SA Bladder and Urethral Sx

Question 1

Surgical diseases of the lower urinary tract?

Answer 1

Bladder calculi.
Bladder neoplasia - relatively rare.
Bladder rupture.
Urethral calculi.
Urethral obstruction.
Urethral rupture.
Urethral prolapse.

Question 2

Surgical procedures of the bladder.

Answer 2

Cystotomy.
Cystectomy.
Cystostomy.
Cystopexy?

Question 3

Surgical procedures of the urethra?

Answer 3

Urethrostomy.
Urethrotomy.
Urethropexy.
Urethral anastomosis?
Urethral stenting?

Question 4

Treatment options for bladder calculi?

Answer 4

Medical:
- only struvite can be dissolved.
- ABX.
- voiding hydropropulsion.
– when bladder calculi are not particularly big.
Surgical:
- cystotomy.

Question 5

1. Urethral calculi history.
2. How do they present?

Answer 5

1. Cats and dogs.
   Relatively rare to diagnose in females - shorter and wider urethra so easier to pass.
   Breeds - dalmatians (prone to forming urate stones).
   Multi-cat household?
   Owner may not be familiar with cat’s toileting.
2. Cystitis / stranguria / haematuria.
   Intermittent straining.

Question 6

Urethral calculi on clinical exam.

Answer 6

TPR, cardiovascular status (may be bradycardic, may be tachycardic - depending on potassium), pain score.
May be BAR, may be collapsed.
- depends on extent of blockage.
May be normovolaemic, may be hypovolaemic.
Abdominal palpation.
Check around genital area for small pieces of stone passed already - may be able to sample.

Question 7

1. Investigation for complete urethral obstruction.
2. Preliminary treatment for complete urethral obstruction.
3. Definitive treatment of complete urethral obstruction.

Answer 7

1. Bloods - renal function and electrolytes.
   Urinalysis - sediment and C&S.
   Imaging.
   - radiography, ultrasonography.
2. Analgesia - can help reduce urethral spasm.
   Stabilisation e.g. fluids.
   Bladder decompression.
3. Retrohydropropulsion:
   - push stones from urethra back into bladder.
   Followed by cystotomy.

Question 8

Retrohydropropulsion.

Answer 8

Avoids urethral surgery.
Decompress bladder.
- leave a little urine behind.
– as decompressing bladder, bladder wall gets closer and closer to the needle, which can cause iatrogenic damage to the mucosa.
– advised to perform under ultrasound guidance.
Prepare the patient.
- incontinence pads, clip patient.
Prepare self.
Flushing equipment:
- appropriate catheter – with end hole rather than side holes.
- sterile lube.
– mix with lidocaine (help spasm).
Assistant.
- gloved finger in rectum, applying downward pressure to compress urethra on bladder side of stone.
- then flush up via catheter , dilating urethra at the other side of the stone.
- then assistant lifts finger, allowing stone to pass up into the bladder.

Question 9

Feline retrohydropropulsion top tips.

Answer 9

Catheter choice - end hole rather than side holes.
- some have metal stylets which may cause trauma.
Prepuce pulled caudally to straighten the penile urethra.
Flush and advance.
Dilution is the solution for plugs.
- flush out the bladder.

Question 10

Imaging options for urinary tract rupture.

Answer 10

Plain radiographs.
- can be unreliable.
Intravenous urogram (IVU).
- time consuming.
More useful for kidneys and ureters than for bladder and urethra.
Retrograde urethrogram for urethra.
Positive contrast cystogram for the bladder.
Do not perform negative contrast (air). - risk peritonitis.

Question 11

Other used diagnostics for urinary tract rupture.

Answer 11

Bloods.
- rising kidney values.
- compare to abdominal fluid if abdominal fluid present.
- keep checking potassium levels.
If fluid in abdomen, tap fluid and test:
- if higher creatinine and urea levels in the abdominal fluid than are in the plasma in blood sample.

Question 12

Urinary tract rupture presentation.

Answer 12

Depends which anatomical structures ruptured.
- +/- uroabdomen.
Progressively more and more unwell.
- 12, 24, 48 hours to progress to serious condition.
Can still be urinating.

Question 13

What species have a sigmoid flexure in their penile urethra?

Answer 13

Bull.

Question 14

Surgical treatment of a bladder rupture.

Answer 14

Stabilise prior to attempting repair.
Ventral midline ex lap.
Methodical four quadrant check.
Repair:
- debride damaged bladder.
- Suture closed as for cystotomy.
- +/- tube cystostomy.
- omentalise.
- flush abdomen.

