JULY 1991, VOL54, NO I
AORN JOURNAL
Carney Procedure A CONTINENT URINARY DIVERSION TECHNIQUE
Judy Rauscher, RN; Robert D. Farber, MD; Raul 0. Parra, MD
P
atients undergoing radical cystoprostatectomy for the treatment of invasive bladder cancer have their urine diverted most often via standard ileal conduit. This has been the procedure of choice since it was first introduced in the 1950s. Increased interest in avoiding external appliances has arisen during the past decade. As a result, several techniques are currently used for the continent diversion of urine. This article illustrates the technique of ileocystoplasty (ie, Camey procedure) for urinary diversion.
Patient Selectiori
P
atient selection for any continent urinary diversion procedure is very important. The patient should understand the procedure, comply with instructions, and be willing to participate in his postoperative care. There should be no form of carcinoma in situ at or near the urethral stump to avoid the possibility of local recurrences. This is confirmed by preoperative biopsies of the prostatic urethra. The Carney procedure applies only to men because the entire urethra is removed when a cystectomy is performed on a female.
Preoperative Preparation
T
he patient is admitted the day before surgery for routine preoperative testing. This testing includes chest x-ray and electrocardiogram, a complete blood count, blood chemistries, coagulation studies, and a 34
routine type and cross-match for two to four units of blood. The day before surgery, the patient receives only clear liquids and lactated Ringer’s at a rate of 125 to 150 mL/hr intravenously for hydration. The afternoon before surgery, the patient is given oral laxatives followed by enemas until clear and is started on wide spectrum IV and oral antibiotics. The day of surgery, transfer personnel bring the patient to the operating room holding area where the holding area nurse checks and evaluates the preoperative testing. The nurse also verifies the patient’s identification band, allergies, and operative consent form. The perioperative nurses prepare the operating room for a major abdominal procedure. The scrub nurse ensures that a routine laparotomy instrument set with long instruments is
Judy Rauscher, RN, is a clinical nurse specialist, urology, at S t Louis University Medical Center. She earned her diploma in nursing at Jewish Hospital School of Nursing, St Louis. Robert D. Farber, MD, is chief resident nt the St Louis University Medical Center. He earned his medica! degree at St Louis University School of Medicine. Raul 0. Parra, MD, is director, division of u r o l o g y , St L o u i s U n i v e r s i t y S c h o o l of Medicine. He earned his medical degree at the University of Seville, Spain.
AORN JOURNAL
available. He or she also prepares self-retaining retractors, Babcocks, Berlishers, right angles, clip appliers, extra Kelly clamps. Pott scissors, Greenwald sound (ie, large metal sound with a groove in the tip), and TA-55 and GIA surgical staplers with additional staple cartridges.
Intraoperutive Care
T
he circulating nurse meets the patient in the holding area, identifies himself or herself, and again checks the chart and
JULY 1991, VOL 54, NO 1
interviews the patient concerning allergies, consent form, NPO status, and patient identification. The circulator then transfers the patient to the OR and helps him move to the operating room bed. The nurse covers the patient with warm blankets and positions the safety strap over him. The circulating nurse remains at bedside providing comfort to the patient and assisting the anesthesiologist with induction and intubation as needed. The patient is monitored by standard electrocardiogram, pulse oximetry, and arterial line tracings. The nurse helps to obtain IV access on both of the patient’s arms. After induction of anesthesia and intubation, the anesthesiologist places a central line or a pulmonary artery catheter if indicated. The nurse inserts an indwelling Foley catheter and attaches it to
Fig I . The plasty is created from a 40-cm segment of ileum that reaches the pelvic floor. (Reprinted from Surgical Rounds 13 (June 1990), R 0 Parra, L Shaker, R Wolf; with permission from Romaine Pierson Publications, Port Washington, N Y ) 36
JULY I99 1, VOL 54,NO 1
AORN JOURNAL
gravity drainage. This enables the operative team to monitor the patient’s urine output every 30 minutes. The nurse also routinely applies sequential compression stockings to prevent deep venous thrombosis. The nurse positions the patient in the supine or semi-lithotomy position, depending on the surgeon’s preference. He or she pads all potential pressure areas with foam pads and applies an electrosurgical dispersive electrode pad. The operative area is from the nipples to midthigh, including the perineum, and it is prepped with a povidone-iodine soap and solution.
