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CVSOH 4 > Urinary Tract Surgery > Flashcards

Urinary Tract Surgery Flashcards

1
Q

Define neoureterostomy.

A

Treatment for intramural ectopic ureters

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2
Q

Define ureteroneocystostomy.

A

Treatment for extramural ectopic ureters

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3
Q

How is renal and ureteric disease diagnosed?

A
  • Bloods – biochemistry, haematology, electrolytes, clotting
  • Urine – full urinalysis including culture
  • Blood pressure – hypertension
  • Imaging – primary disease, secondary changes and in the case of congenital abnormalities, other hidden abnormalities
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4
Q

What are the renal biopsy sampling options?

A

FNA – a few hundred cells, risk of bleeding depends on zone being targeted

Tru-cut – several thousand cells, higher risk of bleeding

Incisional – will be diagnostic but potentially riskier

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5
Q

What are the contraindications for renal biopsy?

A

Coagulopathies
Severe infections
Ureteral obstructions

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6
Q

What must be considered before doing a renal biopsy?

A
  • Weigh up risks against value of information likely to be obtained
  • Will a biopsy change your management of the case? Weigh up the risks against the value of the information likely to be obtained
  • Consider the sampling method and resulting sample size in relation to the chances of a diagnostic sample that will guide treatment
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7
Q

What are the pre-operative considerations of renal and ureteric surgery?

A
  • Patients may be hypoproteinaemic and drug dosages might need adjusting
  • Hypo/Hyperkalaemia will predispose to cardiac arrhythmias
  • Patients should not be hypovolaemic/dehydrated before surgery
  • Anaemic patients may require blood transfusing
  • Those with clotting abnormalities might need platelets
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8
Q

What are the peri-operative considerations of renal and ureteric surgery?

A
  • Many drugs should be avoided - ACP (hypotension) and NSAIDs (renotoxic)
  • Antibiotics – based on culture and sensitivity, avoiding nephrotoxic ones. Aminoglycosides, tetracycline, sulfonamides (not doxycycline). Generally pick a penicillin (G+), cephalosporin (G+/-)
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9
Q

List the surgical diseases of the kidney and ureter.

A

Neoplasia
Renal calculi
Hydronephrosis
Developmental abnormalities
Renal cysts/pseudocysts
Renal abscess
Renal trauma

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10
Q

What is the presentation of renal neoplasia?

A

Non-specific – weight loss, lethargy, inappetence

Urinary signs with/without haematuria

Renal failure signs – dehydration, azotaemia, uraemia, anaemia

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11
Q

In addition to renal neoplasia, what are the other causes of renomegaly?

A

Hydronephrosis, polycystic disease, abscess

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12
Q

What is the difference between dog and cat renal neoplasia?

A

Almost all malignant
Dogs = carcinomas
Cats = renal lymphoma

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13
Q

How are renal masses staged?

A
  • Lab work
  • Assess local extent of disease
  • Assess for intra-abdominal and distant metastasis
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14
Q

What are renal caliculi?

A

5% of all uroliths
Calcium oxalate
Siamese and Bichon frise over-represented

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15
Q

How are renal caliculi medically managed?

A
  • Calcium oxalate cannot be dissolved
  • Lithotripsy not widely available/Lithotripsy not recommended in cats for renal calculi
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16
Q

When are renal caliculi surgically managed?

A

Risks of removal considered high so generally only take to surgery if truly justified

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17
Q

How do renal caliculi lead to renal failure and other conditions?

A

Obstruction > hydronephrosis and renal failure

UTI likely to lead to secondary issues such as pyelonephritis which can also lead to renal failure

Haematuria > chronic, non-regenerative anaemia

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18
Q

What is the presentation of hydronephrosis?

A
  • Urine accumulation
  • Dilation of the renal pelvis
  • Progressive destruction of the renal medulla
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19
Q

What are the causes of hydronephrosis?

A

Pyelonephritis
Obstruction
Congenital stenosis

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20
Q

How us hydronephrosis treated?

A

Ureteronephroectomy

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21
Q

How is a ureteronephrectomy done?

A
  1. Full exploration of the abdomen and adrenals to check for metastasis if checking for neoplasia
  2. Blunt dissect kidney away from retroperitoneal space
  3. Be ready for bleeding
  4. Rotate kidney medially to expose the renal hilus. There can be multiple renal arteries.
  5. Double ligate (or transfix) them close to aorta and to hilus and dissect between.
  6. Repeat for vein. Do not mass ligate arteries and veins – do separately
  7. Dissect out ureter and remove along with kidney
  8. All big vessels double ligated with modified miller’s before transection
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22
Q

Why may identifying normal vasculature in a uteronephrectomy be difficult?

