Surgery of the ureters

Question 1

What breed, sex, and age is more likely to develop an ectopic ureter?

Answer 1

• Breeds
  
  • Siberian husky
  • Labrador/golden retriever
  • West highland terrier
• Age–young
• Sex–females (canine)
• (Rare in cats)

Question 2

What are the clinical signs of an ectopic ureter?

Answer 2

• Incontinence
• Fails to house train
• UTI
• Urine scalding

Question 3

How do you diagnose an ectopic ureter?

Answer 3

• Excretory urography (76% accurate)
  
  • Best if combine with pneumocystography
  • Fluoroscopy
• CT
• U/S
• Cystoscopy

Question 4

What are the classifications of ectopic ureter? What’s the difference?

Answer 4

• Extramural–enters into abnormal location (neck, urethra, or vagina)
• Intramural
  
  • Most common (dogs)
  • Enters normally but exits abnormally

Question 5

What are the treatments for ectopic ureters?

Answer 5

• Neoureterocystostomy
  
  • End to side–extramural
  • Side to side–intramural
• Laser transection

Question 6

What is an end-to-side neoureterocystostomy?

Answer 6

• 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

Question 7

What is a side-to-side neoureterocystostomy?

Answer 7

• 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

Question 8

What is the prognosis for an ectopic ureter?

Answer 8

• 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)

Question 9

Differentiate between the two types of ureteroceles

Answer 9

• Ectopic–have an ectopic ureter as well (neck/urethra)
• Intravesicular–normal entrance/exit but have ureterocele over the ureteral orifice

Question 10

What are the clinical signs associated with a ureterocele?

Answer 10

• UTI
• Incontinence
• Azotemia if obstruction

Question 11

How do you diagnose a ureterocele?

Answer 11

• IV urography
• Cobra head sign
• U/S

Question 12

What are the treatments for ureteroceles?

Answer 12

• Intravesicular = ureterocelectomy
• Ectopic = neoureterocystostomy with ureterocelectomy

Question 13

What are the causes of ureteral trauma?

Answer 13

• #1 cause = iatrogenic
  
  • ​Spay–snag ureter with spay hook
  • Clamp injury–60 min
• Blunt trauma
• Obstruction

Question 14

How do you diagnose ureteral trauma?

Answer 14

• Uroretroperitoneum
• Uroabdomen
• Rads
• IV urography (localizes lesion)

Question 15

What treatments are available for ureteral trauma?

Answer 15

• Nephroureterectomy
• Ureteroureterostomy
• Neoureterocystostomy
• Urinary diversion

Question 16

What are the advantages/disadvantages of a nephroureterectomy following ureteral trauma?

Answer 16

• Disadvantage–financial constraints
• Advantage–minimizes complications

Question 17

What are the advantages/disadvantages of a ureteroureterostomy following ureteral trauma?

Answer 17

• (Ureteral anastomosis)
• Procedure of choice for proximal ureter (can’t re-implant)
• Disadvantages
  
  • Requires magnification
  • Extremely difficult
  • High incidence of complications
    
    • Strictures
    • Dehiscence

Question 18

What two methods are available for urinary diversion after ureteral surgery?

Answer 18

• Ureteral stent
  
  • Double pigtailed catheter
• Nephrostomy tube
  
  • Closed system
  • Urine deposited externally

Question 19

What procedures can be used if you have loss of length of the distal or proximal ureter?

Answer 19

• Transureteroureterostomy
• Renal descensus
• Nephrocystopexy
• Psoas hitch
• Bladder wall flap

Question 20

What is a transureteroureterostomy and when is it used?

Answer 20

• 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

Question 21

What is done during a renal descensus? When is it indicated?

Answer 21

Mobilize the kidney and suture caudally to lumbar musculature

Indicated for inadequate ureter length

Question 22

What is a nephrocystopexy?

Answer 22

Suturing the kidney to the cranial edge of the bladder

Question 23

What is a psoas hitch?

Answer 23

Fixing the bladder in a more cranial position (to apaxial muscles)

Question 24

When/how do you perform a bladder wall flap surgery?

Answer 24

• 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

Question 25

What are the clinical signs of ureterolithiasis?

Answer 25

• Often asymptomatic
• UTI
• Hematuria
• Anorexia
• Lethargy
• Pain

Question 26

How do you diagnose ureterolithiasis?

Answer 26

Rads–most are radiopaque (Ca oxalate)

U/S–also determines dilation of ureter/pelvis

Question 27

What are the indications for surgery or lithotripsy due to ureterolithiasis?

Answer 27

• Complete obstruction
• Azotemia
• Pyelonephritis
• After 2 weeks of unsuccessful medical treatment

Question 28

What are the options for medical management (non-surgical) of ureterolithiasis?

Answer 28

• 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)

Question 29

What are the pre-surgical considerations for ureterolithiasis?

Answer 29

• 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

Question 30

What are the surgical treatment options for ureterolithiasis?

Answer 30

• Cystotomy and retrograde flushing and removal via pyelithotomy
• Ureterotomy

Question 31

What are the advantages/disadvantages of ureteral stenting?

Answer 31

• Advantages
  
  • Decreased morbidity
  • Shorter hospitalization
  • Fewer complications
• Disadvantages
  
  • Specialized equipment
  • Steep learning curve
  • Expensive

Question 32

What is the non-surgical method of ureteral stenting?

Answer 32

Endoscopic placement

• Female/male dogs >8g
• Gen. anesthesia
• Fluoroscopy, guide wire, urethral catheter
• Contrast media to visualize pelvis–>ureteral stent aided by pusher catheter

Question 33

What is the surgical method of ureteral stenting?

Answer 33

• Dogs
  
  • Distal cystotomy approach
  • No pusher catheter required
• Cats
  
  • Usually placed antegrade

Question 34

What is the SUB?

Answer 34

• 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

Question 35

How does the SUB unit bypass the ureter?

Answer 35

• Flow is from the kidney to the shunting port and into the bladder
• Port has silicone diaphragm