urinary tract surgery - recent...
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Urinary Tract Surgery - Recent Developments
Philipp Mayhew BVM&S, MRCVS, DACVSAssistant Professor, Small animal surgery
University of California-Davis, USA
Taiwan College of veterinary surgeons - Taiwan 2011
Lecture formatIntroductionUrinary Tract Trauma and obstruction
-uroperitoneum -catheter-associated trauma
Urolithiasis -Minimally invasive urolith removal -Feline Ureterolithiasis
Urinary incontinence -New therapies for Ureteral ectopia &Urethral sphincter mechanism incompetence
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IntroductionMany new urinary tract therapies have
been introduced in the last few years -new options for previously untreatableconditions -improvements of current standard of care
minimally invasive approaches to manyurinary problems now possible
-ureteral ectopia, trauma, urolithiasis,neoplasia
In our practice majority of urinaryprocedures now involve less invasivetechniques compared to 10 years ago
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Urinary Tracttrauma
Important considerations: -Medical v. surgical emergency -Site of urine leakage -Underlying cause
Important consequences: - Uroperitoneum/Uroretroperitoneum/urinaryleakage into tissues -Urinary obstruction secondary to strictureformation
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Uroperitoneum - Etiology?
Dogs and Cats – 84.6 % trauma -In dogs ! blunt trauma -In cats ! 59% blunt trauma 32% urethral catheterization 9% bladder expression
Other causes - Iatrogenic - post-cystotomy, nephrotomy - Rupture secondary to obstruction, neoplasia
Location: ~70% bladder ~30% urethra
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Diagnosis: uroperitoneumRetrieve abdominal fluid byabdominocentesis
Measure effusion and peripheralblood K and creatinine
If slightly to markedly highervalues in effusion ! suggestsuroperitoneum
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Aumann M et al. Uroperitoneum in cats: 26 cases (1986-1995). JAAHA 34;315-324, 1998Schmiedt C. et al. Evaluation of abdominal fluid: Peripheral blood creatinine and potassium ratios for
diagnosis of uroperitoneum in dogs. JVECC 11;275-280, 2001
Dog Cat
Creatinine 5:1 2:1
Potassium 2.5:1 1.9:1
Imaging: Uroperitoneum Positive contrast cytourethrogram – use
FLUORO -Contrast study of choice for LT -Detected 100% bladder ruptures (only72% with double contrast)
Intravenous urogram -If suspect renal/ureteral trauma
Antegrade pyelogramUltrasound ± contrast
cystography (microbubble)Computed tomography
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Treatment:Bladder trauma
Revision cystotomy
Radical cystectomy
-Complications: pollakiuria,dysuria
gastro-Intestinal conduitdiversion
-Complications: pyelonephritis,renal failure
Colonic augmentationcystoplasty
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Colonic augmentationcystoplasty
Pozzi A et al. J Am Vet Med Assoc 2006;229:235-239
Bladder necknecrosis
Technique forcircumferentialresection of bladderneck
Involves sparing thedorsal vascular andneurological pedicles
Requires bilateralureteral reimplantation
Mainly described fortumor resection
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Saulnier-Troff et al. A technique for resection of invasive tumors involving the trigone areaof bladder in dogs: Preliminary results in two dogs. Vet Surg 37:427-437, 2008
Urethral traumaMost likely to be secondary to catheterizationor pelvic traumaCan be full transection but more often tearIn cats - tend to be mid-pelvic urethraIdeal repair of transection:
-Primary repair+catheter better than primaryrepair or catheter only in dogs (Layton CE et al. Vet Surg 1987;16:175-182)
Anastomoses results in some degree ofstricture
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Algorithm to deal with Feline urethraltears
UrethralTear
Distal Intrapelvic Proximal
PerinealurethrostomyTranspelvic
urethrostomy
Retrograde orantegrade
catheterisation
Pelvicsymphysiotomy/pubic-ischial
osteotomy flapwith primary
repair
Cystostomy
Intrabdominalrepair
Prepubicurethrostomy
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Urethral tearoptions
Prepubic urethrostomy-many complications:incontinence(37%), peristomaldermatitis (44%).
