Treatment of Ectopic Ureters Flashcards
Sex predisposition to ectopic ureter?
Female
Where to ectopic ureters run?
Continue submucosally and instead open in either the urethra (most often) or vagina
Define intramural ectopic ureter
Enter at the normal trigone region but continue submucosally.
Define Extramural ectopic ureters
enter directly into the urethra or more distally.
Breed risk of ectopic ureters? (3)
Golden retriever
Labrador
Skye terrier
What position makes incontinence worse?
Recumbent
Common signs of ecoptic ureter?
UTI - haematuria, pollakuira, dysuria
Perivulval dermatitis - urine scald
Imaging for ectopic ureters?
Fluoroscopy
Ultrasound
Endoscope
“Ectopic ureter-induced urinary incontinence is worse in female than male dogs.” – using anatomical considerations, explain why. (2)
Longer length of the urethra in males compared to females
Presence of the prostate in male dogs.
How are intramural ectopic ureters treated surgically?
neoureterostomy
What is a neoureterostomy?
Distal ureter ligated/resected and a new opening of the ureter is created in the correct position, or by cystoscopic laser ablation (CLA)
When may CLA treatment not be appropriate?
Too small to accept scope
How is intramural ectopic ureter approached surgically?
- Ventrallly and incise bladder.
-The intramural ectopic ureter is identified, aided by applying digital pressure to the distal part to cause bulging towards the bladder lumen. Alternatively, a small catheter can be introduced into the ectopic ureter opening, though this often requires extension of the bladder incision to the proximal urethra.
-An incision is made through the bladder mucosa and into the ureteral lumen at the trigone, the anatomically correct location of the ureteral orifice.
-The ureteral and bladder mucosae are sutured together using 5-0 to 9-0 monofilament absorbable interrupted sutures. Magnification is required.
-A catheter is placed in the distal ureteral segment, and one or two sutures are pre-placed through the dorsal bladder wall and around the catheter within the mucosa/submucosa using 3-0 or 4-0 non-absorbable suture material. The suture(s) should not enter the ureteral lumen.
-The catheter is removed, and the sutures are then tightened to close off the ureteral lumen.
What surgical technique can be used to prevents possible recanalization of the ureter, though it has not been shown to reduce the incidence of post-operative incontinence?
Distal segment of ureter can be excised, and the dorsal ureteral mucosa sutured to the bladder mucosa.
How is the bladder closed?
The bladder is closes routinely using simple interrupted or continuous pattern one or 2 layers - as the bladder is often very small and the incision typically extends into the proximal urethra, a single layer of sutures is preferred.
How are extramural ectopic ureters treated?
Surgically by ureteroneocystostomy which involves distal ureteral ligation, transection and re-implantation into the bladder.
What else is Ureteroneocystostomy indicated for other than ectopic? (3)
distal ureteral masses or rupture,
Distal ureteral obstructions (stones) whereby significant fibrosis of the ureter is present and patency post-ureterotomy would be questionable.
For distal ureteral obstructions (stones) other than Ureteroneocystostomy, what else is required at surgery? (2)
Caudally relocate the kidney (renal descensus)
Cystopexy.
How is Ureteroneocystostomy performed?
- Ventral approach and incise bladder
-The ureter is transected where it joins the urethra (ectopic ureters) or the bladder (ureteral obstruction/mass), and the defect in the urethra/bladder is sutured closed. - An incision in the dorsal bladder wall is made in a position which ensures no tension on the ureter.
- The distal end of the ureter is resected if diseased and is spatulated.
-A small pair of haemostats is passed through the bladder incision from the mucosal surface, and the ureter is grasped and pulled back through.
How are ureteral and vesicular mucosae sutured together?
Simple interrupted pattern using 5-0 to 9-0 monofilament absorbable sutures. A three-suture technique has been described. Magnification is required.
Following surgery - how many cases of incontinence resolve?
30-80%
What medical management may be needed for persistent incontinence?
alpha-adrenergic agonists (e.g. phenylpropanolamine)
Up to 90% of patients with ectopic ureters also have what condition?
Vestibulovaginal septal remnants (VVSR)
Vestibulovaginal septal remnants (VVSR):
- What is a paramesonephric remnant?
Membrane extending less than 1cm within the vagina
Vestibulovaginal septal remnants (VVSR):
- What is a vaginal septum?
membrane extending more than 1cm within the vagina
Vestibulovaginal septal remnants (VVSR):
- What is a dual vagina?
which extend up to the cervix
Treatment for Vestibulovaginal septal remnants (VVSR)?
Open surgery (not recommended)
Laser ablation
What is the term to define a ureterocele causing dilation is within the trigone or intravesicular region?
orthotopic
What is the term to define a ureterocele causing dilation further down urethra?
ectopic (or heterotopic).
What are 3 different types of ureterocele?
A: normal ureterovesicular junction
B: orthotopic ureterocele
C: heterotopic ureterocele.
Clinical signs of ureteroceles?
not associated with clinical signs but if they are, the main one is urinary incontinence.
Ureteroceles associated with urinary incontinence are treated by? (2)
Cystoscopic laser ablation (similar to ectopic ureters)
By open surgery.
Causes of incontinence following surgery of ectopic ureter? (10)
1 Urinary tract infection
2 Recanalization of the ligated ureter
3 Disturbed urethral closure due to residual intramural ectopic ureter
4 Congenital urethral sphincter mechanism incompetence
5 Poorly developed trigone
6 Hypoplastic bladder
7 Vestibulo-vaginal stenosis
8 Neurogenic abnormalities
9 Hormonal imbalance
10 Inadequate surgery
