

Assess NUTRITIONAL status, including

• Weight gain or loss• Presence of anorexia, nausea, or vomiting

Case Study-End Stage Renal Disease

NURSING DIAGNOSES CRF

Nursing Diagnoses for CRF Patient*

• Fluid Vol. deficit of Fluid Vol Excess rt. impaired Renal function

• Altered Nutrition less than Body Requirements rt anorexia, nausea

• Fatigue rt. anemia & altered metabolic state

• Risk for Impaired Skin Integrity

• Knowledge Deficit rt. disease process & treatment

• Risk for Ineffective Management of Therapeutic Regime

• Risk for Ineffective Family Coping-Financial - *80% fed. Gov

Nsg. Diagnoses Continued*

• Activity Intolerance rt. Effects of Anemia

• Impaired Comfort : puritis

• Chronic Sorrow rt. Chronic Illness

• Fatigue rt. Altered Body Chemistry

• Risk for Injury rt. bone changes, muscle weakness

• Decreased Cardiac Output rt. elevated K+ levels

Medical Goals of CRF

• Preservation of Renal Function• Delay of need for Dialysis or transplant • Improvement of Body Chemistry• Alleviation of Extrarenal effects• Provide optimal quality of life

Dietary Restrictions*

• Fluid• Protein –on dialysis – high quality protein

– not limited on hemodialysis• Potassium 60-70 mEg./day• Sodium• Phosphorus

Medications for CRF*

• Diuretics• Vitamins and Minerals• Sodium bicarbonate• Erythropoietin• Calcium Preparations & Phosphorus

Binders• Antihypertensives

NIC Label: Nutrition Therapy

• Nursing Diagnosis:• Imbalanced Nutrition, less than body

requirements

NOC Label: Nutritional Status1= extremely compromised

3= moderately compromisedOutcomes

• Demonstrates improved nutritional status• Consumes adequate nutrition• Identifies nutritional requirements

NIC Interventions

• Collaborate with dietician• Teach family and client about prescribed

diet• Monitor and calculate food intake

NOC Label: Fluid Balance1= extremely compromised

to 5=not compromisedOutcomes

• Remains free of edema, anasarca. • Maintains clear lungs.• Remains free of restlessness, anxiety, or

confusion.• Explains measures to prevent & treat

excess fluid

NIC Label: Fluid Management

• Nursing Diagnosis: • Excess Fluid Volume

NIC Interventions

• Monitor location of edema• Monitor daily weight • Monitor vitals: decreased. BP, tachycardia,

tachypnea. Monitors gallop rhythm• Teach patient & family about sx. of both

excess and deficient fluid volume.

Goals for Dialysis

• removal of end products of protein metabolism from blood- urea, creatinine

• maintenance of safe concentration of serum electrolytes

• correction of acidosis, replenishment of bicarbonate buffer system

• removal of excess fluid from blood

Hemodialysis vs. Peritoneal -Finding the Best Fit*

• Hemodialysis - a quick fix

• Not appropriate when hemodynamically unstable

• Not appropriate when trained personnel & vascular access not available

• Not appropriate for those unable to tolerateanticoagulation

• Peritoneal - slower, less aggressive

• Not appropriate for those with impaired respiratory excursion

• Not appropriate in sepsis, peritonitis, abdominal adhesions, abdominal adhesions or abdominal trauma

Key concepts of Dialysis*

• Diffusion• Filtration/Ultrafiltration• Concentration gradient• Osmosis

Vascular Access for Hemodialysis

• Subclavian / internal jugular double lumen (Udall)

• AV fistula/AV graft

A Surgically Created Venous Fistula

Slide 75.7

An Arteriovenous Shunt of the Forearm

Slide 75.9

Examples of Multilumen caths

A Hemodialysis Circuit

Slide 75.5

Nursing Care of A-V Fistula*

• Initially assess hemorrhage, infection, edema. elevate arm

• No B/P, venipunctures, I.V.s in access arm• assess function of fistula - bruit & thrill• assess distal pulse circulation• Allen’s test• no carrying heavy objects etc.