Perineal urethrostomy-0-18% stricture rate,predisposed to infection
Intrabdominal repair- For rare cases where tear isintrabdominal
Transpelvic urethrostomy-Same complications as PU
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Transpelvicurethrostomy
Gets you a little “higher”Allows access to 1-2cmcranial to thebulbourethral glandsFew complicationsAssymptomatic stricture
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Bernarde A. & Viguier E. Transpelvic urethrostomy in 11cats using an ischial ostectomy. Vet Surg 33:246-252, 2004
Treatment bycatheterizationalone
In many cases urethral tears will heal if acatheter can be passed across the lesionIn ~50% of cases catheter will pass retrogradeIf catheter doesn’t pass retrograde in manycases will pass antegradeThis can be done using guidewire fromcystotomy incisionLeave catheter in place for 5-15 daysPost-operative stricture occurred in 2 /10 catsin one study
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Meige et al. Management of traumatic urethral rupture in 11 cats using primary alignment with aurethral catheter. VCOT 21: 76-84;2008
Minimally invasiveRetrograde/Antegradecatheterization
IV catheter passed percutaneouslyinto bladdersmall soft hydrophilic wire(glide/weasel)passed throughcatheter into bladderUnder fluoroscopic guidance wirepassed into urethra and acrosslesionThen once out of penis can thread alocking loop or pigtail catheterover wire
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Antegrade catheterization
Images and videos courtesy C. Weisse and A. Berent
Antegrade catheterization
Urolithiasis: New optionsIn human medicine limited role
for traditional “open” surgeryfor urolithiasis
Canine/feline cystic/urethralcalculi
-laparoscopic-assisted cystotomy
-Lithotripsy
Ureterolithiasis (mainly feline)
-Surgery
-Ureteral stent placement
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Laparoscopic-assistedCystotomy
Advantages: -less post-operative pain -less wound-related complications -ability to thoroughly evaluate for residualstones
Disadvantages -greater equipment and cost -more time-consuming
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Instrumentation5mm 0° or 30° laparoscope
2 trocar-cannula assemblies
5 or 10mm Grasping forceps
2.7mm cystoscope with cystoscopic sheath
IV fluids with pressure bag
Stone retrieval devices
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Instrumentation: Stoneretrieval devices
Many different devices can beused for stone retrieval oncehave bladder access:
Placed alongsidecystoscope:
-Lap babcock -Carmalt forceps
Placed down workingchannel of cystoscope:
-Biopsy forceps -Basket catheter (different sizes)
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Patient positioning andport placementDorsal recumbency
Trendelenburg (head down)
Camera portal issubumbilical
Instrument portal will belocated on ventral midline atlevel of bladder apex
In males may be parapreputial
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Lap-assisted cystotomy:Surgical techniqueLaparoscope is inserted to view
bladderCan fill bladder with sterilesaline through catheterSecond port established at level
of bladder apex on midline5 or 10mm babcock forceps used
to elevate bladderStay sutures placed followed by
cystotomyCystoscope (1.9-2.7mm 30° degree
cystoscope in sheath) placed intobladder
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Rawlings CA et al. Use of laparoscopic-assisted cystoscopy for removal ofurinary calculi in dogs. JAVMA 2003:222;759-762
securingbladder access
Placing the stay sutures orsuturing the edge of acystotomy to the skin marginallows secure access forrepeated entry into bladder
-Very helpful when manystones
Cannula technique: -Provides closed bladder andbest visualization -Tedious when many or largestones need to be removed
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Recovering urinary calculiCan use babcock forceps placed alongside
telescope to recover individual stones
-Works well for medium to large stones
Can use basket catheter placed throughworking channel of cystoscope sheath
-Works well for medium-sized stones
-Depends on size of the basket
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Retrograde flushing ofstones through cystotomy
Post-operativelyCystotomy incision isclosed routinely
Bladder is replaced intoabdomen and inspected oncemore
Purge pneumoperitoneum
Close camera portal
3 days of analgesia anddogs can usually returnhome the day after surgery
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Feline ureterolithiasis – Avery common problem?
