11 UT- Bladder and Urethra

• Cystotomy

incision into the bladder

• Cystectomy

excision of a portion of the bladder

eg neoplasia

• Cystostomy

hole into bladder allows for drainage while bypassing the urethra

Urethrotomy

creating a hole into the urethra

Urethrostomy

creating a new, permanent stoma into the urethra

• above the point of obstruction

bladder surgery: clean or contaminated

Clean-contaminated surgery

Principles of bladder surgery 5

• Empty bladder prior to surgery— catheterisaiton

• Keep tissues moist, halsted

• Bladder wall heals quickly

  • regains strength 14-21 days

• Absorbable monofilament suture material with swaged-on needle

  • PDS polydioxanone

• patterns: water tight seal, don’t go into lumen!!

  • suture-induced calculi mineral deposit

Surgical anatomy: bladder

• ureter: 1 on each side

  • note hook on caudal ureter

• enter trigone region of urinary bladder

• M—> vas deference pass through bladder; prostate withinirethre wall

Cystotomy INdication 5

• Remove bladder / urethral stones

• Biopsy / resection masses

• Repair of ectopic ureters (referral/ senior)

• Biopsy / culture bladder wall severe cystitis

• Repair bladder trauma

Cystotomy : day 1 competecy

• prep 5

1. Ventral midline clip: exploratory coeliotomy

2. Include genitalia in field

   • allow catheterise intraop

3. Caudal approach or full ex-lap

   • more caudal: may want to flush urethra check patent

4. Bladder easily traumatised

   • Minimise handling

   • Atraumatic forceps— debakey

   • Stay sutures

5. Suction

Cystotomy site: ventral cystotomy

Used most common

• Readily accessible

• Visualise the trigone well on doral (opposite)

• No increased risk of leakage

Cystotomy site: dorsal cystotomy

• Potential damage to neurovascular bundle + ureter

• Less easy to visualise

• Ureters enter dorsally

—> don’t do it :(

Cystotomy steps ** organise diagram 13

1. Isolate bladder from abdomen

2. Place stay suture in apex —> atraumatic handling

3. pack around bladder to minimise spillage

4. Select cystotomy site— ventral

5. ± cystocentesis (unless preop catheter)

6. Stab incision —avascular area

7. Extend with Metzenbaums —> longitudinal apex towards trigone

   • ectopic urether—> more causally

   • sphincter damage will heal with incontinence within. a few day

8. stay suture on either side of incision

9. perform necessary procedure

10. Remove clots before closure

11. Single-layer, appositional pattern – simple interupted/ continuous

    • watertight, do not go into lumen

12. Thickened wall – occasional two-layer closure

13. Leak test and omental wrap

    • leak test: inject sterile saline/ via catheter

Cystectomy • For mass lesion excision

• considerationa nd principle 2

• Excise affected area with as big a margin as possible

• Principles same as cystotomy

Cystostomy

• indication 2

uncommon, Allows bladder drainage whilst bypassing the urethra

• neoplasm: divert prior to chemo; uroliths: transport from referral temporary diversion

• Used to pexy bladder to body wall – e.g. retroflexed bladder in perineal hernia

• Foley catheters, mushroom catheters

Cystostomy • The same technique as tube gastrostomy

A cranial midline coeliotomy is performed to access the stomach5 .

For gastropexy in GDV, a pyloric antrum gastrotomy is performed6 .

• A de Pezzer catheter (mushroom tipped) is commonly used as the gastrostomy tube5 ....

  The tube is pulled through a tunnel in the left body wall (or right body wall for GDV according to one source6 )5 .

  A purse-string suture is placed on the stomach wall, and a stab incision is made in the centre5 ....

  The feeding tube is inserted into the gastric lumen, and the purse-string suture is tightened around the tube5 ....

  Pexy sutures are placed to secure the stomach to the abdominal wall5 ....

  The tube is further secured to the body wall, often using a Chinese finger trap suture5 .... This helps prevent the patient from removing the tube5 .

FIX THIS

• care: M dog: cauda; epigastric + retractor penis m.

1. foley catheter

2. purse-string in urinary baldder→ stab purse string

3. tighten purse string

4. tacking suture: bladder and body wall

Urethral surgery • Indications 3

1. Urethral obstruction: urolithiasis or FLUTD

2. Penile / urethral trauma or disease

3. Urethral prolapse

Urethral obstruction usually

urolithiasis

FLUTD (medx management ok)

Urethral obstruction Consequences: 4

emergency

• Postrenal azotaemia

• Hyperkalaemia

• Hydronephrosis

• Bladder damage

Urolithiasis dx imaging

• plain radiograph

• contrast (if radiolucent stone): retrograde urethograms

—> important to include the ENTIRE UT

Urethral obstruction urolithiasis

• Options for management 3

• which one most common and first choice?

1. Push stones into the bladder

2. Remove stones from urethra (uncommon)

3. damage/stricure—> Create a new stoma into urethra above the obstruction (uncomon)

Push urolithiasis into bladder— how? 8

Preferred option: retrograde urohydropropulsion

• Remove stones by medical dissolution or cystotomy

1. feel pelvic brim through rectal

2. squish finger between recum and pelvic brim

   • tube like structure—> urethra

   • squish distal to stone

3. introduce foley catheter until tip of penile urethra

4. inject saline through catheter

   • dilates everything distal to stone

   • urothelium fills and lift up until pressure build up

5. once pressure if high, lift finger

   • release occlusion, urolithiasis fly into bladder

6. ± lidocaine, ± KY jelly

7. repeat a few time. cystocentesis may be needed .

