Urinary tract surgery SA (Case)

Question 1

Lecture goals

Answer 1

1. Undersetand basic pathophysiology
   
   • calculi and FUS
2. Know indications for bladder and urethral surgery
3. Know suture materials and patterns for bladder and urethral sx
4. Know principles of bladder and urethral sx
5. Know common complications of bladder and urethral surgery
6. Know of various sx procedures
   
   • nephrectomy
   • nephrotomy
   • ureterotomy

Question 2

To visualize right gutter

Answer 2

• retract mesoduodenum to visualize
  
  • R. Kidney
  • vena cava
  • ureter
  • bladder

Question 3

To visualize trigone of bladder

Answer 3

• extend incision caudally enough and retroflex bladder
  
  • UVJs (ureteral vesicular junctions)

Question 4

To visualize left gutter

Answer 4

• retract spleen and descending colon medially and caudally

Question 5

Bladder suture and patterns

Answer 5

• 4-0 to 7-0
  
  • bladder, urethra, ureter
• absorbable
  
  • bladder, urethra, ureter
• monofilament
  
  • bladder, urethra, ureter
• avoid luminal sutures
  
  • bladder
• simple continuous/simple interrupted are ok

*PDS full thickness closure would be a bad idea! :-D

Question 6

Nephrotomy

Answer 6

• rare
• renoliths/nephroliths
  
  • rarely a problem
• avoid

Question 7

Nephrectomy

Answer 7

• rare
• indications
  
  • trauma
  • neoplasia
  • abscess
• structures
  
  • vessels: double ligate artery and transfixing ligament as 2nd ligature
  • ureter: remove completely

*Kidneys can usually be saved

Question 8

Ureterotomy

Answer 8

• not done as commonly as previously
  
  • stint and special devices now
• high complication rate
  
  • 20% mortality rate for cats
• magnification
• suture: 5-0 to 7-0

Question 9

Cystotomy

Answer 9

• very common
• indications
  
  • calculi
  • rupture
  • mass/polyp
  • access to ureter/urethra

Question 10

dog-epidemiology

stones

Answer 10

• Sex predisposition
  
  • females - calculi
  • males - obstruction
• Breed
  
  • dalmations
• vascular malformations
  
  • PSS

Question 11

Dog

type of stones

Answer 11

• calculi
  
  • struvite
  • oxalate
  • urate
  • cysteine
• submit your stones (medically mandated)

Question 12

Calculi epi dogs

sex predisposition

Answer 12

• Females
  
  • calculi
  • anatomy = inc incidence of UTI
    
    • struvite formation secondary to urease bacteria
• Males
  
  • most commly obstructed
  • Anatomy
    
    • urethral diameter
    • lenth
    • os penis
  • Ca-oxalate, urate, cystine

Question 13

Calculi epi dogs

Breed

Answer 13

• dalmations
  
  • uricase transport defect
  • urate

Question 14

Calculi epi dogs

vascular malformations

Answer 14

• Portosystemic shunt
  
  • ammonia excretion
  • urate

Question 15

Two most common urinary stones

Answer 15

• Calcium Oxalates
• Struvite

Question 16

most common stone in female dogs

Answer 16

• struvites
  
  • short-wide urethra next to source of contaminates = bacterial infection
    
    • staph, clebsiella, …

Question 17

Feline Urologic Syndrome (FUS)

Answer 17

• sterile, inflammatory cystitis
• multifactorial
  
  • dietary, obesity, stress, neuroendocrine, viral?
• Neg bact culture (97%)
• 45% recur in 6 months

Question 18

Cat epi

Sex

Answer 18

• Females
  
  • sterile cystitis
  • non-obstructive
  • hematuria, pollakiuria (extreme urinary frequency)
• Males
  
  • urethral plugs
    
    • mucus, blood, crystals
      
      • struvites (90%)
      • oxalates (1%)
  • recur in weeks to months (50% of cases)

Question 19

Preoperative treatment

Dog

Answer 19

• Retrograde urohydropulsion
  
  • goal: flush urethral calculi back into bladder
  • allows stabilization before sx
  • avoids emergency urethral sx
    