A Surgically Created Venous Fistula

Slide 75.7

Native Arteriovenous (AV) Fistula

• the preferred type of vascular access for patients with end stage renal disease.

• AV fistulae result in significantly lower rates of complication (such as infection and clotting), longer patency, fewer hospitalizations, lower patient morbidity, and significantly lower costs compared to other accesses

Dialysis - Nursing Care*

• Prior to Dialysis• During Dialysis

KB – Dialysis at 10AM

• Meds: Atacand, Lasix, Regular insullin, Digoxin, Tums – What do you give?

• Other Nsg. Duties?• Nausea, hypertensive,

The Client Undergoing Hemodialysis

• Weigh the client before and after dialysis.

• Know the client's dry weight.

• Decide whether any of the client's meds should be withheld until after dialysis.

• Be aware of events that occurred during the dialysis treatment.

• Measure blood pressure, pulse rate, respirations, and temperature..

Slide 75.17

Continued• Assess for symptoms of orthostatic hypotension.

• Assess the vascular access site.

• Observe for bleeding.

• Assess the client's level of consciousness and assess for headache, nausea, and vomiting.

Post- Dialysis Nsg. Management*

• Disequilibrium syndrome• Monitor for bleeding, hematoma & patency• Neuro assessment, LOC

Peritoneal Dialysis*

• Osmosis• Diffusion • Dialysate Concentrations• Dwell time

Manual Peritoneal Dialysis Via Implanted Abdominal Catheter (Tenckhoff Catheter)

Slide 75.13

Nursing Management of Peritoneal Dialysis*

• installations and dwell periods• dialysate• outflow times

Peritoneal Dialysis - types

• Continuous Ambulatory Peritoneal Dialysis (CAPD)

• Automated Peritoneal Dialysis (ADP) can be run at different time intervals -

• Two forms of ADP 1. (CCPD) continuous cyclic with 3 cycles at noc and one 8 hr. in morning -2.(IPD)intermittent 10-14 hrs/ 3-4 x wk., NPD nightly peritoneal dialysis 8-12 hrs at noc.

The used Dialysis Bags are 'Clinical Waste'. The Renal Unit will contact the local authority for you and arrange

for free yellow coloured clinical waste bags to be delivered to your home (usually four a week. You will

need only two bags but they need to be double wrapped). They will also arrange for a free weekly

collection of the full bags.

Flatten your cardboard boxes (see diagram on the box) and put out for your regular rubbish collection.

Please click on the links below for further CAPD info.Weight & Fluid Balance | Clean Procedures : Infection |

General Info

Complications of Peritoneal Dialysis*

• Peritonitis- meticulous aseptic technique. Check fever, rebound tenderness, nausea, WBCs, malaise

• Hyperglycemic & hyperosmolar states Esp. with high glucose dialysate

• Cath. Displacement• Abd. Discomfort• Lack of compliance when self dialysing

Assess laboratory data, including

• BUN & Creatinine• Creatinine clearance• CBC• ElectrolyteAssess psychosocial

status, including• Presence of anxiety• Presence of maladaptive

behaviorSlide 75.20

Nsg. Management of ESRD at Home

MonitoringCommunity Resources

Kidney Transplant*• Living Related• Living Unrelated• Cadaver• United Network for Organ Sharing, Richmond Va.• National kidney transplant waiting list - 38,760 • First successful transplant -1954 - Dr. Jos. Murray,

Brigham & Women’s Hospital Boston MA.

Kidney Donor

Selection Process

Hand-assisted Laproscopic Donor Nephrectomy

• www.or-live.com/meritcare/1145/• www.matchingdonors.com• 3-5 incisions in donor abdomen• Full recovery in up to 6 weeks

Placement of a Transplanted Kidney to the Right Iliac Fossa

Slide 75.16

Nursing Responsibilities

Post Transplant

Renal Transplant Complications*

• Graft rejection -hyperacute, acute, or chronic

• Other complications: infection, disease recurrence, complications of drug therapy, ulcers, HTN, steroid-induced diabetes etc.

