Urogenital Surgery, Pt. 2 Flashcards
What are the 4 indications for canine castration?
- sterilization
- elimination of male characteristics (aggression; better early before it becomes learned behavior)
- treatment of prostatic disease (decreased testosterone = involution)
- cryptorhidism
What are some additional indications for castration?
- perineal hernia (common in older males)
- testicular torsion/abscesses
- urethral obstruction (part of scrotal urethrostomy)
- scrotal/testicular trauma
- endocrine disorders
- scrotal or inguinal hernias
- testicular, scrotal, and perianal gland neoplasia
What are the 4 most common approaches to castration in dogs?
- pre-scrotal
- scrotal ablation
- perineal (caudal)
- scrotal
What are the 2 most common approaches to castration in cats?
- scrotal
- scrotal ablation as a part of perineal urethrostomy
What are the indications for pre-scrotal and scrotal approaches in canine castrations?
PRE-SCROTAL = routine/elective procedures
SCROTAL = scrotal/testicular neoplasia or trauma, scrotal urethrostomy, pendulous scrotum
What are the indications for inguinal/abdominal and perineal approaches to canine castrations?
I/A = cryptorchidism
PERINEAL = avoid repositioning when patient is already in a perineal position
How does surgical preparation for castrations compare in dogs and cats?
DOGS = aseptic, clip hair, chlorhexidine prep
CATS = “clean”, pluck hair from scrotum, chlorhexidine prep
What is a closed castration? How does it compare to an open one?
parietal vaginal tunic is not incised
- less anesthesia time
- less risk of abdominal infection
- less secure ligation
What is an open castration? How does it compare to a closed one?
parietal vaginal tunic is incised and any attachements are broken down
- more secure ligations
- communication with the abdominal cavity
What are the 3 goals to castration?
- complete removal of both testicles
- secure ligations
- no post-op bleeding
How are bleeders taken care of? How is the testicle brought out of the incision?
sponge + pressure or hemostats
apply pressure caudally and sideways to pop it out —> will have a shiny, smooth surface
What is done after the testicle is elevated?
pull up and slide other hand holding gauze down to bluntly disrupt the scrotal ligament, allowing for the release of the testicle
- strip fat and SQ tissue until the spermatic cord is completely isolated
How is the testicle ligated? What is included in the clamps?
3 clamp technique —> first ligature (circumferential) in the distal crush, second (transfixing) in distal to the middle clamp, then transected between the remaining 2 clamps
parietal tunic and cremaster muscle
Why is the order of the ligations important?
circumferential is placed first in the distal crush to avoid bleeding into the abdomen
How is an open castration performed?
- once the testicle is released, find a window between parietal tunic, cremaster muscle, and vas deferens/testicular arteriy and vein and pierce them
- clamp across the tunic to the tail of the epididymis and separate the attachment
- push the vaginal tunic down
- ligate together or separately (if large)
Open castration
pushing down the vaginal tunic
Open castration, clamps:
3 clamp technique
- each portion can be ligated separately or together, depending on size
What is important to be cautious for when making the initial incision of pre-scrotal neuters?
pre-scrotal approach - fibrous tubular structure of the urethra will be present —> do not penetrate by cutting or with bites!
- don’t include retractor penis muscle either!
How is the castration incision closed?
spermatic fascia and SQ are sutured as a single layer to reduce dead space
- intradermal
- simple interrupted
What post-operative care is recommended following a castration?
- cold pack to surgical site for 10-15 mins
- E-collar
- restrict exercise for one week to decrease chances of developing a seroma
What are the 4 most common complications associated with castrations? In what animals is this most common?
- hemorrhage/bleeders
- scrotal irritation or bruising
- scrotal hematoma
- infection
dogs —> cats heal by second intention
What is the recommended treatment for scrotal swelling or hematomas following a castration? What is avoided?
compress and wide-spectrum antibiotics
opening and draining leads to abscess formation —> check back in 3-5 days
What do complications with scrotal castrations lead to?
debridement of pedicles and removal of remaining scrotum
How is a castration with scrotal ablation done?
