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Small animal surgery I > Surgery of the bladder > Flashcards

Surgery of the bladder Flashcards

1
Q

What ligaments attach the bladder? Which should you avoid during surgery?

A
  • Ventral ligament
    • Urachus in fetus
    • Cut during cystotomy
  • Lateral ligaments
    • Contain distal ureters
      • Avoid during sx
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2
Q

What is the trigone of the bladder?

A

Region between the urethral and ureteral openings

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3
Q

What is the nerve supply of the bladder?

A
  • Hypogastric n.–sympathetic
  • Pelvic n.–parasympathetic
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4
Q

What is the blood supply of the bladder?

A

Caudal vesicular, prostatic/vaginal artery

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5
Q

What are the various types of urachal abnormalities? Which is the most common?

A
  • Persistent urachus
  • Vesicourachal diverticulum–most common
  • Urachal cyst
  • Urachal sinus
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6
Q

What is a persistent urachus and how do you treat it?

A
  • 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
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7
Q

Explain a vesicourachal diverticulum (urachal abnormality). How is it treated?

A
  • External opening is closed, bladder attachment patent (–>urine pulling)
  • Treatment = partial cystectomy and diverticulectomy
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8
Q

What are the various causes of bladder rupture? Which is most common?

A
  • Trauma
    • Most common = HBC
  • Severe cystiti
  • Neoplasia
  • Urethral obstruction
  • Iatrogenic (also very common)
    • Cytocentesis, catheterization, manual expression, dehiscence
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9
Q

T/F: In any trauma case you should assume there is a bladder rupture until you can rule it out

A

TRUE

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10
Q

T/F: A bladder rupture can be ruled out if one of the following exists:

Palpable bladder

Normal urination

Urine retrieval by catheter

A

FALSE–these do NOT rule out bladder rupture!

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11
Q

If a patient has a ruptured bladder, what might you see on radiographs?

A
  • Free abdominal fluid
  • Absence of bladder
  • Decreased serosal detail
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12
Q

How can ultrasound diagnose a ruptured bladder?

A
  • Free fluid
  • Concurrent injuries
  • Guide for abdominocentesis
  • Helps determine source of injury
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13
Q

How reliable is positive contrast urethrocystogram in diagnosing a ruptured bladder? What will you see?

A
  • Contrast urethrocystogram is the most diagnostic test for a ruptured bladder
  • Contrast material will leak into abdomen
    • Highlights intestinal loops
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14
Q

How are urea and creatinine used when diagnosing a ruptured bladder? What about potassium?

A
  • 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
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15
Q

T/F: You should always immediately treat a ruptured bladder surgically because it is an emergency

A

FALSE–must stabilize first (fluids and abdominocentesis)

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16
Q

What is the surgical management for a ruptured bladder?

A
  • 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
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17
Q

What are the indications for a tube cystostomy?

A
  • Any need for urinary diversion
    • Stabilize patient with LUT obstruction (cannot catheterize)
    • Bladder or urethral trauma
    • Bladder or urethral sx
    • Neurologic bladders
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18
Q

Describe the procedure for a tube cystostomy

A
  • 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
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19
Q

What are the complications of a tube cystostomy?

A
  • 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
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20
Q

What are the indications for a cystopexy?

A
  • Tube cystostomy
  • Perineal hernia
  • Urinary incontinence associated with pelvic bladder
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21
Q

How do you perform a cystopexy?

A
  • Cranial traction
  • Bladder wall to abdominal wall
  • 2 lines of sutures
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22
Q

T/F: Over 90% of cystic calculi are either struvite or Ca oxalate

A

TRUE

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23
Q

What is the most common cause for a cystotomy?

A

Cystic calculi

24
Q

Where is the most common location for cystic calculi?

A

Bladder

25
Q

What are the clinical signs of cystic calculi?

A
  • 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
26
Q

How do you diagnose cystic calculi?

A
  • Plain rads (>90% confirm)
  • Pneumocystography
  • Double contrast cystography
  • Ultrasound
27
Q

T/F: You should always radiograph any abdomen that comes in with signs of UTI in order to rule out stones

A

TRUE

28
Q

What are the 4 non-surgical options for treatment of cystic calculi?

A
  • Voiding hydropropulsion
  • Transurethral cystoscopy
  • Dietary modifications
  • Electrohydraulic lithotripsy
29
Q

What are the advantages/disadvantages of voiding hydropropulsion?

