Chapter 66 - Bladder Flashcards
What is the bladder’s capacity in a 500-kg horse, and how does its position change when empty or full?
The bladder can hold** 4 L or more of urin**e in a 500-kg horse. When empty, it may lie entirely in the pelvic canal, and when full, it drops over the pelvic brim to extend to the level of the umbilicus.
What are the round ligaments of the bladder, and what is their origin?
The round ligaments of the bladder are the cranial free edges of the lateral ligaments, remnants of the umbilical arteries.
How is the bladder covered anatomically, both cranially and in the remainder of the retroperitoneal space?
Cranially at the apex, the bladder is covered with peritoneum, and in the remainder of the retroperitoneal space, it is covered with adventitial tissue.
What are the two muscle layers in the bladder wall, and how are they arranged anatomically?
Bladder wall contains an** outer layer of longitudinal** to obliquely arranged muscle fibers
**inner layer of transversely **or **circularly arranged **muscle fibers.
They are partly interwoven but become external to each other at the dorsal aspect.
Why is the dorsal wall of the bladder considered inherently weak, and what is the potential consequence of excessive bladder distention?
The** dorsal wall** is considered** weak** due to the anatomical arrangement of muscle fibers. Excessive bladder distention may lead to rupture, particularly at the dorsal wall.
What muscles form the urethral sphincter, and how are they arranged around the pelvic urethra?
The urethral sphincter is formed by an outer longitudinal and an inner circular layer of smooth muscle surrounding the pelvic urethra.
What is the lining of the bladder, and what allows the bladder to stretch considerably during filling?
the bladder is lined with transitional epithelium overlying a thick submucosa that allows considerable stretching.
How is sympathetic innervation provided to the bladder, and what receptors do the fibers supply in the bladder and proximal urethra?
Sympathetic innervation is provided via the hypogastric nerve, with fibers supplying the** bladder** (β2-adrenergic receptors) and proximal urethra (primarily α1- and some α2-adrenergic receptors).
What is the origin of parasympathetic innervation for the bladder, and how is somatic innervation primarily directed to the lower urinary tract?
Parasympathetic innervation originates in the sacral segments of the spinal cord, forming the pelvic nerve.
Somatic innervation is primarily directed to the lower urinary tract via a branch of the pudendal nerve.
What is the detrusor muscle, and how is it innervated in the bladder wall?
The detrusor muscle is the smooth muscle of the bladder wall. It is innervated by the parasympathetic pelvic nerve and β2-adrenergic postganglionic fibers.
Describe the filling/storage phase of the bladder, and what is the role of sympathetic nerve activity during this phase?
During filling/storage, there is an increase in tone of the urethral sphincter muscles. Sympathetic nerve activity is dominant, leading to relaxation of the detrusor muscle
What receptors mediate the relaxation of the detrusor muscle during the filling/storage phase?
Relaxation of the detrusor muscle during filling/storage is mediated by α-receptor–mediated inhibition of pelvic nerve afferents and stimulation of sympathetic β2 receptors in the smooth muscle of the bladder.
How is the detrusor muscle reflexively relaxed during bladder filling, and what triggers detrusor contraction during the elimination phase?
the detrusor muscle reflexively **relaxes during bladder filling due to sensory input from bladder stretch and pressure receptors**. Detrusor contraction is triggered by signals for voluntary micturition during the elimination phase.
What is the role of brainstem upper motor neurons in micturition, and what triggers the end of micturition?
Brainstem upper motor neurons transmit signals to trigger detrusor contraction during micturition. Micturition ends when detrusor stretch receptors cease firing, and pelvic nerve efferent activity stops.
How is sympathetic nerve and pudendal nerve activity involved in the post-micturition storage/filling phase?
Sympathetic nerve and pudendal nerve activity resumes for the next storage/filling phase after micturition.
What triggers the initiation of voluntary micturition signals, and what muscles are concurrently inhibited during this phase?
Voluntary micturition signals are initiated in the cerebrum, leading to the inhibition of pudendal nerve and hypogastric α- and β2-sympathetic activity, allowing relaxation of the urethral sphincter and facilitating detrusor muscle contraction.
How does sympathetic innervation contribute to the relaxation of the detrusor muscle during the filling/storage phase?