Hyperacute Rejection*

Hyperacute RejectionOnset• Within 48 hr after surgery

Clinical Manifestations• Increased temperature• Increased blood pressure• Pain at transplant site

Treatment• Immediate removal of the transplanted

kidneyBUN = blood urea nitrogen.

Slide 75.21

Acute Rejection*

Acute RejectionOnset• 1 wk to 2 yr postoperatively (most common

in first 2 wk)Clinical Manifestations• Oliguria or anuria• Temperature over 37.8° C (100° F)• Increased blood pressure• Enlarged, tender kidney• Lethargy• Elevated serum creatinine, Blood Urea Nitrogen, potassium levels• Fluid retention

Treatment• Increased doses of immunosuppressive drugs

BUN = blood urea nitrogen.. Slide 75.22

Chronic Rejection*

Chronic RejectionOnset• Occurs gradually during a period of

months to yearsClinical Manifestations

• Gradual increase in Blood Urea Nitrogen and serum creatinine levels

• Fluid retention• Changes in serum electrolyte level• Fatigue

Treatment• Conservative management until dialysis is

requiredSlide 75.23

Immunosuppressive therapy after Renal Transplant*

• Corticosteroids -Prednisone or methylprednisone (Solu-medrol)

• Azathioprine (Imuran, CellCept,

• Cyclosporine - used with steroids (Sandimmune or Neoral)

• FK-506 - 100 X more potent than cyclosporin

• OKT-3 - monoclonal antibody

• Antilymphocyte globulin - Atgam (ALG)

Nursing Problems rt. Immunosuppression

• increased risk of infection• bone marrow suppression• incidence of malignancy- lymphoma• c/o with steroids - gastritis & peptic ulcer

disease, bone weakness, GI bleeding, steroid induced DM, F&E imbalance

Common Types and Locations of Renal Trauma

Minor Trauma

Slide 74.7

Common Types and Locations of Renal Trauma

Pedicle Injury

Slide 74.8

Common Types and Locations of Renal Trauma

Major Trauma

Slide 74.9

Common Types and Locations of Renal Trauma

Slide 74.11

NURSING MANAGEMENT

The Patient with Bladder Cancer*

• Primary prevention: Stop Smoking – doubles the risk

• Secondary prevention: Hematuria?• Men 3X more likely• Chemicals in the workplace – dye, leather,

rubber• Whites more likely• Age – late 60’s• 53,000 new cases in 2000• 94% survival rate

Symptoms

Blood in the urine (slightly rusty to deep red in colour).

Pain during urination. Frequent urination, or feeling the need to

urinate without results.

Bladder Cancer

Bladder Tumors

Treatment Modalities*

• Chemotherapy• Radiation• Surgery: Partial Cystectomy

Total CystectomyTURP

Treatment Continued

Total Cystectomy with Urinary Diversion*

• Ileal Conduit• Continent Internal Ileal Reservoir (Kock

Pouch)• Cutaneous Ureterostomy• Vesicostomy

Urinary Diversion Procedures Used in the Treatment of Bladder Cancer

Slide 73.9

Urinary Diversion Procedures Used in the Treatment of Bladder Cancer

Slide 73.10

Urinary Diversion Procedures Used in the Treatment of Bladder Cancer

Slide 73.11

Urinary Diversion Procedures Used in the Treatment of Bladder Cancer

Slide 73.12

Hollister*

• •

Sure-Fit Natura

Face Plate –Cut to Fit Skin Barrier*

Karaya 5 Lo-Profile UrostomyPouch

Nursing Management of Patients Requiring Urinary

Diversion*• Psychological Needs• Immediate Post-op

Postoperative Nursing Care of Patient with Urinary Diversion*

• Immediate Post-op: Hypovolemia, hematuria, stoma checks

• 48 hrs. or more: peritonitis• Stoma care

Case Study

Patient with Ileal Conduit

Nsg. Dx & Outcomes rt. Pt with Ileal Conduit*

• Knowledge Deficit rtStoma Care

• Social Isolation rtFear of Accidental leakage

• Risk for Imapired Skin Integrity

• Disturbed Body Image

• Demonstrates how to perform pouch change & ostomycare 1=no knowledge 5= extensive knowledge

• Participates in activities to level of ability & desire 1= no social involvement;5= extensive

• Regains integrity of skin surface.