A
  • Must be very small stones
    • Smaller than urethral diameter
  • Anesthesia
30
Q

What are the advantages/disadvantages of transurethral cystoscopy?

A
  • Must be small stones
  • Urethral size limitations
  • Stone basket can assist
  • Too many stones will cause significant irritation to urethra
31
Q

What are the advantages/disadvantages of dietary modification for the management of cystic calculi?

A
  • Non-invasive
  • Must know the type of stone
    • Incorrect diet can worsen stone’s effects
  • Cannot be obstructed
32
Q

What are the advantages/disadvantages of electrohydraulic lithotripsy?

A
  • Very expensive
  • Not readily available
  • Urethra size limitations
  • Complications
    • Bladder perforation
    • Residual fragments
    • Small urethra
33
Q

When is surgery indicated for cystic calculi?

A
  • Urinary tract obstruction
  • No medical options
  • Other retrieval methods failed
34
Q

What is the preferred approach when surgically removing cystic calculi?

A

Ventral approach

Increased exposure of the bladder neck and can visualize ureteral orifices

35
Q

Describe the procedure for the surgical removal of cystic calculi (without closure).

A
  • 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
36
Q

How do you close the bladder following surgical removal of cystic calculi?

A
  • 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
37
Q

What are the appropriate suture options for surgical removal of cystic calculi?

A
  • 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?
38
Q

What suture patterns are acceptable for the surgical removal of calculi?

A
  • 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!
39
Q

What is polypoid cystitis?

A
  • Non-neoplastic process affecting the mucosa
  • Resembles neoplasia–mimics tumor of bladder
    • TCC
  • Occurs in females
  • Very rare
40
Q

How do you diagnose polypoid cystitis?

A
  • U/S
  • Cystocope
  • Confirm with biopsy
  • CANNOT do needle aspirate​
  • Patients often come in with signs of hematuria
41
Q

How do you treat polypoid cystitis?

A
  • Surgery
    • Exploratory
    • Take biopsy sample of polyps
    • Resect
42
Q

What is the most common bladder tumor in the dog and cat?

A

Transitional cell carcinoma (TCC)

43
Q

What is the most common urinary tract tumor in dogs and cats?

A
  • Dogs = TCC
  • Cats = renal lymphoma
44
Q

How does TCC differ in the dog and cat?

A
  • Dog
    • Most common UT tumor
    • Older females
    • Trigone
  • Cat
    • 2nd most common UT tumor
    • Middle-aged males
    • Apex
45
Q

What are the predisposing factors for TCC?

A
  • Obesity
  • Insecticide exposure
  • Herbicide
  • Cyclophosphamide
46
Q

T/F: Yorkshire terriers are predisposed to TCC

A

FALSE–Scottish terriers

47
Q

T/F: The clinical signs of TCC are similar to those of LUTD

A

TRUE

48
Q

What are the physical exam findings of TCC?

A
  • Palpable abdominal mass
  • Painful abdomen
  • Weight loss
  • Signs of metastatic disease
    • Lymphadenopathy
    • Coughing/dyspnea
    • Lameness
49
Q

What is the key diagnostic procedure for TCC?

A

Physical exam!

50
Q

How can you diagnose TCC (beside the PE)?

A
  • Urine cytology (30% exfoliate cells)
  • Cystoscopy
  • Positive contrast cystography
  • Ultrasound
  • Rads (kinda)
51
Q

How helpful are radiographs and u/s in diagnosing TCC?

A
  • 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)
52
Q

What are the advantages/disadvantages of using the bladder tumor antigen test (BTAT)? How is it best used?

A
  • 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
53
Q

How do you treat TCC medically?

A

Chemotherapy (can be done w/ or w/o sx)

Piroxicam, cisplatin, mitoxantrone

54
Q

How do you treat TCC surgically?

A
  • Partial cystectomy with >1cm borders
    • Tumor seeding
  • Often involves trigone–might req. salvage procedure
    • Ureterocolonic anastomosis
    • Ureterouterine anastomosis
  • Chemotherapy
55
Q

T/F: Surgical treatment of TCC does not increase MST, but combination therapy significantly increases MST

A

TRUE

56
Q

What is the MST of TCC following treatment?

A

4-6 months

Small animal surgery I (25 decks)

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