Surgery of the bladder Flashcards
What ligaments attach the bladder? Which should you avoid during surgery?
- Ventral ligament
- Urachus in fetus
- Cut during cystotomy
- Lateral ligaments
- Contain distal ureters
- Avoid during sx
- Contain distal ureters
What is the trigone of the bladder?
Region between the urethral and ureteral openings
What is the nerve supply of the bladder?
- Hypogastric n.–sympathetic
- Pelvic n.–parasympathetic
What is the blood supply of the bladder?
Caudal vesicular, prostatic/vaginal artery
What are the various types of urachal abnormalities? Which is the most common?
- Persistent urachus
- Vesicourachal diverticulum–most common
- Urachal cyst
- Urachal sinus
What is a persistent urachus and how do you treat it?
- Patent urachal canal (connection from bladder at ventral ligament all the way down to umbilicus)
- Treament = surgical removal of urachal tube
- Don’t leave remnant tissue at bladder–>UTI
Explain a vesicourachal diverticulum (urachal abnormality). How is it treated?
- External opening is closed, bladder attachment patent (–>urine pulling)
- Treatment = partial cystectomy and diverticulectomy
What are the various causes of bladder rupture? Which is most common?
- Trauma
- Most common = HBC
- Severe cystiti
- Neoplasia
- Urethral obstruction
- Iatrogenic (also very common)
- Cytocentesis, catheterization, manual expression, dehiscence
T/F: In any trauma case you should assume there is a bladder rupture until you can rule it out
TRUE
T/F: A bladder rupture can be ruled out if one of the following exists:
Palpable bladder
Normal urination
Urine retrieval by catheter
FALSE–these do NOT rule out bladder rupture!
If a patient has a ruptured bladder, what might you see on radiographs?
- Free abdominal fluid
- Absence of bladder
- Decreased serosal detail
How can ultrasound diagnose a ruptured bladder?
- Free fluid
- Concurrent injuries
- Guide for abdominocentesis
- Helps determine source of injury
How reliable is positive contrast urethrocystogram in diagnosing a ruptured bladder? What will you see?
- Contrast urethrocystogram is the most diagnostic test for a ruptured bladder
- Contrast material will leak into abdomen
- Highlights intestinal loops
How are urea and creatinine used when diagnosing a ruptured bladder? What about potassium?
- Urea molecule equilibriates across peritoneum, but creatinine is too large
- Urea in peritoneal fluid = serum
- Creatinine in peritoneal fluid > serum creatinine
- Potassium is also higher in peritoneal fluid
T/F: You should always immediately treat a ruptured bladder surgically because it is an emergency
FALSE–must stabilize first (fluids and abdominocentesis)
What is the surgical management for a ruptured bladder?
- Exploratory laparotomy
- Isolate bladder–stay sutures
- Debride tear and necrotic tissue
- Close bladder wall
- Omentalize (place omentum over incision to promote healing) or serosal patching
- Catheterize urethra (to keep bladder empty)
- Urinary diversion
- Urethral catheter, tube cystostomy
What are the indications for a tube cystostomy?
- Any need for urinary diversion
- Stabilize patient with LUT obstruction (cannot catheterize)
- Bladder or urethral trauma
- Bladder or urethral sx
- Neurologic bladders
Describe the procedure for a tube cystostomy
- Place tube from exterior into bladder to keep compressed
- Ventral midline incision, stab incision into bladder
- Purse string around wall and tube–>pull tight to help seal area where tube enters
- Mushroom tip catheter (expands as pull tube out)
- Some form of closure to prevent infection
-
Cystopexy
- Don’t want bladder to move back/forth
What are the complications of a tube cystostomy?
- Inadvertent tube removal
- Pet chewing on tube
- Breakage of mushroom tip
- Fistula formation after removal
- Urine leakage
- Rectal prolapse
- Inflammation
- Hematuria
- Bandage sores
- Breakage of anchoring sutures
What are the indications for a cystopexy?
- Tube cystostomy
- Perineal hernia
- Urinary incontinence associated with pelvic bladder
How do you perform a cystopexy?
- Cranial traction
- Bladder wall to abdominal wall
- 2 lines of sutures
T/F: Over 90% of cystic calculi are either struvite or Ca oxalate
TRUE
What is the most common cause for a cystotomy?
Cystic calculi
Where is the most common location for cystic calculi?
Bladder
What are the clinical signs of cystic calculi?
- Similar to other LUTD syndromes
- Straining to urinate
- Blood in urine
- Palpation of large, thickened bladder
- Sometimes palpate large calculi
- UTI (76% of cases)
- More severe signs if obstructed
How do you diagnose cystic calculi?
- Plain rads (>90% confirm)
- Pneumocystography
- Double contrast cystography
- Ultrasound
T/F: You should always radiograph any abdomen that comes in with signs of UTI in order to rule out stones
TRUE
What are the 4 non-surgical options for treatment of cystic calculi?
- Voiding hydropropulsion
- Transurethral cystoscopy
- Dietary modifications
- Electrohydraulic lithotripsy
What are the advantages/disadvantages of voiding hydropropulsion?
- Must be very small stones
- Smaller than urethral diameter
- Anesthesia
What are the advantages/disadvantages of transurethral cystoscopy?
