SA Renal and Ureteric Sx

Question 1

Overview of diagnostic techniques for renal and ureteric disease.

Answer 1

CE.
Lab work.
BP.
Imaging.
Biopsies.

Question 2

Options for renal biopsies.

Answer 2

Ultrasound-guided.
Laparoscopic.
Surgical.

Sampling options:
- FNA.
- Tru-cut biopsy.
- Incisional biopsy.

Sampling location in the cortex, not through into vascular medulla.

Question 3

Considerations/contraindications for renal biopsies.

Answer 3

Risk/benefit.
Check for coagulopathy.
Severe infection will risk widespread peritonitis.
Ureteral obstruction - will back-fill the kidney with blood.
Consider sample size and number of samples.

Question 4

Considerations for ureteric and renal surgery.

Answer 4

Your practice facilities.
Your abilities.
Owner preferences.
Owner financial constraints.
Advanced surgical techniques.

Question 5

1. Pre-op patient considerations for renal and ureteric surgery.
2. Peri-op patient considerations for renal and ureteric surgery.

Answer 5

1. Hypoproteinaemia - drug dose adjustments.
   Electrolytes - predispose to cardiac arrhythmias under GA.
   Fluid status - cardiac arrhythmias, hypovolaemia, hypertension.
   Haematology - anaemia and clotting.
   Clotting abnormalities (BMBT).
2. Anaesthetic and analgesic options.
   Antibiotics - based on C&S.

Question 6

Anaesthetic monitoring during renal and ureteric surgery.

Answer 6

Fluid status.
HR, RR.
BP.
ECG for electrolyte disturbances.
SpO2.
EtCO2.
Temperature.
Urine output.

Question 7

List surgical diseases of the kidney and ureter.

Answer 7

Neoplasia.
Renal calculi.
Hydronephrosis.
Developmental abnormalities.
Renal cysts / pseudocysts.
Renal abscesses.
Renal trauma.
Ureteral calculi.
Ureteral ectopia.
Ureteral neoplasia.
Ureteral trauma.

Question 8

Renal neoplasia presentation.

Answer 8

Non-specific.
Urinary signs.
Renal failure signs.
Clinical exam.
Generally found incidentally.

Question 9

1. Renal neoplasia common?
2. Renal neoplasia activity.
3. Common renal neoplasias.

Answer 9

1. Uncommon.
2. Malignant.
3. Carcinoma (dogs), lymphoma (cats), and others.

Question 10

Process of staging renal neoplasia.

Answer 10

Lab work:
- Biochemistry.
- Haematology.
- Electrolytes.
- Clotting.
- Urinalysis.
- Urine C&S.
Assess local extent of disease:
- Abdominal palpation.
- Imaging.
Assess for intra-abdominal and distant mets:
- Abdominal ultrasound / CT.
- Lung.
- Adrenal.

Question 11

Prognosis for renal neoplasia.

Answer 11

Dogs:
- carcinoma – 16m.
- sarcoma – 9m.
- nephroblastoma (seen in young dogs) – 6m.
Cats:
- lymphoma (good option to refer for palliative chemotherapy) – 3-6m.

Question 12

1. % uroliths that occur in the kidneys.
2. Urolith type found in the kidneys.
3. Breeds most commonly found the have renal calculi?
4. Diagnosing renal calculi.

Answer 12

1. 5%.
2. Calcium oxalate.
3. Bichon frises, siamese.
4. Radiography as radiopaque.
   May see on ultrasound if not calcium oxalate.

Question 13

1. Treatment options for renal calculi?
2. Px for renal calculi?

Answer 13

1. Medical management:
   - cannot be dissolved (calcium oxalate).
   - lithotripsy – not widely available.
   - masterly inactivity.
   Surgical:
   - obstructive.
   – could lead to hydronephrosis and secondary renal failure.
   - refractory UTI.
   – if bacteria within the urolith, remove the source of the infection.
   - refractory haematuria.
   – can cause severe anaemia if untreated.
2. High risk complications.
   Success = improved renal function.

Question 14

1. Hydronephrosis presentation.
2. Causes of hydronephrosis.
3. Treatment for hydronephrosis.

Answer 14

1. Urine accumulation.
   Dilation of the renal pelvis.
   Progressive destruction of the renal medulla.
2. Pyelonephritis.
   Obstruction.
   Congenital stenosis.
3. Tricky to decide if should take to surgery as do not know how functional the kidney is.
   Ureteronephrectomy.

