17 and 18. Surgery of the Bladder and Urethra 1 and 2

surgical incision into urinary bladder

define cystotomy

creation of an opening into the bladder

define cystostomy

removal of portion of urinary bladder

define cystectomy

incision into the urethra

define urethrotomy

urinary bladder calculi

define cystolithiasis

removal of urinary bladder calculi

define cystolithectomy

area of bladder which is a smooth triangular portion of mucous membrane near base of bladder where ureters empty

what is the trigone

done to provide cutaneous urinary diversion in animals with urethral obstruction or trauma

when might you perform a prepubic catheterization (aka temporary cystotomy, tube cystotomy)

presence of urine in abdominal cavity

what is uroabdomen (uroperitoneum)

creation of permanent fistula into urethra

what is a urethrostomy

for irreparable or recurrent urethral stricture or to prevent repeated obstruction such as in feline idiopathic cystitis (FIC)

when might a urethrostomy be indicated

1. removal of calculi most commonly

2. repair trauma

3. resect or biopsy neoplasms

4. correct congenital abnormalities

5. evaluation of urinary tract infection resistant to tx.

what are some indications for cystotomy

varies depending on urine it contains

the location of the bladder...

urethra

when approaching a cystotomy, you perform a longitudinal incision on the ventral or dorsal aspect of the body of the bladder away from the ____

ease of access and done when ID or catheterization of ureteral openings is needed....also less likely to cut the blood supply

what is a ventral approach for a cystotomy more ideal than dorsal

cystotomy incision sites...in caudal abdomen

what is shown here

cystotomy

what procedure is shown here

to obtain a watertight seal that will not promote formation of calculi...traditionally done by single or double layer appositional or inverting suture patterns

the goal of a cystotomy closure is....

single-layer appositional

what form of cystotomy closure is sufficient if the bladder wall is thick

single-layer appositional

even in normal bladders, a ___ ___ ____ suture pattern (simple continuous or interrupted) is typically adequate

absorbable monofilament suture

luminal penetration is common in thin-walled bladers but it is NOT believed to be associated with formation of calculus if _______ suture is used

suturing bladder mucosa as separate layer in simple continuous

if hemorrhage is expected to be severe when closing a cystotomy incision, what may be considered to reduce postoperative bleeding

NO you cannot

can we dx. the type of stone based on the crystals found in the urine

if stones can be flushed into bladder preoperatively or intraoperatively

when should cystotomy be performed over urethrotomy in the case of bladder stones

cystotomy + scrotal urethrostomy

what may be the most effective Tx. in preventing recurrence of C/s in Dalmations w/ urate calculi

1. cystotomy + incision small piece of bladder for culture + remove the stones

2. use retrohydropulsion in male dogs to be certain no stones remain in urethral lumen....use catheter to add pressure to retropulsed stones back to the bladder

what are key parts of the sx. technique for stone removal

retrohydropropulsion

what technique is shown here to push stones back into the bladder...helps to avoid performing urethrotomy

retrohydropropulsion in female dog

what is shown here

failure to remove all the stones

though cystotomy complications are uncommon, what is the primary complication

hemorrhage

what is the primary complication of urethrotomy

uncommon

urethral stricture in urethrotomy is (common/uncommon)

1. traditional lithotripsy using shock waves to break up stones

2. laser lithotripsy via cystoscopy using Ho:YAG laser

what are some of the nonsurgical removal techniques for bladder stones

bladder spoon

what device is shown here

provide cutaneous urinary diversion in animals with urinary obstruction, traumatized urethra, and sx. repairable urethra

when might prepubic catheterization (cystotomy + placement of long term catheter to help drain) be indicated

different catheter option for prepubic catheterization....

what is shown here

cystotomy/prepubic catheterization

what procedure is shown here

reviewed

review the "how to" for cystotomy aka prepubic catheterization

1. male dogs to remove urethral calculi that cannot be retrohydropropulsed into bladder

2. facilitate placement of catheters into the bladder

3. occasionally for biopsy of obstructive lesions like strictures, scar tissue, and neoplasms

when might urethrotomy (prescrotal or perineal) be indicated

cystotomy is preferred over urethrotomy

to prevent possible postoperative urethral stricture....if calculi can be advanced back into bladder by retrohydropulsion

1. removal of calculi from distal penile urethra

2. placement of foley catheters into urinary bladder if catheter is of sufficient length and if obstruction is distal to proposed urethrotomy incision

indications for prescrotal urethrostomy

1. performed in distal penile urethra

2. can be left to heal by second intention (hemorrhage for 3-5d) or closed by primary closure if apposition can be achieved

3. ventral midline incision between caudal aspect of os penis and scrotum

4. incision into urethral lumen over a catheter extended w/ iris scissors

general characteristics of prescrotal urethrostomy

1. remove calculi lodged at ischial arch

2. place catheters into bladder of large male dogs

indications for perineal urethrostomy

1. less commonly indicated than urethrotomy at other sites

2. should be closed (simple interrupted absorbable) to prevent SQ urine leakage

3. involves purse string at the anus

general characteristics of perineal urethrostomy

1. recurrent obstructive calculi that cannot be managed medically

2. calculi that cannot be removed by retrohydropropulsion or urethrotomy

3. urethral stricture

4. urethral or penile neoplasia or severe trauma

5. preputial neoplasia requiring penile amputation

indications for urethrostomy (prescrotal, scrotal, perineal, prepubic) ...more permanent opening

if castration is an option and if the lesion is distal to the scrotum

when is scrotal urethrostomy done

cats

perineal urethrostomy is routinely performed in what species

often causes unacceptable urine scalding so should only be used in dogs when issues cannot be solved by other means

what is notable about canine perineal urethrostomy

preferred over perineal and prepubic urethrostomy because urethra is wider and more superficial

characteristics of canine scrotal urethrostomy

1. prevent recurrence of obstruction in male cats with feline idiopathic cystitis (FIC)

2. tx. obstruction that cannot be eliminated by catheterization

3. tx. strictures secondary to urethral obstruction and catheterization

what are the indications for feline perineal urethrostomy

1. place purse-string suture in the anus and catheterize the penis if possible

2. elliptical incision around the scrotum and prepuce to excise them followed by placing Allis tissue forceps to help manipulate

3. avoid being too aggressive when dorsally dissecting

what is the process like for feline perineal urethrostomy

pass closed halsted mosquito hemostat to the level of the boxlocks as they are about 5mm in diameter and should pass without resistance

how do you know when urethral width is adequate (that you have opened it enough) when performing a feline perineal urethrostomy

passing the closed Halstead mosquito hemostats to the level of the box locks up the urethra

failure to perform which step in feline perineal urethrostomy can result in a urethral opening of insufficient diameter and predispose the patient to urinary tract blockage...defeats the whole point of the sx.

completed perineal urethrostomy in a cat

what is shown here

reviewed

review the steps to closing a feline perineal urethrostomy