Urinary surgery pt 2 Flashcards
how should we close a bladder that is thickened and unhappy?
Simple continuous full thickness only since oversew will be very difficult and will invert too much tissue
after bladder closure, what do we do before releasing bladder into abdomen? what if contamination occurred?
- Local lavage prior to releasing into the abdomen
- Abdominal lavage only if contamination occurred (short
incision so difficult to suction out)
when is a culture and sensitivity useful after a cytotomy? what material / tissue should we send in?
§ If cysto sample was negative for growth or no preop culture result, collect bladder mucosa +/- urine and crushed calculi
§ Typicallly grew the same as cysto sample if positive culture preop so could skip (save $) it if you know it is +ve and already have a sensitivity or one pending
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Theoretically once stone is removed, UTI should resolve
should we take post-op radiographs after cystotomy? what if stones remain?
§ Ensure that all radioopaque stones have been removed
§ What if stones remain??
- Go back to surgery! Right away!
how do we assess that all radiolucent stones have been removed by cystotomy?
§More difficult
§Historically would perform a contrast urethrocystogram
§ Can be hard to interpret as there will be air in the abdomen, bladder, etc.
§Urethrocystoscopy using a flexible endoscope*
why should we do a stone analysis after a cystotomy?
§Determine the type of mineral §Formulate a preventive plan
(diet, medications, etc.)
§In most instances, struvite stones should not be removed surgically b/c they can be dissolved medically…
cystotomy post-op care
§ Fluids
> Diuresis
> Flush out hemorrhage / hematoma / bacteria
§ Antibiotics ?
§ Analgesia
§ E-collar
§ Hematuria and pollakiuria x 3-5 days
§ Suture removal & dietary recommendations
cystotomy most common complications
Incomplete removal or recurrence of stones
> Go back
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Incisional complications
§ Abdomen (infection, seroma)
§ Bladder (uroabdomen and peritonitis)
> Poor suturing
§ Ureteral entrapment
> Dorsal cystotomy
> Anatomy
> Large suture bites closer to the trigone / urethra
advantages of percutaneous or laparoscopic assisted cystotomy
§ Minimally invasive
> 2cm skin & 5mm bladder incision
§ Less hematuria and dysuria
§ Shorter hospital stay
§ Less adhesions
§ Less suture so less risk of suture induced recurrent calculi
§ Requires endoscopic instruments and training
what if hydroretropulsion does not work to push urethral stones into bladder?
urethrotomy
what is the purpose of performing a urethrotomy? where anatomically is it most likely performed?
Create a temporary urethral incision
* Remove urethral calculi wedged in os penis
that cannot be retropulsed even in surgery
* Bypass a urethral obstruction
* Remove a FB (piece of catheter)
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* Most often performed in pre-scrotal region for removal of stones lodged at the base of the os penis in dogs (if they cannot be retropulsed for cystotomy)
steps for performing pre-scrotal urethrotomy
- Incise the skin and subcutaneous tissues
- Identify & retract the penile retractor muscle
- Identify the urethra (palpate stone or catheter)
- Incise the urethra 1-3 cm along its midline (blade)
- Control hemorrhage with digital pressure
- Remove calculi (& advance the catheter)
- Flush the urethra (retrograde)
- Leave to heal by second intention without a catheter (or close primarily with suture)
- Elizabethan collar
(no urinary catheter post-op unless going for cystotomy to remove bladder stones – remove when surgery is done)
urethrotomy post op - how does it heal? what do we expect to see post-op?
§ Heal by second intention without a urinary catheter
§ Hemorrhage for 3-5 days post-op
> Urination & excitement
urethrotomy - When to suture the incision? what suture?
§ Coagulopathy (e.g. VWB Doberman)
§ decreased postop care (but increased surgical difficulty to prevent sticture)
§ Suture over a urinary catheter but remove catheter
immediately postop
§ Use absorbable monofilament (SC or SI) (4-0)
what is a urethrostomy? indicated when?
Creation of a permanent (sutured) urethral opening between the urethra and skin (mucosa to skin) – preferably at a level where the urethra is widest to allow stones to be voided during normal urination
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Indicated when:
§ Recurrent obstructive calculi with no medical management options or response (e.g. cats and Dalmatians)
§ Calculi that cannot be dislodged with retropulsion or urethrotomy (to bypass obstruction)
§ To bypass a stricture, neoplasia, severe trauma distal to chosen urethrostomy site
