Urinary organ surgery Flashcards
Cystotomy versus Cystectomy
Cystotomy – surgical opening of the urinary bladder
Cystectomy – surgical removal of a part of the urinary bladder
Urethrotomy versus Urethrostomy
Urethrotomy – surgical opening of the urethra
Urethrostomy – creation of a permanent urethral fistula
surgical removal of urinary bladder stones is termed…
Cystolithectomy
The position of the urinary bladder depends on
its degree of fulfilment and the species.
In carnivores, the urinary bladder, irrespective of the degree of fulfilment, is always located on the ventral abdominal wall, extending, in case of an excessively
full bladder, till the umbilical region.
Urinary bladder can be considered as a distensible balloon of smooth muscle, covered by serosa and lined by epithelium.
The urinary bladder consists of:
neck
body
apex
Where do the ureters meet the bladder?
on the ventral surface of the bladder neck
The smooth mucosal area located between two ureter orifices and internal urethra orifice is termed vesical trigone.
Do not touch this area in surgery!
Urinary bladder ligaments:
median and lateral ligaments
Median vesical ligament (lig. vesicae medianum) is a thin ligament that extends to the umbilicus and holds urinary bladder attached to the pelvic floor (A).
The bladder is laterally attached to the sides of the pelvis with a pair of lateral vesical ligaments (lig. vesicae laterale) (B).
Ureters enter the neck of the bladder and, in males, what enters the opening of the urethra?
sperm ducts, located in the urogenital sulcus on top of the bladder, enter the opening of the urethra as well.
Urethra starts at
the neck of the bladder.
Blood supply of the bladder: (3)
cranial, middle and caudal vesical arteries.
The vesical wall comprises (from outside inwards) (3)
serous membrane,
muscular layer, and
mucous membrane.
vesicular trigone
Describe the Innervation of the urinary bladder. (3)
parasympathetic pelvic nerve
somatic pudendal nerve
sympathetic hypogastric nerve
Blood supply of the urinary bladder in males versus females.
Males: umbilical artery, caudal vesical artery
Females: umbilical artery, vaginal artery, caudal vesical artery
Main principles of urinary bladder
surgery. (2)
It only takes mucous membrane ? days to heal?
It only takes the entire vesical wall ? days to regain its normal strength?
Incision wounds in a healthy bladder heal very quickly.
It only takes mucous membrane five days to heal.
It only takes the entire vesical wall 14–21 days to regain its normal strength.
Main principles of urinary bladder
surgery.
Appropriate suture material for bladder?
Size?
Needle type?
Various resorbable synthetic monofilaments are suitable for sutures of the vesical wall.
The thickness of suture material is 3–0 to 5–0.
Round atraumatic needle is used.
Non-resorbable suture material or surgical clamps are not suitable for closing vesical wall as they may cause the formation of vesical concrements (in 9.4% of dogs and 4% of cats).
Main principles of urinary bladder
surgery.
Rules for closing the urinary bladder. (3)
The suture must not penetrate mucous membrane!
One–layer sutures used for closing vesical wall.
Simple continuous suture.
You do not need to water test the bladder because you’ll always be able to make it leak with water pressure after fresh sutures.
Main principles of urinary bladder
surgery.
Antibacterial therapy points to remember. (3)
AB are not commonly needed. But you should flush the abdominal cavity because urine is irritating.
E. coli, Proteus spp., Staphylococcus intermedius most commonly if an infection occurs.
If the surgery lasts longer than 90 min, the following drugs are used:
Amoxicillin with clavulanic acid
Third generation cephalosporins
Enrofloxacin
In what situations are AB always indicated in the context of bladder surgery?
always when a urinary catheter has been in place or will remain in place after surgery.
Cystotomy approach.
caudal median laparotomy;
in male dogs, the incision is continued laterally from the prepuce.
Cystotomy: after entry into abdomen but before incising the bladder. (4)
After entering the abdo cavity, first the surgeon checks whether there is any free urine in the abdominal cavity.
The urinary bladder is carefully palpated, if it is full – it is either punctured and emptied using a syringe, or expressed by hand.
Before opening, the bladder is taken out of the wound and isolated using large tampons and sheets to avoid abdominal contamination.
On both sides of the presumable incision at the (dorsal or ventral) apex of the bladder, fixating sutures are placed.
Cystotomy: incision into the bladder.
The incision into the ventral or dorsal wall is made using a scalpel nr 11 (or other).
The incision is close to the apex and away from ureters and urethra, in between the blood vessels. And be careful not to touch the trigone!
The incision is lengthened using scissors.
All the layers are penetrated.
Ventral cystotomy allows for more efficient examination of the vesical trigone region.
Mucous membrane needs to be handled very carefully!
Bladder stones need to be carefully removed using
a surgical spoon.
(sometimes forceps)
(in image: the bladder wall is very thick due to chronic irritation from large stone)
(Always do post-op xrays to ensure complete removal!)
Cystotomy: after closing the bladder wall, the bladder is
reduced back into abdominal cavity.