8. confirm with radiography

urolithiasis— Remove from urethra

• how?

• uncommon in

Urethrotomy — hole into

• Create temporary hole into urethra

• Remove stones

• Allow urethra to heal by second intention

• Uncommon in female dogs or cats — Shorter and wider urethra

Urethrotomy in male dog

• common location

usually prescrotal region

– Urethrotomy in male dog

• how?

• do we like this sx?

• Prescrotal urethrotomy

• Place urinary catheter

• Incise skin behind os penis

• Reflect retractor penis muscle

• Incise urethra

• Remove stones

• Flush to ensure all stones removed

• Suture or leave open to heal by second intention

NO IT IS BLOODY FIDDLY AVOID IF YOU CAN

– Permanent urethral stoma: Urethrostomy

• performed whem

– Can’t dislodge stones – Stricture has formed – Repeated obstructions

**MCQ SAQ EXAM Urethrostomy male dog: ideal location

• prepubic x

• perineal (uncommon)

• prescrotal (too much vasculature, thin urethra)

SCROTAL REGION is the most common

Scrotal urethrostomy

• consideration 2

• Castrate • Make stoma large: 2.5 – 4 cm

perineal urethrostomy

• indication

• Scrotal urethrostomy and prescrotal urethrotomy cannot be performed in the male cat

• severely obstructed FLUTD cases: cats

Perineal urethrostomy— how?

1. ventral recumbancy, tail reflected to dorsum

2. teardrop shape incision around penis

3. pull penus towards me, blunt dissection going forward

4. spiral shape debridement

5. when cannot move forward—> ischial cavenosus muscle— between ischium and penis

   • transect

6. urethrostomy site: bulbourethral gland (when narrow urethra becomes wide)

7. suture urothelium to skin: aim for primary closure

Complications of urethrostomy 4

• Haematuria : UT trauma/cyctitis/ ooze around surgical site

• Stenosis: stoma can reduce 50% of size

  • ensure meticulous appositional urothelium and skin closure

  • big enough stoma as possible

  • no one pokes the site! do not clean!

• Incontinence

• Urinary tract infection

Urethral prolapse is commonly seen in 4

• Young male dogs that likes to hump

• Sexually intact

• Brachycephalic breeds

• Self-inflicted trauma (or 2dry)

Urethral prolapse: surgery

• Resect prolapse — same as rectal prolapse

  • double-check and add

• Castrate

• Alternatively: urethropexy

advise to owner pre bladder surgery

even if leak tested, still uroabdomen risk

• can place temp foley to help with healing

Uroabdomen - causes

Trauma

• Ureter avulsion

• Bladder rupture

• Urethral rupture

• Pelvic fracture—> laceration

Secondary to bladder disease

Iatrogenic

• Urinary surgery

• Traumatic catheterisation

• Cystocentesis

Uroabdomen - presentation

similar to blocked bladder

• uraemia + hyperkalaemia

• cardiac arrythmis: sinus brady, peak t wave

• Ascites, abdominal discomfort

• Initially bladder often palpable

• Animal is often able to urinate

bladder rupture rx

• how long?

rupture bladder: Radiography at 1 hour

bladder rupture rx

• how long?

Radiography at 8 hours

• cannot see bladder

• idelaly want to dx before 8hr

what to do for early diagnosis imaging of uroabdomen?

US

Uroabdomen - diagnosis

• Serum biochemistry + urinalysis

• what else will you do?

• where do u find abdo fluid

• increased Urea, Creatinine, Potassium (postrenal azotemia +hyperkalemia)

• +/- Haematuria

• Urine SG 1.008 to >1.050

Look for free abdominal fluid: usually collects in apex of urinary bladder and liver

• Abdominal fluid analysis : crea: high, abdo>blood; urea: high, abdo=blood

• Urinary tract imaging

Abdominal fluid collection mehtods: 3

• test of choice

• Abdominocentesis

• POCUS scan

• Diagnostic peritoneal lavage (like 4 sepsis)

uroabdomen: Abdominal fluid analysis

• which one is more indicative

• confirmed if

Urea: small molecule equilibrates quickly

Creatinine: large molecule does not equilibrate, stay high in abdo

confirmation:

• [Creatinine (ascites)] > [Creatinine (serum) - mean 2:1

• [Potassium (ascites)] > [Potassium (serum)]- dog 1.9/ cat 1.4:1

what deos this contrast radiography shoe

leakage of contrast into abdomen

• urethrea lost…

Uroabdoman: management once diagnosed

5

Medical stabilisation

• IV fluid therapy (shock dose for hyper K)

• Analgaesia (full mu opioid)

• +/- Urinary diversion

• Treat hyperkalaemia

Surgery once stabilised—> Exploratory coeliotomy

** MCQ SAQ EXAM treatment for arrythmia in hyperK 3

IV fluid

Calcium Gluconate intravenously over 20 minutes (unless hypophosphatemia)

Glucose and Insulin