Carney Procedure
T
he surgeon makes a midline incision from the symphysis pubis cephalad to approximateFig 2. The antirefluxing anastomosis. ly 4 cm superior to the umbilicus. He or she routinely explores the abdomen for possible metastasis. The surgeon begins the urinary diversion procedure after A 3- to 3.5-cm mucosal furrow that extends completing a bilateral pelvic lymphadenectomy from the enterotomy distally is constructed. and radical cystoprostatectomy to confirm that This will be the bed for the ureter. The surgeon the patient’s disease is organ-confined with cuts the end of each ureter with Pott scissors negative urethral margins as reported by frozen and makes a 0.5- to I-cm incision along the section diagnosis. longitudinal aspect of the ureter. This opens the The surgeon identifies 40 cm of ileum that, end of the ureter and allows anastamosis of the when shaped into a “U,” will allow the apex to ureter and the mucosal furrow without overlapreach the urethra without tension (Fig 1). If the ping suture lines, thereby reducing the chance mesentery does not allow tension-free anastoof strictures. The surgeon sutures the distal end of each mosis, which happens in approximately 15% of patients, another form of urinary diversion must ureter to the distal end of the mucosal furrow be chosen. with approximately three 5-0 polyglycolic acid Once the appropriate length of small bowel sutures. He or she fixes the lateral borders of is identified, the surgeon divides the bowel the ureter to the edges of the furrow with interwith a GIA stapler and restores bowel continurupted 5-0 polyglycolic acid sutures that pass ity with a side-to-side ileoileostomy using the through the adventitia of the ureter only. This GIA and TA-55 staplers. The surgeon opens results in an antirefluxing anastomosis (Fig 2). both ends of the U-shaped segment of ileum Both ureters are then stented with #8 French along the antimesentery border. At a distance feeding tubes that are brought out through of 1.5 to 2 cm, he or she performs the ureteral small enterotomies at each side of the limb of ileo anastomosis by bringing the ureters into the “U’ (Fig 3). The surgeon identifies the midpoint of the the bowel lumen through small enterotomies. 37
JULY 1991, VOL 54, NO 1
AORN JOURNAL
Fig 3. The stents used for ureteral intubation exit via the opening that later will be anastomosed to the urethra (top). Details of intubation (bottom). (Reprintedfrom Surgical Rounds 13 (June 1990),R 0 Parra, L Shaker, R Wolf; with permission from Romaine Pierson Publications, Port Washington,IVY) 39
AORN JOURNAL
JULY 1991, VOL 54, NO 1
Fig 4. Note the importance of hemostasis to perform the anastomosis (top). Detailed illustration of the completed urethroileal anastomosis (bottom). (Reprintedfrom Surgical Rounds 13 (June 1990), R 0 Parru, L Shaker, R Wolf; with permission from Romaine Pierson Publications, Port Washington, NY) 40
AORN JOURNAL
JULY 1991, VOL 54, NO 1
isolated ileal segment and makes an opening approximately 1 to 1.5 cm in diameter. The mucosal edges of this opening are everted with interrupted 4-0 chromic catgut sutures to ensure an ideal mucosa-to-mucosa anastomosis to the urethra. The surgeon closes the previously opened limbs of the ileum with one layer of running 3-0 polyglycolic acid suture. The surgeon performs the urethral-ileo anastomosis using a Greenwald urethral sound to help identify the urethra and place the sutures. We prefer to use a UR5 needle and five to six 2-0 chromic catgut sutures. We bring the sutures from the outside in on the urethral side and from the inside out on the ileal side (Fig 4). After all the sutures are placed, the surgeon replaces the sound with a #20 French Foley catheter. The Foley catheter balloon is inflated with approximately 10 mL of fluid and placed under slight traction. The surgeon ties the sutures snugly, and the anastomosis is completed. The procedure is then terminated by securing the neobladder on each side of the pelvic wall with interrupted 3-0 silk seromuscular sutures that are tied securely to the endopelvic fascia. A closed suction drain is left in the pelvis, and each ureteral stent is brought out through separate stab wounds bilaterally and secured to the skin with 2-0 silk. The surgeon closes the abdomen in the standard fashion.