- Must be small stones
- Urethral size limitations
- Stone basket can assist
- Too many stones will cause significant irritation to urethra
What are the advantages/disadvantages of dietary modification for the management of cystic calculi?
- Non-invasive
- Must know the type of stone
- Incorrect diet can worsen stone’s effects
- Cannot be obstructed
What are the advantages/disadvantages of electrohydraulic lithotripsy?
- Very expensive
- Not readily available
- Urethra size limitations
- Complications
- Bladder perforation
- Residual fragments
- Small urethra
When is surgery indicated for cystic calculi?
- Urinary tract obstruction
- No medical options
- Other retrieval methods failed
What is the preferred approach when surgically removing cystic calculi?
Ventral approach
Increased exposure of the bladder neck and can visualize ureteral orifices
Describe the procedure for the surgical removal of cystic calculi (without closure).
- Caudal ventral midline approach
- Moistened lap sponges
- Empty bladder
- Compression
- Small needle and syringe
- Males: drape prepuce in field
- Avoid handling tissue
- Stay sutures
- Lateral aspect
- Apex
- Least traumatic way to handle bladder
- Choose avascular area
- Make stab incision at apex (suction out urine if needed)
- Extend incision with scissors
- Make incision long enough to allow thorough evaluation
- Evert walls to allow full inspection
- Remove calculi with instrument
- Pass urethra catheter (antegrade) and flush to ensure patency
How do you close the bladder following surgical removal of cystic calculi?
- Water-tight closure
- Sutures should not penetrate lumen–layer of string in closure is submucosa
- Avoid impingement of the ureters
- Serosa-to-serosa contact encourages fibrin seal
- Submucosa is the layer of strength
- Many patterns can be used successfully
What are the appropriate suture options for surgical removal of cystic calculi?
- PDS, monocyl, vicryl, dexon, prolene, nylon
- Absorbable vs. non-absorbable
- Will it be exposed to the lumen?
- Ureteral implantation–don’t want non-absorbable suture
- Is infection present?
- Don’t use braided sutures with infection or in lumen
- Is delayed healing expected?
What suture patterns are acceptable for the surgical removal of calculi?
- 1 or 2 layer inverting pattern
- Cushing followed by a Lembert
- Insures water-tight closure
- Simple continuous in the submucosa followed by a Cushing pattern
- 1 or 2 layer appositional pattern
- Simple continuous in submucosa followed by a simple continuous in the seromuscular layer
- No influence on bursting strength
- Always leak check bladder after closure!
What is polypoid cystitis?
- Non-neoplastic process affecting the mucosa
- Resembles neoplasia–mimics tumor of bladder
- TCC
- Occurs in females
- Very rare
How do you diagnose polypoid cystitis?
- U/S
- Cystocope
- Confirm with biopsy
- CANNOT do needle aspirate
- Patients often come in with signs of hematuria
How do you treat polypoid cystitis?
- Surgery
- Exploratory
- Take biopsy sample of polyps
- Resect
What is the most common bladder tumor in the dog and cat?
Transitional cell carcinoma (TCC)
What is the most common urinary tract tumor in dogs and cats?
- Dogs = TCC
- Cats = renal lymphoma
How does TCC differ in the dog and cat?
- Dog
- Most common UT tumor
- Older females
- Trigone
- Cat
- 2nd most common UT tumor
- Middle-aged males
- Apex
What are the predisposing factors for TCC?
- Obesity
- Insecticide exposure
- Herbicide
- Cyclophosphamide
T/F: Yorkshire terriers are predisposed to TCC
FALSE–Scottish terriers
T/F: The clinical signs of TCC are similar to those of LUTD
TRUE
What are the physical exam findings of TCC?
- Palpable abdominal mass
- Painful abdomen
- Weight loss
- Signs of metastatic disease
- Lymphadenopathy
- Coughing/dyspnea
- Lameness
What is the key diagnostic procedure for TCC?
Physical exam!
How can you diagnose TCC (beside the PE)?
- Urine cytology (30% exfoliate cells)
- Cystoscopy
- Positive contrast cystography
- Ultrasound
- Rads (kinda)
How helpful are radiographs and u/s in diagnosing TCC?
- Plain rads not very useful
- Sublumbar lymphadenopathy
- Bone metastasis
- U/S very sensitive
- Determines degree of bladder invasiveness
- Evaluates abdomen (metastasis/LN)
- Avoid FNA (seeding)
What are the advantages/disadvantages of using the bladder tumor antigen test (BTAT)? How is it best used?
- Advantage: will confirm TCC
- Disadvantages
- Doesn’t differentiate between hematuria, proteinuria, and infection
- High incidence of false positives
- Best used as a screening test for older animals
How do you treat TCC medically?
Chemotherapy (can be done w/ or w/o sx)
Piroxicam, cisplatin, mitoxantrone
How do you treat TCC surgically?
- Partial cystectomy with >1cm borders
- Tumor seeding
- Often involves trigone–might req. salvage procedure
- Ureterocolonic anastomosis
- Ureterouterine anastomosis
- Chemotherapy
T/F: Surgical treatment of TCC does not increase MST, but combination therapy significantly increases MST
TRUE
What is the MST of TCC following treatment?
4-6 months
