Urinary - Bladder

Question 1

Which ligament (patent urachus) are we likely to cut during cystotomy that is firmly attached to bladder wall at the level of the umbilicus?

Answer 1

Ventral ligament *avoid lateral ligaments as they contain ureters*

Question 2

Name the region/separation between the ureteral orifices and the urethra….

Answer 2

Trigone

Question 3

What is the most common congenital abnormality of the bladder?

Answer 3

Urachal abnormalities

Question 4

What is the holding layer of the bladder? What does this mean?

Answer 4

Submucosa! So whenever we suture the bladder, we must make sure we engage the submucosa

Question 5

How long does it take for the bladder to heal just about to full strength?

Answer 5

~14 days! (Much better than most other abdominal organs)

Question 6

What is the most common TYPE of urachal abnormality?

Answer 6

Vesicouracheal diverticulum

Question 7

What is a persistent urachus?

Answer 7

A (tube) connection from the bladder all the way to the umbilicus; This causes dribbling of urine at the level of the umbilicus —> will cause urine scalding/omphalitis

Question 8

How do we surgically treat a persistent urachus?

Answer 8

Remove the patent urachus (which should be the ventral ligament of the bladder): - ligate at the level of the bladder, dissect out, and ligate at the level of the umbilicus and remove that patent tissue, thru a ventral midline incision

Question 9

What is a vesicouracheal diverticulum?

Answer 9

Diverticulum* at the level of the bladder wall, but it doesn’t continue all the way to the umbilicus - it becomes the ventral ligament of the bladder *Allows accumulation of urine pooling in that area - predisposing to UTIs, urolithiasis, urge incontinence

Question 10

How do we surgically treat vesicouracheal diverticulum?

Answer 10

Partial cystectomy (cut out part of the bladder wall associated with the diverticulum) And Diverticulectomy (removing the remnant attached to the bladder wall)

Question 11

What are the clinical signs of a ruptured bladder?

Answer 11

Sometimes none (asymptomatic) Many cases will show hematuria, anuria, abdominal pain In trauma cases, just assume you have a ruptured bladder until you can rule it out

Question 12

What is the progression of signs associated with a bladder rupture?

Answer 12

Over a period of time, metabolic abnormalities start (12-24 hours)… Dehydration, acidosis, azotemia, hyperkalemia *death in 47-90 hours*

Question 13

How do we rule out ruptured bladder?

Answer 13

Plain radiographs: -can see free abdominal fluid (distension) -absence of bladder -decreased serosol detail of the intestinal silhouette US: - fluid accumulation - US-guided FNA - visualize and evaluate bladder wall

Question 14

What is the best and most accurate diagnostic modality for bladder rupture?

Answer 14

Positive Contrast Urethrocystogram: Taking urethral catheter, placing it in the bladder, and inject radio-opaque material into the bladder —> take rads and see if contrast media is leaking out of bladder (pathopneumonic)

Question 15

How do we evaluate the fluid from abdominocentesis when diagnosing a ruptured bladder?

Answer 15

Urea: (small molecule; will diffuse across peritoneum) compare to serum BUN —> should be about equal [urea in peritoneal fluid and serum urea] Crea: (larger molecule; does not readily diffuse across peritoneum) Crea in peritoneal fluid should be > serum Crea

Question 16

How is it that we can use the presence of hyperkalemia as a factor in diagnosing bladder ruptures?

Answer 16

Development of acidosis —> displacement of H+ with K+ —> K+ becomes extracellular —> hyperkalemia

Question 17

What is serosal patching?

Answer 17

Take a piece of serosa (of a mobile intestine - so the antimesenteric border) and you suture it to the level of incision of your ruptured bladder closure *helps to seal, even if incision breaks down, and will re-mucosalize*

Question 18

Although the dorsal approach to cystotomy was once advocated, the ventral approach is preferred because …?

Answer 18

Better visualization of the trigone (where stones hide) And you can see the ureteral orifice

Question 19

What type of suture has been known to predispose a patient to urolith formation?

Answer 19

Monofilament nonabsorbable *it’s ok to use this, but if you do, don’t expose it to the lumen! —> serosal—>muscular—>submucosal layer, but no bladder mucosa if we use this

Question 20

What suture do we choose to close the bladder?

Answer 20

Absorbable or non-absorbable, it depends the patient and presentation: PDS, monocryl, vicryl, dexon, prolene, nylon, etc

Question 21

What layer of the bladder does polypoid cystitis affect? What can it be confused with?

Answer 21

Mucosal layer; can be confused with TCC due to resemblance —> biopsy confirms

Question 22

Most common tumor of the urinary tract in the canine?

Answer 22

TCC

Question 23

Obesity, Insecticide exposure, Herbicide, And cyclophosphamide Are predisposing factors for…?

Answer 23

TCC

Question 24

What peculiar clinical signs may a patient with TCC present with?

Answer 24

Those similar to LUTD; Metastatic disease
—>lameness/coughing

Question 25

If we suspect TCC, what type of biopsy should we attempt for confirmation?

Answer 25

Transurethral biopsy
place urethral catheter (palpate the neoplasia rectally),
push it up against tumor, & inject a little saline; aspirate cells

*AVOID FNA*{could reseed!}

Question 26

How do we treat TCC?

Answer 26

Partial cystectomy with >1cm borders

Often involves trigone so may require salvage procedure:
-ureterocolonic anastomosis -ureterouterine anastomosis

Chemotherapy: - Piroxicam, Cisplatin, Mitoxantrone
*still even with Tx, MST: 4-6 mo :(

could do cystostomy tubes to buy time for the chemotherapeutics to work

Question 27

When would you use a non-absorbable suture in closing the bladder?

Answer 27

In immune-compromised patients;
but cannot pass thru the lumen of the bladder!!
—> predisposes to urolith formation

Question 28

Cushing goes thru the ____, ____, & ____ layer… and the Lambert just goes in the _____ layer.

Answer 28

Serosa, muscular, & submucosal layer… Seromuscular