Surgery Of The Ureters

Question 1

What are surgical diseases of the ureters?

Answer 1

Ureter ectopica
Ureterocele
Trauma
Obstrucion

Question 2

What are common associated abnormalities associated with ectopic ureters?

Answer 2

Hydroureter
Small/absent kidney
Pelvic bladder

Question 3

Breeds predisposed to ectopic ureters?

Answer 3

Siberian husked
Labrador/golden retrievers
West highland terreris

Females> males
Young

Rare in cats

Question 4

Clinical signs associated with ectopic ureters?

Answer 4

Incontinence
Fails to house train
UTI
Urine scalding

Question 5

What are the best ways to diagnose ectopic ureters?

Answer 5

Excretory urography

• > pneumocytography
• > fluoroscopy

CT
Ultrasound
Cytoscopy

Question 6

What are the two classifications of ectopic ureters?

Answer 6

Extramural —> less common, enters into neck urethra, or vagina

Intramural —> enters normally but exits abnormally (most common in dogs)

Question 7

Cystoscopic laser treatment can be used on what type of ectopic ureter?

Answer 7

Intramural

-> abalation of the ureter from the desired opening to the actual

Question 8

What is the prognosis for ectopic ureters?

Answer 8

Incontinence improves in 60%

90% improvement when medications added (PPA- phenylpropanolamine )

Question 9

What surgical technique can be used for either extramural or intramural ectopic ureters?

Answer 9

Neoureterocystostomy

-> create new opening for ureter in bladder and suture to bladder wall

Question 10

What is a ureterocele?

Answer 10

Dilation of distal ureter

Persistent membrane in embryonic development

Question 11

Clinical signs associated with ureterocele ?

Answer 11

UTI, incontinence

Azotemia if obstructed

Question 12

How does a ureterocele appear with IV ureogrpay?

Answer 12

Cobra head sign

See ureter entering bladder with enlarged ball in the bladder

Question 13

Treatment for an intervesicular ureterocele ?

Answer 13

ureterocelectomy

Question 14

Treatment for an ectopic ureterocele?

Answer 14

Neoureterocystostomy with ureterocelectomy

Question 15

What is the number one cause of ureteral trauma?

Answer 15

Iatrogenic - during spay

Other causes
-blunt trauma or obstruction

Question 16

How can ureteral trauma be diagnosed?

Answer 16

Presence of uroretroperitoneum or uroabdomen
Radiographs
IV urograph - localized lesion

Question 17

What are the possible treatments for ureteral trauma?

Answer 17

Nephroureterectomy (if financial constraints, and minimizes complications)

Ureteroureterostomy (ureteral anastomoses)
Neoureterocystostomy (ureteral reimplanation)
Urinary diversion

Question 18

What is the procedure of choice for a case of ureteral trauma where there is poor function in the contralateral kidney and the injury is of the proximal part of ureter?

Answer 18

Cannot reimplant this ureter into bladder

Ureteroureterostomy —> anastomoses

Catheterize through cystotomy
—> avoids back wall getting caught in suture
—> angle cut ends

Catheter is left proximal to the anastomoses and extends down through the bladder and urethra
—> catheter is removed in 5-7days

Question 19

When is a nephrostomy tube used? How is it placed?

Answer 19

To divert urine after ueter surgery, hydronephrosis, or obstruction

Fenestrated tube passed through kidney to renal pelvis
Place tube outside patient

Anchor kidney
Closed system

Question 20

What technique is used when proximal urethral length is insufficient to reach the bladder but is long enough to cross midline?

Answer 20

Trans ureteroureterostomy

—> distal ureter is brought across midline and anastomosed to the other ureter

Question 21

What surgical techniques can you use if you have loss of ureter length?

Answer 21

Renal decensus —> mobilize kidney and sutures caudally to lumbar musculature

Nephrocystopexy —> suture the kidney to the cranial edge of bladder

Psoas hitch —> fix bladder in a more cranial position

Question 22

When is a bladder wall flap used?

Answer 22

Significant loss of distal ureter

Question 23

How is a bladder wall flap made?

Answer 23

Rectangular bladder wall section cut on 3/4 sides

—> flap elevated ureter is implanted into end of flap wall and opening sutured into flap wall

Suture flap into a tube and close defect

Question 24

What is the most common indications for ureteral surgery?

Answer 24

Ureterolithiasis

Question 25

Clinical signs of ureterolithaiasis ?

Answer 25

Asymptomatic (unilateral)

UTI
Hematuria
Anorexia, lethargy
Pain

Question 26

T/F: IV fluids are indicated in cases with Ca oxalate ureterolithiasis?

Answer 26

True

-help increase flow

Question 27

What are indications for lithotripsy of the ureters?

Answer 27

Complete obstruction
Azotemia
Pyelonephritis
After 2 weeks of unsuccessful medical treatment

Question 28

If you have a unilateral ureteral obstrucion but your animal has an azotemia, what does this indicate?

Answer 28

Bilateral renal disease

Question 29

Most cats have preexisting __________ which is unrelated to obstruction

Answer 29

Interstitial nephritis

Question 30

What are possible treatments for ureterolithiasis?

Answer 30

Cystotomy and retrograde flushing follow by removal via pyelithotomy (try this first)

Ureterotomy 
—> longitudinal incision 
—> lavage ureter 
—> transverse or longitudinal closure 
—> nephrostomy drainage

Question 31

What are the advantage to permanent ureteral stenting??

Answer 31

Decreased morbidity
Shorter hospitalization
Less complications

Question 32

Indications for permanent ureteral stenting?

Answer 32

Stone
Tumor
Stricture
Blood clot