A

Neoplasia neovascularisation

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23
Q

You have just taken a lateral abdominal radiograph of a 6year old Bichon Frise and can see 2 small renal calculi. The dog’s bloods show normal BUN and creatinine. What investigation and/or treatment should you recommend?

A

Abdominal ultrasound, full urinalysis including culture and sensitivity, masterly inactivity, orthogonal radiograph, repeat biochemistry in 1-3 months

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24
Q

How are ureteric calculi medically managed?

A
  • Diuresis 4-5 days my encourage ureterolith to move into bladder
  • Ureteral relaxant
  • Lithotripsy
  • With/without oral/IV relaxants such as glucagon/amitriptyline
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25
Q

When should ureteric caliculi/ureteroliths be managed surgically?

A

Obstructive, refractory UTI, refractory haematuria

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26
Q

What 3 ways can ureteroliths be managed surgically?

A
  • Ureteral stenting – stones stays in place, stent allows urine drainage past the stone
  • SUB – bypasses so urine goes from kidney straight to bladder used when the ureter is blocked but kidney does not need removal
  • Ureteronephrectomy – for if ureter and kidney both sufficiently damaged to justify removal of both
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27
Q

What is the presentation of ectopic ureters?

A

Incontinence, difficulties house training, nocturia, dysuria, haematuria

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28
Q

Describe the incontinence caused by ectopic ureters.

A
  • Intermittent or constantly dripping urine
  • Intermittent if retrograde bladder filling occurs
  • Incontinence often worse at night, particularly females
  • Still can urinate normally when unilateral
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29
Q

How can ectopic ureters surgically managed?

A
  • Cystoscopic laser ablation for intramurals
  • Neoureterocystostomy - making a new stoma between a ureter and bladder that currently are not directly connected
  • Ureteroneocystostomy - in bladder
  • Ureteronephrectomy - ureter opened and anastomised to bladder
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30
Q

What is the prognosis of ureteral ectopia?

A
  • Post-operative medical management
  • Concurrent abnormalities - USMI, hypoplastic bladder, UTI, intrapelvic bladder
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31
Q

What can be done post surgery for ureteral ectopia for incontinence that has improved but not resolved?

A

Alpha adrenergics and oestrogens – help contract urethral sphincter

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32
Q

What are some surgical diseases of the bladder?

A

Caliculi
Bladder neoplasia
Bladder rupture - RTA, iatrogenic
Persistent urachus
Hypoplastic bladder

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33
Q

What are some surgical conditions of the urethra?

A

Urethral calculi
Urethral obstructions
Urethral rupture
Urethral prolapse

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34
Q

What is a urethrostomy?

A

A diversion to allow urine to be passed through a new stoma because the normal one is not available for some reason. Site depends on species and location of the blockage. Cats = perineal or prepubic, dogs = prescrotal or prepubic

35
Q

What is a urethrotomy?

A

Typically used to retrieve urethroliths that cannot be voided or returned back to the bladder

36
Q

What is a urethropexy?

A

A simple procedure used to treat urethral prolapse where the mucosa is replaced and suture used to keep it in place

37
Q

What are 2 referral lower urinary tract procedures?

A

Urethral anastomosis
Urethral stenting

38
Q

Which is better to perform, a cystotomy or a urethrotomy and why?

A

A cystotomy rather than an urethrotomy due to risk of stricture formation

39
Q

How can bladder caliculi be managed medically?

A
  • Struvite dissolution potentially risky for males as can cause life-threatening obstruction
  • Bacterial underlying cause = antibiotics
  • Voiding hydropropulsion
40
Q

How is voiding hydropropulsion used to medically manage bladder caliculi?

A

In cases where the bladder calculi are estimated to 2/3rd-1/2 smaller than the diameter of the patient’s urethra. Uses gravity and the pressure generated by a saline filled bladder to have the stones expelled under anaesthetic.

41
Q

How might urethral caliculi present on clinical examination?

A
  • BAR or may present collapsed
  • Hypo or normovolaemic
  • May be bradycardic or tachycardic with/without an arrhythmia
  • If painful abdomen without tachycardia that is a red flag for hyperkalaemia so should prioritise getting the bloods first
42
Q

How is a complete urethral obstruction managed?

A
  • Triaging
  • Pain relief
  • If large bladder, prioritise that
  • If unstable, can’t attempt catheterisation so cystocentesis
  • Prioritise emptying the bladder to avoid iatrogenic uroabdomen
  • Ideally, obstruction by urolith turned into cystotomy with retrohydroprpulsion
43
Q

What are the preliminary and definitive treatments for complete urethral obstruction?

A

Preliminary - analgesia, stabilisation, bladder decompression

Definitive - retrohydropropulsion, surgery

44
Q

When is retopropulsion used?