SCROTAL APPROACH - make an elliptical incision at the neck of the scrotum and remove it, then suture SQ to close the dead space
What manipulation may be necessary when approaching retained testicle(s)? How are the testicles ligated?
move bladder caudally
2 ligatures —> in deferens and in vascular pedicle of the testicle
How do undescended testicles compare to normal testicles?
usually smaller, softer, and lighter in color due to compression and increased temperature in the abdomen
What is the approach like with one undescended testicle?
use the proper abdominal/inguinal approach to the pathologic testicle first
How can a cryptorchid testicle be confirmed following possible palpation?
ultrasound
What are the 3 most common testicular neoplasias? What do they cause?
- Sertoli cell tumor
- seminoma
- interstitial cell tumor
testicular enlargement
How do most testicular neoplasias act? How are they treated?
malignant, with low rate of metastasis to regional LNs
castration
What increases the risk of developing testicular neoplasia? Which neoplasia in particular is common in this case?
cryptorchidism
Sertoli cell tumors —> secrete estrogen, which can block erythropoiesis in the bone marrow = anemia
How is testicular neoplasia diagnosed?
- palpation*
- ultrasonography or radiology
- presence of paraneoplastic syndromes: hyperestrogenism (Sertoli cell)
What are the 6 most common signs of testicular neoplasia?
signs of hyperestrogenism
- alopecia
- gynecomastia
- testicular atrophy
- penile atrophy, pendulous prepuce
- prostatic cysts, prostatic atrophy
- reduced male behavior with possible attraction of males
What is pseudohermaphroditism? How do animals typically present?
incomplete formation of both gendered reproductive tract, typically a penis/vulva with ovaries or undescended testes in the abdomen
chronic UTIs
What are the 4 indications for feline castration?
- sterilization
- urethral obstruction (as a part of perineal urethrostomy)
- testicular or scrotal trauma
- elimination of male characteristics, like urine odor and fighting
How do feline testicles need to be handled before they are able to be exteriorized?
caudal traction placed on testicles until the scrotal ligament breaks
What approach is preferred for feline castrations?
SCROTAL —> incision over both testicles (or in the middle of the scrotum)
How should felines be positioned for castrations?
cranial movement of legs forward to properly visualize scrotal sac and urethra
What surgical techniques are used in feline castrations?
- open or closed
- proper circumferential, then transfixing ligations
- separate ductus deferens and tie to vessels with 2 square knots
- use absorbable ligature or hemoclip
What are other options other than suture material?
- overhand auto-ligation
- ductus deferens tie
- hemoclips
What are the pros and cons to using the ductus deferens tie for castrations?
PRO: no foreign material used
CONS: tie can be thin and easily unraveled, plucking of hair makes hair contamination common which leads to fistula formation, must be sinched extremely tight
How are scrotal incisions in feline castrations managed?
second intention —> leave incisions open to drain and heal
- owners should use shredded paper or un-popped corn (?) instead of litter for a few days to decreases changes of infection
What complication is most common in feline castrations?
perineal fistula formation due to loose hair from plucking of the scrotal sac
What is a vesicourachal diverticulum? What does this cause? How is it treated?
persistence of part of the urachus (used to communicate with umbilicus for waste removal in fetus) at the apex of the bladder
detrusor muscle does not cover it, so urinary stasis with occur here, making it more prone to persistent UTIs
partial cystectomy (diverticulectomy) with remove of part of the apex
Macroscopic vesicourachal diverticulum:
nipple-like outpouching at the apex
What are the 2 most common types of trauma that cause bladder rupture? How do they cause rupture?
- BLUNT - impact on abdominal wall while bladder is full (males = females)
- PENETRATING
both result in acute increase in abdominal pressure
What are the 3 most common causes of spontaneous bladder rupture?
- urethral obstruction
- tumor
- severe cystitis
What are the 3 most common causes of iatrogenic bladder rupture?
- improper catheterization - can poke hole through thin walls
- cystocentesis (not common)
- manual expression of the bladder - common in patients with neurological disease that require manual expression multiple times a day
How does a ruptured bladder affect biochemistry results? How quickly do patients need to be treated?