Question 15

Surgical treatment of a urethral rupture.

Answer 15

Conservative = urethral stenting.
Surgical:
- urethral repair – very unlikely to want to perform anastomoses as intricate and may need to perform pelvic split.
- urethral stenting – more likely treatment of choice.

Question 16

Bladder neoplasia treatment options.

Answer 16

Surgery alone = cystectomy:
- can be curative for benign lesions.
- futile for all malignant tumours (bladder neck location).
Medical alone:
- large variety of protocols available (chemo seems better than radiation).
- COX-2 selective NSAIDs.
Surgery and medical:
- multi-modal medical protocols = better survival with partial cystectomy.
Palliative measures:
- diversion (tube cystostomy).
- stenting (can render incontinent).

Question 17

Treatment of urethral prolapse.

Answer 17

Push mucosa back to correct position and suture in place.
Worst case scenario - resect mucosa and suture either side together.
Castrate these cases (caused by over-excitement or UTI).

Question 18

Cystotomy - approaching the bladder.

Answer 18

Pre- placed urinary catheter?
- care about sterility.
- ease of placement.
Caudal midline / paramedian (male) laparotomy.
Swab count!
Pack off abdomen.
Place stay sutures in bladder apex.

Question 19

Is the female urethral diameter less or more than that of the male?

Answer 19

More - females have a wider urethra than males.

Question 20

Cystotomy - entering the bladder.

Answer 20

Plan incision site.
- as avascular as possible.
Stab incision.
- 15 blade.
Enlarge incision.
- not too close to bladder neck.
– risk affecting sphincter.
Suction.
Inspect.
Take samples - mucosa etc.
Flush - to remove stones.

Question 21

Cystotomy - closing the bladder.

Answer 21

Close bladder.
- appositional, monofilament.
Omentalise.
Swab count.
Change kit.
Close abdomen routinely.
Radiograph.

Question 22

Cystotomy complications.

Answer 22

Residual calculi.
- mitigate with post-op radiographs.
Uroabdomen.
Suture-associated calculogenesis.
Post-op pain.
- multi-modal analgesia.
Haematuria/dysuria.

Question 23

1. Indications for cystectomy.
2. Cystectomy technique.

Answer 23

1. Polypoid cystitis.
   Necrotic bladder found at surgery.
   Early neoplastic lesion.
2. Choose margins.
   Resect abnormal tissue.
   - can remove at least 70% of bladder.
   – will need to urinate more frequently.
   – eventually sorts itself out and patient can manage well.
   Close as you would for a cystotomy.

Question 24

Tube cystostomy approach.

Answer 24

Caudal laparotomy.
Foley catheter pulled through a stab incision in body wall adjacent to bladder.
Purse-string suture (absorbable).
Stab incision made into bladder in its centre.
Tip of Foley placed through and inflated.
Purse-string tied.
Couple of sutures placed between bladder and body wall.
Laparotomy incision closed.
Foley attached to external skin with tape.
Sutured and held in place with Surgifix string vest.

Question 25

1. Indication for urethrostomy.
2. Location of urethrostomy in the dog.
3. Location of urethrostomy in the cat.

Answer 25

1. Recurrent urethral obstruction.
2. Scrotal.
3. Perineal.

Question 26

History of a urethral ‘sphincter’ mechanism incompetence (USMI).

Answer 26

Urinary incontinence.
Young (primary).
Older (secondary).
Female more commonly than males.

Question 27

Diagnosis of USMI?

Answer 27

Bloods.
Urinalysis.
Imaging.
Exclude other causes.

Question 28

USMI medical management.

Answer 28

Female :
- Masterly inactivity if congenital.
- Diethylstilboestrol.
- Alpha-adrenergics e.g. phenylpropanolamine.
- Combinations.
Male:
- testosterone supplementation.

Question 29

USMI surgical management.

Answer 29

Colposuspension.
- pull bladder further iinto abdomen so urethral sphincter is under influence of abdominal pressure.
Artificial sphincter.
- placed around the ureter at neck of bladder to increase tone.
Bladder reposition.
- cystopexy.
- vas-deferensopexy.
Intra-urethral injection of collagen.
- do not last long.
Most surgical techniques get ~50% increase in continence.
Some improvement, sometimes cure.

Question 30

Steps for performing a voiding urohydropropulsion.

Answer 30

Catheterise urethra.
Fill bladder.
- care not to rupture.
Remove catheter.
Occlude urethra.
Position the patient.
- use gravity – hold them up.
Agitate bladder - jiggle.
Apply steady digital pressure to induce voiding.
Less risky in females than in males,.