transports the patient to the postanesthesia care unit where he remains for one to one and a half hours or until his condition is stable. The sequential compression stockings remain in place for 48 hours. Postoperatively, the nurse documents the patient’s intake and output, assesses the patient for pain, assists the patient with pulmonary care, and encourages the patient to ambulate as soon as possible. The ureteral drains remain in place for five to seven days or until the patient is eating a regular diet. The nurse irrigates the neobladder with approximately 30 mL of normal saline every four hours to ensure that excessive mucous formation does not plug the catheter. The patient undergoes an intravenous pyelogram (IVP) at approximately day 10 to determine if there is any obstruction (Fig 5). If there is no obstruction or leakage, the surgeon removes the pelvic drain the following day, and the patient is discharged. The Foley catheter
Postoperative Care
A
fter the incision is dressed, the circulating nurse assists with the removal of the drapes and secures the dressings. He or she attaches the ureteral catheters to separate urine collection bags. After the patient is extubated, the nurse removes the dispersive electrode pad and checks the integrity of the skin beneath the pad. He or she removes the safety strap and helps the surgical team transfer the patient to the OR stretcher. The team
Fig 5. The postoperative IVP followed by a cystogram shows no obstruction.
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JULY 1991, VOL 54, NO 1
AORN JOURNAL
remains in place for a minimum of three weeks to ensure good healing of the anastomosis. The nurse should advise the patient that he may experience some stress urinary incontinence as well as leakage. especially during the evening hours, for the first few weeks postoperatively. The nurse instructs the patient to try to minimize this nighttime incontinence by setting an alarm clock to awaken every four hours and empty the neobladder to avoid over distension. If this is not acceptable to the patient, he may wear an external catheter instead. Three weeks after discharge, the patient reports to the surgeon’s office for the first postoperative visit. T h e surgeon removes the catheter at this time if no extravasation is seen on the ileogram. The patient undergoes a voiding cystourethrogram to document appropriate emptying of the neobladder. The surgeon checks the patient every month for the first three months with urine cultures and blood chemistries. Follow-up appointments are every three months for the first year and every six months after the first year. An IVP is repeated in one year. Complications with the Camey procedure are similar to those of an ileal conduit (ie. bowel leak, obstruction, ileus, and urine leak). The neobladder has a capacity between 300 and 500 mL after i t is established. Patients sense the need to urinate as a vague abdominal discomfort. Some may complain of pressure or cramping every two to four hours as a sign to void. Micturition is accomplished through the urethra with relaxation of the perineal muscles and a Valsalva maneuver. which may take time to master. Even though nothing replaces the normal human bladder, this simple form of continent urinary diversion offers, in selected patients. a higher quality of life than they will otherwise experience with a standard ileostomy, Suggested reading
Bricker. E M. “Bladder substitution after pelvic evisceration.” Surgictrl Clinics of North Arnrricu 30 (1950) 1511-1521.
Sagalowsky, A I . “Continent urinary diversion excluding the Kock’s pouch, Part I.” Amrricun 44
Urologicul Association Update Series 6 lesson 2 ( 1987) 2.
Sagalowsky, A I. “Experience with the ileal bladder (Carney Procedure) and cecoileal reservoirs for continent urinary diversion.” Seminars in Urolog? 5 (February 1987) 28-45.
Do-Not-Resuscitate Guidelines The American Medical Association’s Council on Ethical and Judicial Affairs issued a report updating guidelines for the appropriate use of do-not-resuscitate (DNR) orders. The report, published in the April 10, 1991, issue of the Joirriiril oj‘the American Medical Association, states that physicians have an ethical obligation to honor a patient’s preference regarding resuscitation efforts. The guidelines state that, in general, consent to administer cardiopulmonary resuscitation (CPR) is presumed because the patient is unable to communicate his or her preferences and failure to act would lead to death. There are, however, two exceptions to this presumption. The first is when the patient or his or her designated decision maker expresses in advance a preference to withhold CPR. If the attending physician judges the attempt to be futile, CPR also may be withheld. The report calls an attempt futile if it cannot be expected either to restore cardiac or respiratory function or if i t cannot achieve the patient’s expressed goals. The report further states that physicians should not let their personal beliefs prevent them from conforming with patients’ preferences. If the physician does not agree with a patient’s beliefs, he or she should consider obtaining a second opinion or transferring the patient to another physician. Hospitals should have explicit DNR policies, and those policies should be reviewed and revised based on experiences, according to the report. The guidelines state that DNR orders should be elicited by the physician and should be entered in the patient’s medical record.
