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
urethrostomy complications
§Does not lead to incontinence (sphincter is left intact) but may predispose to urinary tract infections (UTIʼs)
§Can cause localized skin irritation d/t urine scalding
>Especially early on or if obese
urethrostomy possible sites, most common for cats and dogs, which are less used?
- *Perineal - #1 site for cats
- *Scrotal - #1 site in dogs
- Prescrotal (penile) – thinnest urethra / os penis – not ideal
- Prepubic – last resort
scrotal urethrostomy is ideal for what animal?
requires what other procedures?
urine scaliding risk?
good things about this site?
Ideal site in dogs (not cats)
§ Requires castration and scrotal ablation
(if intact at time of surgery)
§ Less risk of urine scalding d/t ventral location
§ Largest urethral diameter is an advantage (less chance of stricture)
§ Urethra is superficial at this level (easier to appose to the skin)
§ Less cavernous tissue ( ̄ bleeding)
scrotal urethrostomy technique
- Insert catheter to the level of obstruction
- If intact, perform routine scrotal ablation &
castration, or make a midline skin incision - Move / transect the retractor penile muscle
- Identify the urethra
- Longitudinal urethral incision on midline (2.5 - 5 cm depending on patient size)
- Appose urethral mucosa to the skin (beware of tension*)
> Suture corners at 45 degrees
> Mucosa, fibrous tissue and skin - Non-absorbable (4-0 or 5-0 polypropylene – will need to remove) or absorbable suture (Monocryl is ideal)
- Simple interrupted (or continuous)
urethrostomy post op care
§Elizabethan collar §Bleeding for 3-5 days
§Urination & excitement
§Do not touch, clean or catheterize
§Vaseline on surrounding skin to ̄ urine scalding
§Hydrotherapy (low pressure) to clean / reduce swelling
§Can remove sutures 10-14 days post-op under sedation + E-collar for 3-5 more days
urethrostomy complications
Complications: UTI, stricture, skin irritation/scalding, recurrent calculi / obstruction
feline lower urinary tract disease AKA blocked cat
- typical cause? when medical vs surgical approach?
- do we need any other procedures along with this one?
§ Typically inflammatory +/- struvite sand
> Primarily a MEDICAL DISEASE
§Surgery is recommended if:
– Urethral stricture
– Unable to pass urinary catheter
– Documented narrowing/stricture on urethrogram
– Some cases of urethral rupture
– Multiple offenses (often recommended after 3 episodes) of re-obstructing not responsive to appropriate medical management
– ~21% of cats have stones and will also need a cystotomy
perineal urethrostomy
- when / why do we do this
- risks
- outcomes
- Salvage procedure
- Increase risk of urinary tract infections (have shortened urethra and removed protective mechanisms)
- Risk of stricture if not performed properly > 10% recurrence of signs
- 80% of cats have good long-term outcome
- 60% asymptomatic after surgery
how to perform a perineal urethrostomy
- positioning, set-up
- incision
- suture
- how to ensure its ok
§ Position in dorsal or sternal
recumbency
* Purse string in anus
* In sternal recumbency:
> Tail tied over back
> Rolled towel under pelvis
* Circumferential incision made around the prepuce
* Dissection continued to ischiocavernos us muscles
* Muscle elevated off the pubis with a periosteal elevator or blade
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- Incision made on middle of dorsal urethral surface starting distally and continued proximally to the level of the bulbourethral glands (widest urethra)
- Ensure a mosquito forceps boxlock or 8Fr urinary catheter fits in the uppermost opening
- Do not handle the urethral mucosa with forceps
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* Suture the urethral mucosa to the skin
– Simple interrupted 4-0 or 5-0 PDS Monocryl
– Place a urinary catheter in the urethra into the bladder if needed to delineate the opening as you suture but then remove it
– Place at least 3-4 dorsal sutures to ensure the uppermost opening is wide enough
* Attach cut urethral edges to the skin ventrally to create a draining board
* Amputate the penis distally and close remaining skin incision
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§ Ensure the incision has been continued proximally enough by placing a mosquito forceps to the level of the box lock (or 8 Fr catheter) in the uppermost oppening
§ Gently express the bladder at the end of the procedure and ensure an adequate stream of urine is produced
feline perineal urethrostomy
- complications
- Stranguria / pollakuria / hematuria due to irritation / inflammation
> Treat with an NSAID for 3-5 days if not contraindicated (check renal values) - Urine scalding
> Vaseline placed on skin adjacent to incision (not on surgical incision) for first few weeks - Urine leakage / incontinence
> Usually if bladder atony is present after prolonged obstruction - Stricture
> If incision is not proximal enough, too much tension / or self-
trauma (licking during healing) - Recurrent UTIs
- Recurrence of lower urinary tract disease
urethral prolapse
- signalment at risk
- what it looks like, issues
§Young bulldogs,
§Red protrusion at tip of penis
§Intermittent penile bleeding
§Associated with UTI, stones, and brachycephalic obstructive airway syndrome (BOAS)
urethral prolapse treatment
§Resect the redundant urethral mucosa and suture around the tip of penis over a catheter (4-0 monocryl)
§ʻPexyʼ urethral mucosa (mattress suture) through
wall of penis
§Address BOAS abnormalities to prevent recurrence
bladder rupture causes
- Trauma
- Iatrogenic
> Manual Expression
> Cystocentesis
> Flushing for de-obstruction - Secondary to obstruction
bladder rupture treatment
– Urinary catheter placement and patient stabilization
– Identify the source of leak (contrast study)
– Surgical debridement (conservative) and close similar to a routine cystotomy
– Identify and avoid the ureters
– Place postoperative abdominal drain
– If significant tension or large amount of tissue debridement (small bladder remaining) or if the remaining tissues do not provide a strong closure, place a urinary catheter for 2-3 days while a seal forms
