Ectopic Ureters Flashcards
ectopic ureters risk factors
- sex, breed
- obervations
- Female dogs +++
- Breeds
> Siberian Huskies, Mini and Toy Poodles, Labrador Retrievers, Fox Terriers, West Highland White Terriers, Collies, Welsh Corgis - Rare in cats (males+++)
- Constant/intermittent dribbling of urine since birth or weaning
what is an ectopic ureter
normal goes to trigone, ectopic goes somewhere else eg. urethra
Types of Ectopic Ureters
- Unilateral/bilateral
- Intra/extramural
> With extramural ectopic ureters, the ureter completely bypasses the bladder before opening distally into the urethra or vagina. With intramural ectopic ureters, the ureter enters the bladder wall in the normal location, but then tunnels distally within the bladder wall before opening into the urethra or vagina.
urinary incontinence in puppies Ddx
- Urethral sphincter mechanism incompetence (75-89%)
- Urinary tract infection (65-85%)
- Persistent paramesonephric septal remnants (90%)
- Hydroureter (50%) and hydronephrosis (25%)
- 90% of male dogs with EU
- Short urethra (20%)
- Vaginal septum/dual vaginas (10%)
- Renal agenesis (5%)
- Renal dysplasia (10%)
- Vaginal strictures
- Pelvic bladder
- Patent urachus
- Female pseudohermaphroditism
Paramesonephric vaginal remnant - what is it, why is it an issue?
- normally, vestible is free of tissues
- in PVR, paramesonephric membrane is still present and pulls on vestibule wall, keeping urethral hole open
Incontinence in Puppies - how do we notice on PE
- Perineum stained with urine
- Perivulvar dermatitis
Incontinence in Puppies
Work-up
- Blood work: unremarkable
- Urine culture: positive in 64% cases
- Vaginal palpation : stricture?
> If doubtful: vaginography/vaginoscopy - Imaging studies
> Urogenital tract ultrasound
> Excretory urography
> CT-Scan
> Cystoscopy
Incontinence in Puppies - Ultrasound
- what can we evaluate?
- drawbacks?
Evaluates if:
* Intrapelvic bladder
* Ureteral jet visible (but not sensitive)
* Ureteral distension
* Pelvic distension
<><>
Drawbacks:
* Entire urethra not visible
* Ectopic ureters not followed
what might we see if we ultrasound a puppy with an ectopic ureter?
Possible
* Ureteral distension
* Hydronephrosis
<><>
* ureterocele??????
Radiographs: Excretory Urography
- what is this technique?
- pros and cons?
Technique
* Under anesthesia
* IV injection of contrast agents
<><><>
Advantages
* Equipment easily available
<><><>
Drawbacks
* Extramural or intramural ureter ??
* Superimposition of pelvic bones, GI tract
* Diagnostic for only 70 to 78% of ectopic ureter
CT-Scan Excretory Urography
- is it useful? drawbacks?
- In the past= gold standard
- Drawbacks:
> $$$$
> Experienced operator required
Cystoscopy of incontinent puppies:
- technique
- pros and cons
Technique
* Endoscopic visualisation of urethra and bladder
<><>
Advantages
* Direct visualisation of ureteral papillas
* Distinction intra and extramural
* Eval entire urethra and vagina
* Treatment (laser) at the same time
<><>
Drawbacks
* Experienced operator required
Imaging studies for ectopic ureters
- rank from lowest to highest sensitivity
Ultrasound: poor
excretory urography: 70-78%
CT-scan: 91%
Cystoscopy: 100%
Treatment of Congenital Disorders
* Patent urachus or urachal diverticulum
Surgery
Treatment of Congenital Disorders
* Ectopic ureters
- Extramural: surgery (reimplantation)
- Intramural: laser removal
when treating a congential urinary tract diorder, should we guarantee continence afterward? Eg. for:
* Patent urachus or urachal diverticulum
* Ectopic ureters
Do not guarantee continence (possible urethral incompetence)
ectopic ureter surgery
- ureteral re-implantation
> complication rates? what can happen? continence?
- Overall complication rates:16-50%
- 25-50% worsening hydroureter
- 14% uroabdomen
- Continence rate for females low: 25-70%
- Continence rate for males >90%
Cystoscopic Laser ablation of Ectopic Ureters
- what is this process?
- what do we do?
- contraindication?
- Simultaneous diagnosis and treatment
- Diagnosis
> Ectopic ureters (intra vs extramural)
> Other abnormalities (vaginal septal remnants…) - No opened surgery
- Ablation of the medial ectopic wall
- Reposition of the opening
- Contraindication: extramural ectopic ureter
<><><><><>
For intramural ectopic ureter: - zap medial part with laser, open up ureter in trigone
what happens if we try Cystoscopic Laser ablation of Ectopic Ureters on an extramural ectopic ureter?
uroabdomen
Laser Ablation Ectopic Ureters
- outcomes
- complications
females: 77% continence
males: 85% continence
<><><><>
Complications
* Proliferative reaction along the laser tract +/-
obstruction (3%)
> Recheck US 6 weeks post procedure
ectopic ureters prognosis overall, and things we can do to help
- Persistent incontinence in 44 -67% patients
> Medical management
> Urethropexy or colposuspension
> Periurethral injection of collagen - Hydroureter and hydronephrosis partial or complete resolution