A

When you have identified a movable physical urethral obstruction

45
Q

How is retropulsion done?

A
  1. Decompress bladder
  2. Catheter with a single end hole is best
  3. Sterile lubrication
  4. Flushing solution - saline, KY jelly, with/without lidocaine for spasm
  5. Assistant gloved finger into rectum to apply pressure to pelvic urethra
  6. Start to build up pressure within the urethra distal to the finger
  7. Pressure on pelvic urethra should then be suddenly released while pressure from flushing is maintained
  8. Care with volume
  9. If unsuccessful, repeat cystocentesis and try again in 12 hours
45
Q

What is done after obstruction has been relieved using retrohydropropulsion?

A

Flush bladder repeatedly to remove blood clots, other debris, crystals, smaller stones

46
Q

How is urinary tract rupture diagnosed?

A
  • Retrograde urethrogram for the urethra
  • Positive contrast cystogram for the bladder > could just wait for the IVU contrast to reach
  • Negative contrast contraindicated as we don’t want to put air into the abdomen
  • Bloods – rising plasma urea/creatinine (also commonly hyperkalaemic)
  • Abdo fluid – higher levels of urea/creatinine in free abdominal fluid compared to plasma
47
Q

How does urinary tract rupture present?

A
  • Animals present with progressive depression 12 and 48 hours post-trauma
  • Cannot be ruled out just because animal is urinating
48
Q

How is bladder rupture surgically managed?

A
  1. Stabilise prior to attempting repair
  2. Ventral midline exploratory laparotomy
  3. Methodical four quadrant check
  4. Debride damaged bladder
  5. Suture closed as for cystotomy
  6. With/without tube cystostomy
  7. Omentalise
  8. Flush abdomen
  9. Partial cystectomy is performed to remove damaged/devitalised/unhealthy bladder tissue
  10. Tube cystostomy should be considered depending on the severity of tissue trauma and amount of bladder that has to be debrided/resected
49
Q

What are the conservative and surgical treatments for urethral rupture?

A

Conservative – urethral stenting

Surgical – urethral repair, stenting

50
Q

How can surgery alone treat bladder neoplasia?

A

Cystectomy – can be curative for benign lesions. Futile for all malignant tumours

51
Q

How can medical management alone treat bladder neoplasia?

A

Chemo seems better than radiation
COX-2 selective NSAIDs

52
Q

What are the possible palliative care options for bladder neoplasia?

A
  • Diversion
  • Stenting
  • Cystostomy for urine diversion when tumour obstructing the urethra. Low profile tubes available
  • Urethral stenting to relieve obstruction > can lead to incontinence
  • Laser debulking
53
Q

What are the problems of surgery and bladder neoplasia?

A

Getting margins on a transitional cell carcinoma can be highly challenging (if not impossible) and anatomical location means surgery high risk for complications - damage to ureters/neurological function of bladder

54
Q

How is urethral prolapse treated?

A
  • Replacement of mucosa and sutures to keep it in place
  • Resection of the prolapsed urethra and suturing to the penis
  • Castration recommended at same time
55
Q

How is the bladder approached surgically in a cystotomy?

A
  • Pre-placed urinary catheter?
  • Caudal midline/paramedian laparotomy
  • Pack off the abdomen
  • Stay sutures in the bladder apex
  • Foley catheter must be placed - ensure the bladder neck is free of stones ensure they are all free floating
  • Ensure prepuce and penis in male dogs is not in the way
56
Q

Does the male or female urethra have a smaller diameter?

A

Male

57
Q

How is the bladder surgically entered in a cystotomy?

A
  • Find a relatively avascular area
  • Ventral
  • Stab incision
  • Suction the urine
  • Save a sample of urine from the bladder lumen and biopsy bladder wall next to incision
  • Save some caliculi for culture and sensitivity and quantitative analysis
  • Flushing normograde and retrograde up the urethral catheter by a non-sterile assistant is helpful
58
Q

What are the indications for cystotomy?

A
  • Polypoid cystitis
  • Necrotic bladder found at surgery
  • Early neoplastic lesions
59
Q

How is tube cystotomy done?

A
  1. Caudal laparotomy
  2. Foley catheter pulled through a stab incision in the body wall adjacent to the bladder.
  3. Purse-string suture (absorbable)
  4. Stab incision made into the bladder in its centre
  5. Tip of the Foley placed through and inflated
  6. Purse-string suture is then tied
  7. Couple of sutures placed between the bladder and the body wall
  8. Laparotomy incision closed
  9. Foley attached to the external skin with tape
60
Q

What are the indications for tube cystotomy?