- uremia
- dehydration, hypovolemia
- electrolyte abnormalities
withing 36-48 hrs
How does the peritoneal fluid and serum compare in cases of suspected bladder rupture? Why?
- urea in peritoneal fluid = serum urea
- creatinine in peritoneal fluid > serum creatinine
urea molecules equilibrate rapidly across peritoneum, but creatinine molecules are too large to cross the membranes
In what 4 ways can ruptured bladders be diagnosed?
- free fluid in peritoneal cavity seen on radiographs/ultrasound
- creatinine in peritoneal fluid exceeds serum creatinine
- IV pyelogram (upper) or cystogram
- exploratory celiotomy
Does voluntary urination always indicate the bladder is intect?
NO —> if rupture is small, the bladder may fill partially, allowing the animal to void voluntarily
How are patients stabilized before surgery to fix ruptured bladders?
correct uremia, hypovolemia, and electrolyte abnormalities with IV fluids or urethral/peritoneal catheters, peritoneal dialysis (severe uremia)
What is done on exploratory celiotomies in cases of bladder rupture?
- debride tear in bladder and suture
- peritoneal lavage
- maintain urethral catheters for several ays
What conservative treatment of bladder rupture can be done to avoid surgery?
catheter or needle holes to keep bladder compressed, which allows for healing
What is the most common indication for cystotomies in dogs and cats? How are they treated?
cystic calculi
surgery —> calculi not medially soluble, risk of urethral obstruction is high
- submit urine, bladder mucosa, and calculus for culture and sensitivity
What is laser lithotripsy? What are 3 differences compared to cystotomy?
minimally invasive, safe, and effective removal of calculi in the bladder and urethral of dogs by breaking down stone to allow them to pass naturallu
- hospitalization is shorter
- procedure time longer in females
- anesthesia cost is higher
Are all filling defects in the bladder calculi?
NO —> ultrasound can be used to differentiate blood from air
What approach is used for cystotomies?
ventral midline approach to the caudal abdomen
- stay sutures or Babcock forceps to elevate bladder (leave room to close!)
- pack off bladder
What ligaments of the bladder can be excised? Which cannot?
ventral
lateral —> contain ureters
What is done before the bladder is cut into? Where is the incision made? How can edema be avoided?
empty it by compression or by aspiration of urine with a small needle
avascular area on ventral surface to avoid trigone (near apex to remove possible patent urachus)
avoid tissue handling
How are cystotomies closed? What 3 patterns are used?
1 or 2 with absorbable sutures
- Cushing - Lembert
- simple continuous in submucosa
- simple interrupted in submucosa
How can a bladder incision closure be leak tested? When is this not necessary?
compress the neck of the bladder while injecting saline
if the bladder is already filling with urine
What must be done before and after cystotomies?
placement of a urethral catheter with flushing
When will only a 1 layer closure be done on the bladder?
if there is intense fibrosis and edema of the bladder wall that makes multiple layers too difficult
(submit biopsy just in case, stones, neoplasia, and cystitis present the same)
What is the most common benign and malignant neoplasias of the bladder?
papilloma + hyperplasia
TCC (most common overall)
What commonly mimics bladder neoplasia in dogs?
inflammatory polyps
(polypoid cystitis)
What signalment most commonly presents with TCC in the bladder? What is thought to be its etiology?
female Scottish Terriers
MULTIFACTORIAL = insecticide exposure, obesity, genetics
(most commonly will have metastasized by the time of diagnosis)
What are the 3 most common diagnostics for TCC?
- UA - exfoliates well into urine and sediment (dogs without tumors can also have epithelial cells!)
- rectal palpation and transurethral biopsy
- bladder tumor antigent test
How are survey radiographs and ultrasonography used to diagnose TCC?
- r/o prostatic disease and urolithiasis
- allows examination of sublumbar LNs, vertebrae, and pelvis for metastasis
What treatments are recommended for resectable and nonresectable tumors in the bladder?
partial cystectomy
Piroxicam - decreases angiogenesis of tumor
Where is TCC most commonly found in the bladder? What does this mean for surgical treatment?
often at trigone and seeded into other tissue
salvage procedure with partial cystectomy +/- urethral stenting