Question 15

Performing a ureteronephrectomy.

Answer 15

Surgical checklist.
+/- blood available.
Explore abdomen.
Duodenal or colonic maneuver.
Dissection of kidney from peritoneum.
Double ligation of vessels (artery/ies and vein) - separately.
Trace ureter down to bladder neck and double ligate.
- without affecting bladder neck function.
- needed to stop reflux from the bladder into free ureter left behind if take kidney only – infection risk.

Question 16

Surgical diseases of the ureter.

Answer 16

ureteral calculi.
ureteral ectopia.

Question 17

Dx of ureteric calculi.

Answer 17

Radiographs - orthogonal view.

Question 18

1. Treatment options for ureteric calculi?
2. Px of ureteric calculi.

Answer 18

1. Medical:
   - diuresis – furosemide, spironolactone.
   - ureteral relaxants.
   - subcutaneous ureteral bypass (SUB) (commonly in referral).
   Surgical:
   - obstructive.
   - refractory UTI.
   - refractory haematuria.
2. High risk complications.
   Success = improved renal function.

Question 19

Surgery for ureteroliths.

Answer 19

Ureteral stenting.
Subcutaneous ureteral bypass (SUB).
Ureteronephrectomy.

Question 20

Subcutaneous ureteral bypass (SUB).

Answer 20

Urine diverted past the ureter to flow straight from the kidney to the bladder via an inserted ‘Shunting Swirlport’.
Complications with moving out of place and detachments.
- repeat surgeries common.

Question 21

Ectopic ureter presentation.

Answer 21

Signalment:
- dogs more commonly than cats.
- <1yr old – females.
– males older.
- retrievers.
- can be bilateral.
Hx:
- PUPD – high output causes need for high water input.
- incontinence.
- urinary signs – UTI etc.
- can be intermittent.
– sometimes due to secondary infection.
– could be due to re-entry of urine into the bladder from the proximal urethra.
Clinical exam:
- urine dribbling
- urine staining / scalding.
- odour.

Question 22

1. Most common type of ectopic ureter?
2. Less common type of ectopic ureter?

Answer 22

1. intramural.
   - enters bladder wall at correct position but does not open into the bladder, runs within the bladder wall and opens out at some point in the urethra instead.
2. extramural.
   - completely separated from the bladder.
   - enters the urethra wall and opens into the urethra.

Question 23

Dx techniques for ectopic ureter cases.

Answer 23

Lab work:
- bloods.
- urinalysis.
Imaging:
- ultrasound - possibly with a small dose furosemide.
- difficult.
- radiography - need contrast, difficult to interpret. .
- CT.
- cystoscopy.
- often referred.

Question 24

Surgery for ureteral ectopia.

Answer 24

Minimally invasive:
- cystoscopic laser ablation.
Open:
- neoureterocystostomy.
- ureteroneocystostomy.
- ureteronephrectomy.
– if unilateral.
–> and other kidney not diseased.

Question 25

Laser ablation for intramural ectopic ureter.

Answer 25

Minimally invasive option.
Scope size restricted by patient.
Intramural only!
Cystoscopy.
Much easier to perform on females than males as rigid scope used.
- luckily not as common in males.

Question 26

Open surgery for intramural ectopic ureter.

Answer 26

Performed on males or very small females.
Neoureterocystotomy.
- new connection between the ureter and bladder. High risk as swelling can occur in very small tubes.
Within bladder, peel embedded ureter back from within the wall, cut away excess and suture gutter where the ureter had been.
Very intricate.

Question 27

Open surgery for extramural ectopic ureter.

Answer 27

Ureteroneocystostomy.
-from outside the bladder, ligate abnormal entry of ureter into the urethra.
- stay suture in loose ureter.
- make hole in bladder wall to tunnel ureter into the bladder.
High risk of swelling and complications.
Very intricate and delicate.

Question 28

Prognosis of ureteral ectopia?

Answer 28

50-70% success rate.
- may be on the increase due to the cystoscopic laser treatment option.
Concurrent abnormalities.
Post-op medical management for incontinence.