    • elective cystotomy preferred to urethrotomy/urethrostomy

Question 20

Preoperative tx

cat

Answer 20

• sedation
  
  • lidocaine jelly
  • BAR or angry/growling
    
    • low dose injectibles
      
      • butorphanol
      • diazepam
      • ketamine: not too much, metabolized by kidneys

Question 21

Preop tx

Cat: catheter tips

Answer 21

• catheter tips
  
  • dorsal recumbency
  • legs cranial
  • extend penis caudal

Question 22

Suture selection

Answer 22

• absorbable monofilament

Question 23

Cystotomy suture

Answer 23

• monocryl or biosyn
  
  • biosyn if nasty infection (monocryl breaks down VERY quick)
• NO PDS, NO MAXON
  
  • ​suture nidus risk

Question 24

Urethrostomy suture

Answer 24

• monocryl or biosyn

Question 25

cycstotomy procedure

Answer 25

• dorsl recumbancy, wide clip
  
  • caudal midline laparotomy (umbilicus to in front of prebubic tendon)
• Access to urethral catheter
• Isolate with lap sponges
• retract with large guelpis
• 3 stay sutures (hemostats if no assistant)
  
  • cranial one most important
• 15 blade ventral midline stab
  
  • evacuate urine with suction (Poole)
  • protect viscera from urine
  • extend incision to visualize all of bladder
• Spoon out stones
• Flush normograde and retrograde
  
  • drape in prepuce

Question 26

Cystotomy closure

Answer 26

• single layer continuous/interrupted
• double layer cont/int
  
  • decreases luminal volume
  • serosal tearing
• leak test following closure
  
  • retrograde urethral catheter

Question 27

Cystotomy complications

Answer 27

• hematuria and pollakiuria
  
  • common/expecte for 48 hours
• dehiscence/uroabdomen
  
  • rare, related to poor technique
  • bladder gains majority of tensile strength in 5-7 days
    
    • 100% at 14-21 days
  • snug appositional single-layer closure engaging submucosa
• incomplete urolith removal
  
  • stones fall into pelvic urethra
  • copiously flush retrograde
  • must count stones
  • post-op rads: butt-shot

Question 28

cystectomy

Answer 28

• rare
• indications
  
  • neoplasia
  • trauma
  • dalmations
• can excise up to 70%
  
  • unless near trigone and ureters

*resectable TCC is rare

Question 29

Cystectomy procedure

Answer 29

• use stay sutures for exposure
  
  • assistant required
• debride edges
• suture
  
  • one layer
  • approximating pattern preferred

Question 30

Urinary diversion

Answer 30

• rare
• urethral repairs
  
  • cystostomy tube
  • urethral stent
• light fentanyl CRI for sick dog sufficient

Question 31

cystopexy

Answer 31

• rare
• retroflexed bladder in perineal hernia
• incisional
• right side peritoneal lining

Question 32

Urethrotomy

Answer 32

• rare
• remove single calculus
• leave open/suture closed
• risk of structure

Question 33

Urethrostomy

Answer 33

• common
• dogs
  
  • male
    
    • prescrotal
    • scrotal
    • perineal
  • female
    
    • prepubic

Question 34

Scrotal urethrostomy complications

Answer 34

• persistent hemorrhage
  
  • 2-3 days
• hematuria
  
  • up to 5 days
• dehiscence and stricture
  
  • rare; trauma and poor technique
• urine scald and UTI
  
  • intermittent: 20% of cases

Question 35

Urethrostomy

cats

Answer 35

• perineal: larger dilation of urethra
• prepubic

Question 36

Perineal urethrostomy cats

complications

Answer 36

• hemorrhage
  
  • expected first 48 hours
  • don’t disrupt the clot
  • avoid heparin
• dehiscence
  
  • urine dissecation
  • inflammation/infection
  • necrosis
  • self-trauma: E-collar always
• stricture/recurrence
  
  • improper technique
  • must perform complete dissection broximal to BUGs

Question 37

Summary

Answer 37

• know indications for bladder sx
• pathophys of stone formation
• indications for urethral procedures