A
  • Palliative measure for bladder TCC
  • Temporary measure for anything requiring urine to leave the body via another route than the urethra
  • Obstructed bladder due to stone
  • Atony
  • Urethral rupture
61
Q

How is recurrent urethral obstruction avoided when doing urethrostomies?

A
  • Feline patients - good client communication around lifestyle modifications and medication management
  • Males the narrowest part of the urethra is the penile urethra and so we can opt to create a permanent opening into this wider part to allow stones to be passed before the narrower section of urethra.
  • In the cat this is therefore a Perineal Urethrostomy (before the penile urethra)
  • In the dog a scrotal urethrostomy (before the os penis)
62
Q

What is USMI?

A

Urethral Sphincter Mechanism Incompetence

63
Q

How is USMI managed medically?

A
  • Masterly inactivity – for congenital USMI 50% will become continent after 1st season
  • Oestrogen
  • Phenylpropanolamine – acts directly on the Alpha-adrenergic receptors > increased tone. Can get some mild side effects
64
Q

How does oestrogen manage USMI?

A
  • Stimulates the mucosa to hypertrophy > increased tone
  • Increases Alpha-adrenergic receptors
  • Can get some mild/serious side effects
  • Not to be used in intact bitches
65
Q

What are the surgical management options for USMI?

A

Colposuspension – kind of dragging the urethral sphincter into the abdomen to increase the extramural urethral tone

Artificial sphincter – implant around the urethral to increase extramural urethral tone

Bladder reposition includes cystopexy, urethropexy, vas deferentopexy

66
Q

What is the effect of collagen on USMI?

A

Increases intramural urethral tone

67
Q

You want to test urine for culture and sensitivity should you get an ultrasound guided cystocentesis sample at this point?

A

No – if you suspect bladder neoplasia, avoid cystocentesis to avoid neoplastic cell seeding

68
Q

What is the most common type of bladder neoplasia in the dog?

A

Transitional cell carcinoma

69
Q

Where is this type of bladder neoplasia often located?

A

Neck – significance of this is that it can lead to ureteral and/or urethral obstruction, and is difficult location to surgically resect.

70
Q

What is the best way to confirm diagnosis of bladder transitional cell carcinoma?

A

Bladder wall biopsy with a transurethral traumatic catheterisation/cystoscopy (a Tru-cut would risk neoplastic seeding)

71
Q

What are the medical and surgical options available for transitional cell carcinomas?

A
  • Surgical excision
  • COX2 NSAIDs
  • Other chemotherapy - platin-based, doxorubin
  • Urethral stenting
  • Bladder diversion - tube cystostomy
  • Other - complete ureteral re-routing, SUBs, laser ablation debulking
72
Q

How might you increase/decrease you suspicion of urinary tract rupture with hyperkalaemia?

A

ECG and AFAST

73
Q

How does mild and moderate hyperkalaemia appear on an ECG?

A

Mild = peaked T wave

Moderate = P wave flattening, prolonged PR, prolonged QRS

74
Q

Uroabdomen is likely to be present if a rupture has occurred at which of the following sites?

A

Bladder and proximal urethra

75
Q

If free abdominal fluid is present what test would be diagnostic of urinary tract rupture?

A

Fluid/blood ration for K or creatinine (creatinine abdomen to blood 2:1 is highly indicative)

76
Q

Which suture choice is best for repair of bladder rupture?

A

Single layer
Appositional
Monocryl/polyglecaprone

77
Q

How do cats and dogs differ in opioid choice?

A

Opioid not NSAID, cats do not do well with methadone but in serious situations and they need it give it and then drop down onto buprenorphine, this is opposite for dogs

78
Q

What are the values on biochemistry for hyperkalaemia?

A

Mild = >5.5mmol/L
Moderate = > 6.5mmol/L
Severe = > 9mmol/L

79
Q

What is done in moderate to severe hyperkalaemia in a cat with a large bladder and dysuria?

A

Give 5-10ml/kg bolus of Hartmann’s or start treatment for hyperkalaemia

Cystocentesis – ultrasound guided, but empty whole bladder, leave a few mls, but buys you time for pain relief and fluids. Risk of uroabdomen iatrogenically so empty

80
Q

What are the treatment options for blocked cats?

A
  • Therapeutic cystocentesis
  • Urethral catheterisation under GA
  • Cystotomy under GA
  • Low cost option – repeat cystocentesis and SC fluids to avoid GA and hospitalisation
  • Urethrostomy
81
Q

With hydropropulsion, which way are you flushing the stone within the urethra?

A

Up to the bladder

82
Q

Why are you flushing the urethral stone up into the bladder?

A

Easier for surgical removal and avoid urethral surgery

CVSOH 4 (25 decks)

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