The Laparotomy wound is closed with a typical three–layer suture (muscle, subcut, skin).
Always do post-op xrays!
The Urethral wall comprises (from
outside inwards) (3)
external membrane,
muscular layer,
and mucous membrane.
Review male urethra anatomy.
Prescrotal urethrotomy in male dogs is used to
remove stones from distal urethra.
requires general anesthesia
Insert a sterile catheter into urethra until the point of obstruction.
Prescrotal urethrotomy location for approach in male dogs
Prescrotal urethrotomy in male dogs, procedure.
A cutaneous incision of 1–2 cm is made above the obstruction between penile bone and scrotum, the incision continues till retractor muscle of the penis.
Retractor muscle is visualized, mobilized and pushed laterally to get access to urethra.
Urethra is normally 3–4 mm wide, pink, surrounded by white cavernous bodies.
Urethra is opened using a scalpel and the stones are carefully removed, then rinsed using NaCl 0.9% solution.
The catheter is inserted further into the bladder.
The urethra is left to gradually recover (in this case, catheterization is necessary) or closed with simple continuous suture using synthetic fast–resorbable monofilament (4–0 or 5–0).
If closed, The urethral incision wound is closed with a
two–layer suture:
1. subcutaneous tissue is closed with simple continuous suture
2. skin is closed with subcuticular suture
Post–operative complications: hemorrhage, urethral stricture.
Perineal urethrotomy in male dogs is used for…?
How is the animal positioned?
stone removal from isthmus of the urethra, the place where urethra bends around ischial arch (isthmus urethrae).
The animal is in ventral recumbency, the tail is raised and fixated in this position.
Perineal urethrotomy in male dogs, procedure.
The anus is closed with tobacco–pouch suture.
A sterile catheter is inserted into urethra till the obstruction place.
Skin and subcutaneous tissue are cut through with a scalpel in the middle between anus and scrotum.
Retractor muscle is visualized, mobilized and pushed laterally. Paired bulbospongiosus muscles are separated from one another in their adhesion point.
Afterwards, corpus spongiosum is incised and urethra opened. Urinary stones are removed and urethra – rinsed.
A catheter is inserted into the bladder.
Perineal urethrotomy in male dogs, closure after removal of obstruction.
Urethra is left to gradually recover or is closed using resorbable monofilament (4–0, 5–0).
Corpus spongiosum is closed with simple continuous suture using
synthetic resorbable suture material (4 – 0).
The wound is closed with a two–layer suture:
1. bulbospongiosus muscles and subcutaneous tissue are closed with
simple continuous suture;
2. skin is closed with subcuticular suture.
Perineal urethrotomy in male dogs for removal of obstruction in the isthmus of the urethra.
Urethrostomy location. (4)
prescrotal,
scrotal,
perineal and
prepubic urethrostomies are distinguished.
Describe Prescrotal urethrostomy procedure.
Prescrotal urethrostomy is performed similarly to prescrotal urethrotomy. The only difference is that, in case of urethrostomy, mucous membrane is attached to the skin in order to form a fistula.
The length of the incision has to be 6–8 times longer than the diameter of urethra.
Urethral mucous membrane is attached to the skin with simple interrupted suture using synthetic resorbable monofilament 3–0 to 5–0).
Suturing starts in the caudal corner of the incision.
Describe Scrotal urethrostomy procedure in male dogs.
The procedure is performed together with castration.
This is a preferred method because urethra is wider and more superficial in this region, and cavernous tissue around it is thinner.
The animal is castrated via scrotum.
Afterwards, an incision penetrating subcutaneous tissue is made above urethra.
Retractor muscle is visualized, mobilized and pushed laterally.
Urethra is opened longitudinally above the catheter.
Urethral mucous membrane is attached to scrotal skin.
What’s this?
Scrotal urethrostomy in male dogs.
Always make the opening bigger than you’d think to need! The stoma will always shrink down as it heals.
Place a catheter to ensure open urethra throughout length.
Describe Perineal urethrostomy in male dogs.
- This method is only used if other methods are not possible (like prescrotal or scrotal).
- Cavernous tissue in this region is thick and the hemorrhage may be profuse.
- The technique is similar to perineal urethrotomy one.
- The length of skin incision is 4–6 cm, and the length of urethral incision is 1.5–2.0 cm.
- Urethral mucous membrane is attached to the skin with interrupted suture.
Perineal urethrostomy in male cats.
Major site for urethrostomy in cats.
In the majority of cases, this site adequately addresses obstructive lesions in the distal urethra.
Describe surgical manipulations in Perineal urethrostomy in male cats (procedure).
The penis is dissected free of the underlying and surrounding tissues.
Reflect penis dorsally and to either side to enable the ischiocavernosus muscles to be isolated and sectioned.
Separate penile ligaments. Cut retractor penis muscle away from its dorsum (important part! these must must be cut).
Make longitudinal incision into dorsal penile urethra and amputate the distal penis.