Client Education of the Patient with a Urinary DiversionDeveloping a Teaching Care Plan

Cancer of the Prostate*

Function of Prostate Gland-Prevention of Prostate Cancer

and Detection

Anatomy

The Prostate Gland with Cancer and Benign Prostatic Hyperplasia

Slide 79.12

Diagnostic Tests and Physical Exam*

• PSA assay • Rectal exam • Transrectal /Transperineal and

Percutaneous needle aspiration and Biopsy

• Other diagnostic tests

Treatment Modalities and Management of Prostate

Cancer*• Hormone therapy • Chemotherapy • Radiation • Surgery

Pharmacology - Hormone therapy*

• Androgen supressingagents – ex. finasteride (Proscar) flutamide (Eulexin) - a new androgen blocker

• leuprolide (Lupron) -a gonadotropin analogue

Leuprolide (Lupron) s.c. - Side Effects

• Dizziness, HA• N&V, Anorexia, Constipation• Peripheral edema, Cardiac Arrhythmias• Hot flashes, sweats

Chemotherapy or Radiation

Cytoxan

Adriamycin

Types Prostate Surgery*

• Laser• Cryosurgery• Robotic Prostatectomy –

www.davinciprostatectomy.com

Radical Open Prostatectomy*

• Suprapubic approach• Retropubic approach• Perineal approach

Suprapubic, or Transvesical, Prostatectomy

Slide 79.6

Retropubic, or Retrovesical, Prostatectomy

Slide 79.7

Three Way Foley Catheter

Perineal Prostatectomy

Slide 79.8

Nursing Care Following Prostate Surgery*

• Hematuria• Bladder spasms• Hemorrhage• Retropubic - care of the low ABD incision

& Suprapubic catheter• Discharge teaching

Effects of Surgery*

• Client is STERILE• Erective Dysfunction – (if pudental nerve

fx. Spared – 3-6 mos of ED ( impotence)• Urinary Incontinence – if internal &

external urinary sphincters involved.

Care Immediately after Radical Prostatectomy

• Encourage the client to use patient-controlled analgesia (PCA) as needed.The PCA device may be used through the second postoperative day.

• Keep the client on bed rest on the day of surgery. Help the client to get out of bed and ambulate for a short distance by the first postoperative day.

• Keep the client on NPO status as ordered, usually until the first or second postoperative day.

Slide 79.11

Care after Radical Prostatectomy Continued

• Maintain the sequential compression device until the client begins to ambulate. Apply antiembolic stockings until discharge.

• Monitor the client for deep vein thrombosis and pulmonary embolus.

• Keep an accurate record of intake and output, including Jackson-Pratt or other drainage device drainage.

Slide 79.11

Teaching Following Radical Prostatectomy*

You are developing a handout for patients following radical open prostatectomy . What are the

essentials?

Pt. Teaching following Radical Prostatectomy

• Keep the urinary meatus clean using soap and water.• Avoid rectal procedures or treatments.• Teach the client how to care for the urinary catheter

because he will be discharged with the catheter in place.

• Teach the client how to use a leg bag.• Emphasize the importance of not straining during

bowel movement. Advice the client to avoid suppositories or enemas.

• Remind the client about the importance of follow-up appointments with the physician to monitor progress.

Slide 79.11

Leg Bag

Discharge Teaching following Radical Prostatectomy

• Remind client about importance of follow-up appointments with M.D.

• Exercises for Urinary Incontinence :tighten perineal muscles, biofeedback

• Function – ED alternatives:prostheses, vaccum devices, viagra.

Nsg. Diagnoses Associated with Radical Prostatectomy*

• Knowledge Deficit rt Self Care & Home Maintenance

• Acute Pain rt. Bladder Spasm• Risk for Urinary Incontinence• Risk for Sexual Dysfunction – NOC

Outcomes: expresses comfort with sexual expression 1-= never demonstrated; 5 = consistently demonstrated

Potential Complications

• Sexual dysfunction with radical perineal prostatectomy

• Urinary incontinence with radical prostatectomy

The End