Sympathetic innervation leads to the relaxation of the detrusor muscle during the filling/storage phase by inhibiting pelvic nerve afferents and stimulating sympathetic β2 receptors in the smooth muscle of the bladder.
What are some disorders of the bladder that may necessitate surgery in horses?
Foals:
- uroperitoneum,
- patent urachus,
In adult horses,
- cystolithiasis/urolithiasis
- prolapse or eversion of bladder
- neoplasia
What is the most common surgical disorder of the bladder in adult horses?
Cystolithiasis
What can cause uroperitoneum in foals, and what is the prevalence of uroperitoneum after bladder rupture during parturition in colts?
Uroperitoneum in foals can result from bladder rupture during parturition in colts. The prevalence ranges from 0.5% to 2.5%.
What is the commonly accepted explanation for bladder rupture in colts during parturition?
high intravesicular pressure during passage through the pelvic canal and occlusion of the urethra.
what is the typical appearance of bladder tears in foals?
Bladder tears are typically** 2 to 5 cm in length** on the dorsal surface, with hemorrhagic and edematous margins.
What are the potential causes of bladder distention in stillborn and neonatal foals, and how can bladder distention be confused with uroabdomen?
Potential causes of bladder distention in stillborn and neonatal foals include excessively long umbilical cords and anomalies in bladder-urachus fusion. Bladder distention can be confused with uroabdomen, as seen in cases of enlarged, flaccid bladders.
what is the treatment of megavesica in foals
Surgical removal of a large portion of the bladder is the treatment for megavesica with uroabdomen in foals.
and what complications may arise after surgical correction?
Complications may include recurrent colic after weaning, as observed in some cases.
What electrolyte alterations are commonly found in foals with uroabdomen, and how is uroabdomen confirmed?
**Hyponatremia,
hypochloremia,
**
and moderate to marked hyperkalemia
Uroabdomen is confirmed by measuring a ratio of peritoneal fluid to serum creatinine greater than two.
How does bladder rupture in adult horses typically occur?
Bladder rupture in adult horses = less common than in foals
Causes:
- parturition
- urolithiasis
- penile hematoma and swelling
- blunt abdominal trauma
- falling during recovery from anesthesia, or after repair of bladder rupture or treatment of urachal sepsis.
What are the clinicopathologic findings in adult horses with bladder rupture, and how do they compare to neonates with uroabdomen?
Clinico pathologic findings in adult horses with bladder rupture include azotemia and alterations in serum electrolyte concentrations, which are similar to those found in neonates with uroabdomen.
Under what circumstances might foals with perinatal asphyxia syndrome (PAS) exhibit bladder distention
Foals with PAS, especially when recumbent, may exhibit bladder distention.
how is it managed to prevent rupture?
Temporary use of an indwelling bladder catheter is useful to keep the bladder empty and decrease the risk of rupture.
What is the potential complication associated with the temporary use of an indwelling bladder catheter in foals with PAS?
Ascending urinary tract infection
In adult horses, what has been observed as a complication following treatment of urachal sepsis as a neonate?
Uroabdomen has been observed as a complication following treatment of urachal sepsis as a neonate in adult horses.
What is the suggested cause of bladder tears in foals with smooth margins and no evidence of traumatic disruption?
ay be developmental anomalies rather than ruptures
What is the primary cause of lower urinary tract obstruction in male infants, and has it been recognized in horses?
he primary cause of lower urinary tract obstruction in male infants is posterior urethral valves. Although it has not been recognized in horses, bladder rupture, vesicoureteral reflux, and hydronephrosis can result from this condition.
Clinical signs of bladder rupture during parturition when does it manifest? what are the signs?
Foals with bladder rupture during parturition initially appear healthy and nurse well for the first 24 to 48 hours. Early signs include a decrease in nursing vigor, lethargy, and progressive abdominal distention, along with intermittent colic signs.
From what value must be corrected the hyperkalemia?
K>5.5 mEq/L mm tremors and cardiac arrythmias
What is the treatment dosage?
In sever hyperkalemia 50 kgs foal is** 25-50 mL of 23% calcium borogluconat**e added to **1L NaCl 0.9% **and infused 5-10 minutes
Administer more fluids supplemented with **50% dextrose 4-8 mg/kg/min
Drain abdomen go to surgery**
Bloqueio atrioventricular de terceiro grau demonstrando um intervalo R-R irregular sem qualquer relação com as ondas P e um complexo QRS largo (complexo de escape) (seta). O ECG apresenta ondas P regulares que não são seguidas por um QRS e os complexos QRS apresentam uma morfologia larga e bizarra,
Figure 66-1. Longitudinal bladder tear in the dorsal aspect of a 3-day-old colt (arrows). This is the typical surgical finding in a foal that develops uroabdomen consequent to bladder rupture sustained during parturition.