AORN JOURNAL
Carney Procedure A CONTINENT URINARY DIVERSION TECHNIQUE
Judy Rauscher, RN; Robert D. Farber, MD; Raul 0. Parra, MD
P
atients undergoing radical cystoprostatectomy for the treatment of invasive bladder cancer have their urine diverted most often via standard ileal conduit. This has been the procedure of choice since it was first introduced in the 1950s. Increased interest in avoiding external appliances has arisen during the past decade. As a result, several techniques are currently used for the continent diversion of urine. This article illustrates the technique of ileocystoplasty (ie, Camey procedure) for urinary diversion.
Patient Selectiori
P
atient selection for any continent urinary diversion procedure is very important. The patient should understand the procedure, comply with instructions, and be willing to participate in his postoperative care. There should be no form of carcinoma in situ at or near the urethral stump to avoid the possibility of local recurrences. This is confirmed by preoperative biopsies of the prostatic urethra. The Carney procedure applies only to men because the entire urethra is removed when a cystectomy is performed on a female.
Preoperative Preparation
T
he patient is admitted the day before surgery for routine preoperative testing. This testing includes chest x-ray and electrocardiogram, a complete blood count, blood chemistries, coagulation studies, and a 34
routine type and cross-match for two to four units of blood. The day before surgery, the patient receives only clear liquids and lactated Ringer’s at a rate of 125 to 150 mL/hr intravenously for hydration. The afternoon before surgery, the patient is given oral laxatives followed by enemas until clear and is started on wide spectrum IV and oral antibiotics. The day of surgery, transfer personnel bring the patient to the operating room holding area where the holding area nurse checks and evaluates the preoperative testing. The nurse also verifies the patient’s identification band, allergies, and operative consent form. The perioperative nurses prepare the operating room for a major abdominal procedure. The scrub nurse ensures that a routine laparotomy instrument set with long instruments is
Judy Rauscher, RN, is a clinical nurse specialist, urology, at S t Louis University Medical Center. She earned her diploma in nursing at Jewish Hospital School of Nursing, St Louis. Robert D. Farber, MD, is chief resident nt the St Louis University Medical Center. He earned his medica! degree at St Louis University School of Medicine. Raul 0. Parra, MD, is director, division of u r o l o g y , St L o u i s U n i v e r s i t y S c h o o l of Medicine. He earned his medical degree at the University of Seville, Spain.
AORN JOURNAL
available. He or she also prepares self-retaining retractors, Babcocks, Berlishers, right angles, clip appliers, extra Kelly clamps. Pott scissors, Greenwald sound (ie, large metal sound with a groove in the tip), and TA-55 and GIA surgical staplers with additional staple cartridges.
Intraoperutive Care
T
he circulating nurse meets the patient in the holding area, identifies himself or herself, and again checks the chart and
JULY 1991, VOL 54, NO 1
interviews the patient concerning allergies, consent form, NPO status, and patient identification. The circulator then transfers the patient to the OR and helps him move to the operating room bed. The nurse covers the patient with warm blankets and positions the safety strap over him. The circulating nurse remains at bedside providing comfort to the patient and assisting the anesthesiologist with induction and intubation as needed. The patient is monitored by standard electrocardiogram, pulse oximetry, and arterial line tracings. The nurse helps to obtain IV access on both of the patient’s arms. After induction of anesthesia and intubation, the anesthesiologist places a central line or a pulmonary artery catheter if indicated. The nurse inserts an indwelling Foley catheter and attaches it to
Fig I . The plasty is created from a 40-cm segment of ileum that reaches the pelvic floor. (Reprinted from Surgical Rounds 13 (June 1990), R 0 Parra, L Shaker, R Wolf; with permission from Romaine Pierson Publications, Port Washington, N Y ) 36
JULY I99 1, VOL 54,NO 1
AORN JOURNAL
gravity drainage. This enables the operative team to monitor the patient’s urine output every 30 minutes. The nurse also routinely applies sequential compression stockings to prevent deep venous thrombosis. The nurse positions the patient in the supine or semi-lithotomy position, depending on the surgeon’s preference. He or she pads all potential pressure areas with foam pads and applies an electrosurgical dispersive electrode pad. The operative area is from the nipples to midthigh, including the perineum, and it is prepped with a povidone-iodine soap and solution.
