Surgery of the ureters Flashcards
What breed, sex, and age is more likely to develop an ectopic ureter?
- Breeds
- Siberian husky
- Labrador/golden retriever
- West highland terrier
- Age–young
- Sex–females (canine)
- (Rare in cats)
What are the clinical signs of an ectopic ureter?
- Incontinence
- Fails to house train
- UTI
- Urine scalding
How do you diagnose an ectopic ureter?
- Excretory urography (76% accurate)
- Best if combine with pneumocystography
- Fluoroscopy
- CT
- U/S
- Cystoscopy
What are the classifications of ectopic ureter? What’s the difference?
- Extramural–enters into abnormal location (neck, urethra, or vagina)
- Intramural
- Most common (dogs)
- Enters normally but exits abnormally
What are the treatments for ectopic ureters?
- Neoureterocystostomy
- End to side–extramural
- Side to side–intramural
- Laser transection
What is an end-to-side neoureterocystostomy?
- Re-implantation of ureter for extramural EU
- Not as common
- Ligate ureter, transect where it is entering urethra
- Grasp ureter through cystotomy
- Transplant to more normal location
- Spatulate and suture
What is a side-to-side neoureterocystostomy?
- Intravesicular diversion for intramural EU
- cystotomy incision–>find where it’s exiting, occlude
- Slit incision in an area that’s more normal (i.e. trigone)
- Suture mucosa of ureter to mucosa of bladder to create permanent opening
What is the prognosis for an ectopic ureter?
- Other functional abnormalities may still exist
- Difficult surgery but high improvement rate (60%)
- Those that don’t improve can be put on phenylpropanolamine (PPA) to help (90% improvement)
Differentiate between the two types of ureteroceles
- Ectopic–have an ectopic ureter as well (neck/urethra)
- Intravesicular–normal entrance/exit but have ureterocele over the ureteral orifice
What are the clinical signs associated with a ureterocele?
- UTI
- Incontinence
- Azotemia if obstruction
How do you diagnose a ureterocele?
- IV urography
- Cobra head sign
- U/S
What are the treatments for ureteroceles?
- Intravesicular = ureterocelectomy
- Ectopic = neoureterocystostomy with ureterocelectomy
What are the causes of ureteral trauma?
-
#1 cause = iatrogenic
- Spay–snag ureter with spay hook
- Clamp injury–60 min
- Blunt trauma
- Obstruction
How do you diagnose ureteral trauma?
- Uroretroperitoneum
- Uroabdomen
- Rads
- IV urography (localizes lesion)
What treatments are available for ureteral trauma?
- Nephroureterectomy
- Ureteroureterostomy
- Neoureterocystostomy
- Urinary diversion
What are the advantages/disadvantages of a nephroureterectomy following ureteral trauma?
- Disadvantage–financial constraints
- Advantage–minimizes complications
What are the advantages/disadvantages of a ureteroureterostomy following ureteral trauma?
- (Ureteral anastomosis)
- Procedure of choice for proximal ureter (can’t re-implant)
- Disadvantages
- Requires magnification
- Extremely difficult
- High incidence of complications
- Strictures
- Dehiscence
What two methods are available for urinary diversion after ureteral surgery?
- Ureteral stent
- Double pigtailed catheter
- Nephrostomy tube
- Closed system
- Urine deposited externally
What procedures can be used if you have loss of length of the distal or proximal ureter?
- Transureteroureterostomy
- Renal descensus
- Nephrocystopexy
- Psoas hitch
- Bladder wall flap
What is a transureteroureterostomy and when is it used?
- Used when proximal ureter length is insufficient to reach the bladder but long enough to cross midline
- Bring ureter segment across midline and anastomosis to other ureter
What is done during a renal descensus? When is it indicated?
Mobilize the kidney and suture caudally to lumbar musculature
Indicated for inadequate ureter length
What is a nephrocystopexy?
Suturing the kidney to the cranial edge of the bladder
What is a psoas hitch?
Fixing the bladder in a more cranial position (to apaxial muscles)
When/how do you perform a bladder wall flap surgery?
- Performed when significant loss of distal ureter occurs
- Elevate bladder flap
- Implant ureter to end of flap
- Suture flap in a tube and close defect
What are the clinical signs of ureterolithiasis?
- Often asymptomatic
- UTI
- Hematuria
- Anorexia
- Lethargy
- Pain
How do you diagnose ureterolithiasis?
Rads–most are radiopaque (Ca oxalate)
U/S–also determines dilation of ureter/pelvis
What are the indications for surgery or lithotripsy due to ureterolithiasis?
- Complete obstruction
- Azotemia
- Pyelonephritis
- After 2 weeks of unsuccessful medical treatment
What are the options for medical management (non-surgical) of ureterolithiasis?
-
Medical dissolution is not an option
- Most are Ca oxalate
- Not bathed in urine
- If asymptomatic: try to diurese into bladder
- Smooth muscle relaxers
- IV fluids and diuretics
- Helps increase flow
- Serial monitoring for 2 weeks (rads, u/s)
What are the pre-surgical considerations for ureterolithiasis?
- Cannot predict length of obstruction
- 1wk = GFR <65%
- Can’t predict how well kidney will recover
- Most cats have pre-existing interstitial nephritis unrelated to obstruction
- If azotemic with unilateral obstruction–>has bilateral renal disease
- High complication rate
What are the surgical treatment options for ureterolithiasis?
- Cystotomy and retrograde flushing and removal via pyelithotomy
- Ureterotomy
What are the advantages/disadvantages of ureteral stenting?
- Advantages
- Decreased morbidity
- Shorter hospitalization
- Fewer complications
- Disadvantages
- Specialized equipment
- Steep learning curve
- Expensive
What is the non-surgical method of ureteral stenting?
Endoscopic placement
- Female/male dogs >8g
- Gen. anesthesia
- Fluoroscopy, guide wire, urethral catheter
- Contrast media to visualize pelvis–>ureteral stent aided by pusher catheter
What is the surgical method of ureteral stenting?
- Dogs
- Distal cystotomy approach
- No pusher catheter required
- Cats
- Usually placed antegrade
What is the SUB?
- Locking loop kidney catheter with a marker band at one end and a fenestrated and cuffed bladder at the other end
- Both ends connect to a shunting port with 2 catheter outlets
How does the SUB unit bypass the ureter?
- Flow is from the kidney to the shunting port and into the bladder
- Port has silicone diaphragm