Figure 66-2. Transabdominal ultrasonographic images at the level of the umbilicus in foals. (A) A large amount of free peritoneal fluid is present in moderate to severe uroabdomen; (B) Only a modest amount of fluid is visible as would be imaged during the early stages of uroabdomen. BL, Bladder; F, free abdominal fluid [urine]; SI, small intestine; UA, umbilical artery.
Why do you drain the abdomen?
Essencial to remove large amount of potassium and decrease pressure on diaphragm
What can happen if you drain 5L in foal or 50 L in adult??
When a large volume is drained >5 L in foal or 50L in adult}Risk of hemodynamic collaps – administer IV fluids concurrently
what is the treatment of choice in uroperitoneum
surgery + AB + NSAID + protector of mucosa
What is the urachus, and when does it normally close in equine development?
The urachus is the conduit through which fetal urine passes from the bladder into the allantoic cavity. It normally closes at the time of parturition.
Patent urachus is incomplete closure at parturition time is the most common malformation in equine urinary trach. Can be classified in what?
Simple or congenital form from sepsis
How can one distinguish between simple or congenital patent urachus and sepsis of the urachus?
Simple or congenital patent urachus is considered a malformation and results in a persistently moist umbilicus
Sepsis : considered an acquired patent urachus and may lead to urine leakage from the umbilicus within a few hours to days after birth, often accompanied by more severe illness.
What factors have been suggested to cause tension on the umbilical cord attachment, leading to dilatation of the urachus and failure to close at birth?
Greater than average length or partial torsion of the umbilical cord resulting in dilatation of the urachus and failure to close.
What is conservative tx for patent urachus?
Treated with chemical cauterization with concentrated phenol or 7% iodine solution or silver nitrate BID ou QID}These substances can be irritating and predispose to infection
In absence of infection dip w/ 0.5% clorhexidine or 0.1% octenidine
Large spectrum antibiotics}If after 5-7 days is still leaking or there signs of infection – surgery
Why is chemical cauterization contraindicated in cases of local sepsis associated with a patent urachus, and what alternative treatment approach is recommended?
Chemical cauterization is contraindicated in local sepsis cases as it may increase the risk of urachal rupture. Instead, broad-spectrum antibiotic therapy is recommended, and resolution of systemic disease may lead to the closure of the urachus.
When might surgical exploration and resection of the urachus and umbilical vessels be indicated in cases of patent urachus?
Surgery if no decrease in urine leakage is observed after 5 to 7 days of medical therapy
or US reveals abnormalities of multiple structures in the umbilicus.
Urolithiasis
what is the primary treatment for equine bladder stones, and how does it differ from the treatment of cystic calculi in small animals?
Surgical removal is the treatment of choice
What is the classic presenting complaint for cystolithiasis in horses, and how might affected male horses demonstrate signs of urolithiasis?
hematuria after exercise.
Affected male horses may demonstrate signs of stranguria by repeatedly dropping the penis and posturing to urinate but voiding little or no urine.
What role does urinary tract infection (UTI) play in the development of cystolithiasis in horse
uncertain
What are the two basic forms of cystoliths in horses
2 basic forms of cystoliths are:
**- yellow-green spiculated **stones (Type I) +++ common
-** gray-white smooth stones (Type II).**
both are calcium carbonate crystals
b
Figure 66-3. Equine cystic calculi. (A) The more common flattened, sphere-shape type of bladder calculus that is highly spiculated. (B) The less-common form of gray, smooth-surfaced calculi that can be more irregular in shape. (A, Courtesy Julie Rossetto, DVM, Alamo Pintado Equine Medical Center, Fenton, Michigan. B, Reproduced from DeBowes RM. Surgical management of urolithiasis. Vet Clin North Am Equine Pract. 1988;4:461, with permission.)
How is diagnosis usually made for bladder stones in horses, and what is the importance of endoscopy in further evaluating cystoliths?
Diagnosis is usually made by rectal palpation.