Carney Procedure
T
he surgeon makes a midline incision from the symphysis pubis cephalad to approximateFig 2. The antirefluxing anastomosis. ly 4 cm superior to the umbilicus. He or she routinely explores the abdomen for possible metastasis. The surgeon begins the urinary diversion procedure after A 3- to 3.5-cm mucosal furrow that extends completing a bilateral pelvic lymphadenectomy from the enterotomy distally is constructed. and radical cystoprostatectomy to confirm that This will be the bed for the ureter. The surgeon the patient’s disease is organ-confined with cuts the end of each ureter with Pott scissors negative urethral margins as reported by frozen and makes a 0.5- to I-cm incision along the section diagnosis. longitudinal aspect of the ureter. This opens the The surgeon identifies 40 cm of ileum that, end of the ureter and allows anastamosis of the when shaped into a “U,” will allow the apex to ureter and the mucosal furrow without overlapreach the urethra without tension (Fig 1). If the ping suture lines, thereby reducing the chance mesentery does not allow tension-free anastoof strictures. The surgeon sutures the distal end of each mosis, which happens in approximately 15% of patients, another form of urinary diversion must ureter to the distal end of the mucosal furrow be chosen. with approximately three 5-0 polyglycolic acid Once the appropriate length of small bowel sutures. He or she fixes the lateral borders of is identified, the surgeon divides the bowel the ureter to the edges of the furrow with interwith a GIA stapler and restores bowel continurupted 5-0 polyglycolic acid sutures that pass ity with a side-to-side ileoileostomy using the through the adventitia of the ureter only. This GIA and TA-55 staplers. The surgeon opens results in an antirefluxing anastomosis (Fig 2). both ends of the U-shaped segment of ileum Both ureters are then stented with #8 French along the antimesentery border. At a distance feeding tubes that are brought out through of 1.5 to 2 cm, he or she performs the ureteral small enterotomies at each side of the limb of ileo anastomosis by bringing the ureters into the “U’ (Fig 3). The surgeon identifies the midpoint of the the bowel lumen through small enterotomies. 37
JULY 1991, VOL 54, NO 1
AORN JOURNAL
Fig 3. The stents used for ureteral intubation exit via the opening that later will be anastomosed to the urethra (top). Details of intubation (bottom). (Reprintedfrom Surgical Rounds 13 (June 1990),R 0 Parra, L Shaker, R Wolf; with permission from Romaine Pierson Publications, Port Washington,IVY) 39
AORN JOURNAL
JULY 1991, VOL 54, NO 1
Fig 4. Note the importance of hemostasis to perform the anastomosis (top). Detailed illustration of the completed urethroileal anastomosis (bottom). (Reprintedfrom Surgical Rounds 13 (June 1990), R 0 Parru, L Shaker, R Wolf; with permission from Romaine Pierson Publications, Port Washington, NY) 40
AORN JOURNAL
JULY 1991, VOL 54, NO 1
isolated ileal segment and makes an opening approximately 1 to 1.5 cm in diameter. The mucosal edges of this opening are everted with interrupted 4-0 chromic catgut sutures to ensure an ideal mucosa-to-mucosa anastomosis to the urethra. The surgeon closes the previously opened limbs of the ileum with one layer of running 3-0 polyglycolic acid suture. The surgeon performs the urethral-ileo anastomosis using a Greenwald urethral sound to help identify the urethra and place the sutures. We prefer to use a UR5 needle and five to six 2-0 chromic catgut sutures. We bring the sutures from the outside in on the urethral side and from the inside out on the ileal side (Fig 4). After all the sutures are placed, the surgeon replaces the sound with a #20 French Foley catheter. The Foley catheter balloon is inflated with approximately 10 mL of fluid and placed under slight traction. The surgeon ties the sutures snugly, and the anastomosis is completed. The procedure is then terminated by securing the neobladder on each side of the pelvic wall with interrupted 3-0 silk seromuscular sutures that are tied securely to the endopelvic fascia. A closed suction drain is left in the pelvis, and each ureteral stent is brought out through separate stab wounds bilaterally and secured to the skin with 2-0 silk. The surgeon closes the abdomen in the standard fashion.