**
Endoscopy of the urinary bladde**r is important to further evaluate the size, number, and nature of the cystoliths.
What is the recommended treatment for sabulous urolithiasis?
Treatment involves repeated bladder lavage and antimicrobial therapy for concurrent UTI.
why are affected horses not considered surgical candidates?
sabulous urolithiasis are not surgical candidates due to the secondary nature of the problem, which results from bladder paralysis or other disorders interfering with complete bladder emptying.
What is the key difference between sabulous urolithiasis and cystolithiasis in terms of bladder size, and how can the diagnosis be confirmed?
Sabulous urolithiasis is associated with an enlarged bladder compared to the small bladder typical for cystolithiasis.
**
Diagnosis **can be confirmed through careful rectal palpation, allowing indentation of the sabulous mass with firm digital pressure.
What drugs have been recommended for horses with bladder paresis/paralysis and incontinence?
Bethanechol and/or phenoxybenzamine but poor success
Initial presentation of the post-partum mare with aneverted bladder. EVE 2020 Segmental ischaemic necrosis of the jejunum in a post-partummare due to two mesenteric avulsionsL. Vilaregut
What is the cause of bladder evertion or eventration through tear in the vagina in the mare?
associated w/parturition + collic
2 case report revealed jejunal mesentery was avulsed from the intestine and another a small colon was entrapped in the bladder. How was achieved the resolution?
Initial assessment, replacement of the urinary bladder in the normal position did not appear possible.
The mare was immediately prepared for C- section.
The foal was successfully delivered and resuscitated.
Detailed assessment of the bladder during surgery revealed that the small colon had prolapsed through the external urethral opening and was inside the space formed by the everted bladder.
The urinary bladder was opened.
Small colon was replaced into the abdominal cavity; a surgeon gently replaced the small colon through the external urethral sphincter and a second surgeon retrieved the small colon by gentle traction until normally aligned.
The bladder was closed and replaced
Neoplasia can cause what symptoms and is the most common tumor?
SCC
Hematuria, straining, urinary obstruction
What are the diagnosis? Prognosis?
Physical exam rectal palpation US endoscopy biopsy
Poor prognosis
What are the surgical procedures that can be performed in the bladder?
- CYSTORRHAPHY
- CYSTOPLASTY
- CYSTOTOMY
3.1. PARAINGUINAL APPROACH
3.2. PARARECTAL APPROACH
3.3. LAPAROSCOPIC TECHNIQUES
- LITHOTRIPSY
what is the surgical indication of cystorraphy?
Disruption of bladder
Describe surgical approach for cystorraphy
ADULTS! Male penis inside prepuce and sutured
Adult female mamary gland should be prepped in case incision needs to be extended that far
In adult female patient 15-18cm midline incision caudad from a point 2-5 cm cranial to umbilicus
In the male
Skin, subcutaneous layers, of caudal incision directed 2-4cm paramedian to prepuce
After peritoneal cavity is entered, fluid is sent for culture and suctioned
Bladder exposed by traction on urachus Umbilicalv. ligated and transected
ID place and extent of rupture –> need to ID? retrogade injection methylene blue
Wound margins are excised
Place stay sutures
Suture interrupted pattern in 1st layer + continuous inverting pattern
!! Avoid penetration of vesicular mucosa (perpetuate calculi w/ alkaline urine)
Bladder should be distended w/ saline
Urachus is removed if present, abdomen wahsed and closed routinely
Figure 66-5. (A) An enlarged bladder filled with a sphere of inspissated sabulous urine sediment at postmortem examination. The mass of urine sediment weighed 5 kg. (B) The sphere of urine sediment could be cut rather easily with a knife. (Reproduced from Schott HC. Urinary incontinence and sabulous urolithiasis: Chicken or egg? Equine Vet Educ. 2006;8:17, with permission.)
Figure 66-6. Everted bladder in a postpartum 4-year-old Standardbred mare.
Figure 66-7. (A) In male horses or foals, the caudal aspect of the cutaneous midline incision and subcutaneous dissection is directed abaxially to avoid the prepuce and penis. (B) Then the penis and prepuce are retracted laterally so the body wall can be incised on midline.
Figure 66-8. After completing the midline incision and mobilizing the umbilicus and urachal remnant from the abdominal wall, the bladder is exposed by careful traction on the umbilicus. When the bladder is exposed, the tissues are retracted caudad.
In foals what is advised if is not cystorraphy?
Cystoplasty for bladder rupture and patent or persitent urachus
if possible to ressect apex, includes double ligating and** transect both umbilical art.**
The external umbilicus should be oversewn if present of the abdomen.
Fusiform incision is made around the external umbilicus.
The umbilicus and urachus are dissected free from the bodywall.
Umbilical vein is double ligated and resected as farcraniad as necessary to remove any portion of abnormal umbilicalvein.
Sterile moistened laparotomy sponges to pack the intestines.
Ligate umbilical arteries
Exposure of the bladder is achieved by traction on the urachus.
Stay sutures
Isolate urachus in the apex of the bladder
Transverse incision to remove urachus
Cystotomy is the surgical treatment of choice for?
cystic calculi
describe surgery
Figure 66-16. The urolith can be grasped with sponge forceps for expedient removal.
When the bladder is exposed, moistened laparotomy sponges are used to pack off the bowel and elevate the bladder in the surgical field. Large-diameter stay sutures can be positioned at the ventrolateral aspects of the bladder to facilitate control of the cystotomy incision and to reduce urine spillage.
A** transverse incision** is made across the ventral bladder to expose the urolith. Frequently, the urolith is closely adherent to the bladder mucosa, particularly in the case of a type I urolith. The mucosal layer of the bladder must be peeled back from the urolith to permit removal of the calculus (Figure 66-16). The bladder can be** lavaged in an effort to remove small fragments of calcular material and blood clots. Irrigation of the bladder by retrograde introduction of sterile saline through the urinary catheter flushes small fragments of the urolith from the neck of the bladder toward the incision, where they can be evacuated by suction.
The cystotomy is sutured with a two-layer closure of monofilament synthetic absorbable suture material. Continuous inverting suture patterns such as the Cushing and Lembert patterns **are preferred. The sutures should not penetrate the mucosa of the bladder. After closure of the cystotomy, the bladder may be carefully distended with sterile saline to evaluate the closure for leakage. The abdomen is lavaged with sterile balanced saline solution, which is subsequently suctioned off. The **midline incision is closed with USP size 2 or 3 synthetic absorbable** suture material in continuous or interrupted fashion. In very large horses, a suture size of USP size 6 can be used if available. If the caudal limit of the incision was made in a **paramedian location, **the fascial closure is completed in two layers by suturing the internal and external layers of the rectus abdominis sheath separately. Of the two layers, the external rectus sheath is the more critical to the security of the abdominal closure.The subcutaneous tissues and skin are closed in routine fashion.
How would you perform a parainguinal approach of cysototomy?
**- 12-14 cm skin incision parallel **and **2 cm axial to external inguinal ring
**
- Blunt dissection until aponeurosis of external oblique, then incise 12-14cm
- Find** internal oblique **and slip it in direction of fibers
Peritoneum entered w/ finger
Bladder identified
Rest as described before
Advantages of parainguinal approach
This approach eliminates the need to reflect the prepuceand reduces the chances of encountering large vessels prior togaining access to the urinary bladder.
What is the modified parainguinal approach? Why is advantegous?
A 12-cm ventral midline incision is made at thelevel of the umbilicus. The surgeon’s hand is introduced intothe abdomen and the bladder and calculus are grasped. Basedon the mobility of the bladder the** best location for a parainguinalincision is determined**
Transurethral techniques in standing sedate patients where describe in 2 reports. Name them
Direct access to urthra using laparoscopic polyurethane specimen transurethral
Pararectal cystotomy
Describe pararectal cystotomy landmarks and surgery
- 10-15 cm vertical incision made between right side of anus and right semimembranosus mm
- Dissection cranially 15-20cm to expose retroperitoneal aspect of the neck of bladder
- Left hand guides through rectum, right hand carries scalpel to make cystotomy incision
- Calculus is removed
- Can be left to heal by 2nd intention
Laparoscopic technique is used as well to repair cystorrhexis, persistent urachus and umbilical infections what are the portals?
DR - insufflation w/ teat cannula or Veress needle, lower insufflation rates
-1.5 cm incision 5m lateral to ventral midline
- 10-15cm cranial to umbilicus – for laparoscope
- Additional portals 8-10cm lateral, 5cm cranial to umbilicus
In adults?