transports the patient to the postanesthesia care unit where he remains for one to one and a half hours or until his condition is stable. The sequential compression stockings remain in place for 48 hours. Postoperatively, the nurse documents the patient’s intake and output, assesses the patient for pain, assists the patient with pulmonary care, and encourages the patient to ambulate as soon as possible. The ureteral drains remain in place for five to seven days or until the patient is eating a regular diet. The nurse irrigates the neobladder with approximately 30 mL of normal saline every four hours to ensure that excessive mucous formation does not plug the catheter. The patient undergoes an intravenous pyelogram (IVP) at approximately day 10 to determine if there is any obstruction (Fig 5). If there is no obstruction or leakage, the surgeon removes the pelvic drain the following day, and the patient is discharged. The Foley catheter
Postoperative Care
A
fter the incision is dressed, the circulating nurse assists with the removal of the drapes and secures the dressings. He or she attaches the ureteral catheters to separate urine collection bags. After the patient is extubated, the nurse removes the dispersive electrode pad and checks the integrity of the skin beneath the pad. He or she removes the safety strap and helps the surgical team transfer the patient to the OR stretcher. The team
Fig 5. The postoperative IVP followed by a cystogram shows no obstruction.
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JULY 1991, VOL 54, NO 1
AORN JOURNAL
remains in place for a minimum of three weeks to ensure good healing of the anastomosis. The nurse should advise the patient that he may experience some stress urinary incontinence as well as leakage. especially during the evening hours, for the first few weeks postoperatively. The nurse instructs the patient to try to minimize this nighttime incontinence by setting an alarm clock to awaken every four hours and empty the neobladder to avoid over distension. If this is not acceptable to the patient, he may wear an external catheter instead. Three weeks after discharge, the patient reports to the surgeon’s office for the first postoperative visit. T h e surgeon removes the catheter at this time if no extravasation is seen on the ileogram. The patient undergoes a voiding cystourethrogram to document appropriate emptying of the neobladder. The surgeon checks the patient every month for the first three months with urine cultures and blood chemistries. Follow-up appointments are every three months for the first year and every six months after the first year. An IVP is repeated in one year. Complications with the Camey procedure are similar to those of an ileal conduit (ie. bowel leak, obstruction, ileus, and urine leak). The neobladder has a capacity between 300 and 500 mL after i t is established. Patients sense the need to urinate as a vague abdominal discomfort. Some may complain of pressure or cramping every two to four hours as a sign to void. Micturition is accomplished through the urethra with relaxation of the perineal muscles and a Valsalva maneuver. which may take time to master. Even though nothing replaces the normal human bladder, this simple form of continent urinary diversion offers, in selected patients. a higher quality of life than they will otherwise experience with a standard ileostomy, Suggested reading
Bricker. E M. “Bladder substitution after pelvic evisceration.” Surgictrl Clinics of North Arnrricu 30 (1950) 1511-1521.
Sagalowsky, A I . “Continent urinary diversion excluding the Kock’s pouch, Part I.” Amrricun 44
Urologicul Association Update Series 6 lesson 2 ( 1987) 2.
Sagalowsky, A I. “Experience with the ileal bladder (Carney Procedure) and cecoileal reservoirs for continent urinary diversion.” Seminars in Urolog? 5 (February 1987) 28-45.
Do-Not-Resuscitate Guidelines The American Medical Association’s Council on Ethical and Judicial Affairs issued a report updating guidelines for the appropriate use of do-not-resuscitate (DNR) orders. The report, published in the April 10, 1991, issue of the Joirriiril oj‘the American Medical Association, states that physicians have an ethical obligation to honor a patient’s preference regarding resuscitation efforts. The guidelines state that, in general, consent to administer cardiopulmonary resuscitation (CPR) is presumed because the patient is unable to communicate his or her preferences and failure to act would lead to death. There are, however, two exceptions to this presumption. The first is when the patient or his or her designated decision maker expresses in advance a preference to withhold CPR. If the attending physician judges the attempt to be futile, CPR also may be withheld. The report calls an attempt futile if it cannot be expected either to restore cardiac or respiratory function or if i t cannot achieve the patient’s expressed goals. The report further states that physicians should not let their personal beliefs prevent them from conforming with patients’ preferences. If the physician does not agree with a patient’s beliefs, he or she should consider obtaining a second opinion or transferring the patient to another physician. Hospitals should have explicit DNR policies, and those policies should be reviewed and revised based on experiences, according to the report. The guidelines state that DNR orders should be elicited by the physician and should be entered in the patient’s medical record.
![[Continent urinary diversion following anterior exenteration].](/assets/img/hold.png)