Bladder lavage and drained until clear salin
Standard umbilical portal mader after insufflation
5 instrument portals
What does it mean lithotripsy?
Means of fragmenting urinary calculus into smaller pieces so that fragments can be removed through smaller lumen or incision
Manueal crushing associated with high rate recurrence
What are the options for lithotripsy?
Laser dye
Holmium laser
Electrohydraulic shockwave
What is the laser lithotripsy pulse dye wavelenght?
504 nm
- Causes disruption of calculus, generating acoustic wave greater than tensile strength of crystals
If you use Holmium yttrium aluminum garnet wha is the wwavelength?
wavelenght 2100nm}Uses photothermal + photoacoustic effects to fragment urolith
How do you perform electrohydraulic shockwave lithotripsy?
- Can be done standing
- Fiber is passed thtough working channel, and held in contact w/ calculus
- Calculus fragmented until they’re 1 cm in diameter
- Described in 21 males, required average 2.15 sessions (1-6 sessions)
- Only works if calculus is submerged in fluid
What is the aftercare required?
- Antibiotics 48-72h
- Urinary catheter 48-72 h
- Abdominaldrainage if peritonitis
- May require iv fluids and electrolyte supplementation
What can you during laparoscopy to increment you vision of the bladder?
Trendelenburg position
List the complications postoperative
–– Uroabdomen/extravasation of urine
–– Incontinence
–– Infection
–– Urine scalding
–– Stricture/fistula
–– Complications related to suture choice andplacement
–– Complications related to suture choice andplacement
Bernardis et al 2017 Components of the pneumatic lithotripsy equipment. a)Gas regulator, b) Gas line, c) Pneumatic scaler, d) laparoscopicretrieval bags, e) stainless steel lithotrite.
Hall and Rodgerson EVE 2020 describe a transurethral intraluminal closure of a caudally located bladder neck tear in standing mare
Hall 2020 Endoscopic view of the bladder tear, located caudally inthe region of the neck of the bladder.
Describe the surgical procedure of transurethral intraluminal closure
Caudal epidural anesthesia, mepi faeces manually removed, tail tied,
Vaginal speculum
31 cm laparosocope 10 mm and needle holder grasping cutting needle Vicryl that was passed in loop simple continuous pattern and grasped with second needle holder and knot was thrown outside of vaginal speculum and slid down
What was the medication given to the mare postoperatively?
fluidtherapy with a balanced electrolyte solution infusion (2.5 mL/kg/h) supplemented with 250 mL 23% calcium gluconate(Calnate)
Lidocaine administration at0.05 mg/kg/min. She was started on phenazopyridine Wilma.1988%hydrochloride (Pyridium)10 tablets (4 mg/kg t.i.d. per os).
The morning after surgery she was quiet and her vital signs werewithin normal limits. (She had passed dry, formed manure andhad a poor appetite.)
The abdominal drain was removed26 h after surgery following the identification of no free fluidwithin the peritoneal cavity.
The urinary catheter was closelymonitored and remained in place for 7 days post-operatively
Potassium penicillin G (K-Pen4; 500,000 units/mL i.v. q. 6 h)was administered for 6 days post-operatively,
gentamicin(Gentocin2; 6.6 mg/kg bwt i.v. q. 24 h) for 8 days,
flunixinmeglumine for 7 days (Banamine5; 1.1 mg/kg i.v., twice aday for 3 days, once a day for the next 4 days).
Figure 66-9. The bladder is retroflexed to examine a tear on the dorsocranial wall of the bladder.
Figure 66-11. Tissues surrounding a tear in the bladder should be excised before primary repair.
Figure 66-12. A two-layer inverting continuous closure is appropriate for repair of a bladder rupture.
Figure 66-10. A rupture of the urachus (located at the tip of the hemostatic forceps) is readily apparent on inspection of the cranial bladder.
Figure 66-13. After mobilizing and retracting of an umbilical or urachal abscess, the abdomen should be explored for adhesions or additional foci of abscessation.
Figure 66-14. Before urachal-umbilical resection, a clamp is applied to prevent spilling urachal contents into the peritoneal cavity. Here, the bladder has been stabilized by stay sutures transfixed as ligatures around the umbilical arteries. The urachus and umbilical tissues are removed by sharp dissection. The bladder is closed by the two-layer inverting continuous suture pattern.