Increasing numbers of upper tract stones -10x ! in upper tract stones in 20 years -50x ! in Calcium oxalate in UT stones (Lekcharoensuk C et
al. JAAHA 41;39-46,2005)
Increasing prevalence of calcium oxalate overpast 20 years (Ling GV et al. JVIM 1998;12:11-21)
Historical findings non-specific: -Inappetence, vomiting, lethargy, weight loss 83% of cats are azotemic 25% of cats have bilateral ureterolithiasis 62% of cats have concurrent nephroliths
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Feline Ureterolithiasis- Diagnostic imaging
Sensitivity of plainradiographs 81%Sensitivity of ultrasound77%Sensitivity of both 90%Allows assessment ofdegree of hydronephrosis
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Feline ureterolithiasis - Other imaging modalities
Computed tomographyAntegradepyelography
Ureterolithiasis - medicalmanagement
Medical treatment in cats:Serial monitoringIV fluids and diuretics (mannitol)Glucagon - side effects - no longer
recommendedAmitryptyline - no reportsCa channel blockers (nifedipine)Alpha-adrenergic antagonist (tamsulosin)Extracorporeal shockwave therapy
-concerning results in cats but early stageof development
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Does medical managementwork?
Humans: 98% of ureteroliths <5mm willpassDogs: little information on medical
managementCats:
- 64% serially assessed ureteroliths passedinto bladder - 33% euthanased/died within a month
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6mosurvival
12mosurvival
24mosurvival
Medical 1 1 1
Surgical 1 1 1
Ureterolithiasis - Indications forsurgery
Consider surgery if: -obstruction present -chronic infection present -No important co-morbidities
Timing of surgery: -dogs- acute obstruction renal blood flow 40% of control 12-24hrs post -dogs - chronic obstruction 1 wk! GFR returns to 65% normal 2 wk!GFR returnes to 46% normal
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Ureterolithiasis - surgicalmanagement
Consider location, severity of renalimpairmentIf proximal
! pyelotomy/ureterotomyIf mid to distal
! ureterotomy or ureterectomy withureteroneocystostomy
If end-stage hydronephrosis ! ureteronephrectomy
Renal transplantation if severe CRF andavailable
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Ureterotomy - single large stone
Use magnificationGentle use of tourniquet proximaland distal to calculusIncise over single stoneSuture with fine monofilamentsuture
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Multiple ureteral calculiCommonly encountered - multiple calculi inone ureter or bilateral ureterolithiasisWe now prefer ureteral stents to bypassobstruction Can be challenging to place but welltolerated
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Nephrostomy tubeProvides urine drainage temporarilyCan be used in conjunction with
ureterotomy to try and decreaseleakageHowever not without complications
-Post-op uroabdomen 25% -Post-op blockage/dislodgement 21%
Generally a move away fromnephrostomy tubes in these cases
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Ureteral StentingHas been used for palliation ofureterolithiasis, strictures or malignanciesCan be placed cystoscopically in dogs butin cats requires surgical placementIntroduced through the kidney, dilator isused to dilate the ureter and then stent isplaced over the guidewire into the bladderDouble pigtail design is used
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Ureteral StentingIntraoperative fluoroscopy (C-arm) is usedto confirm placement of the pigtail in therenal pelvisPost-operative radiographs confirmplacement and should be done sequentiallyto monitor for migrationCan be placed bilaterallyLeft in long-term and well tolerated
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Urinary Incontinence
From Holt PE. Urinary incontinence in dogs and cats. Vet Record27;347-350, 1990
n=481 female dogsN=82 Male dogs
Juvenilefemale
Adultfemale
Juvenilemale
Adultmale
Ureteral Ectopia 47% 4% 34% 8%
USMI 33% 81% 41% 17%
UE and USMI 8% <1% 0% 0%
Other 12% 14% 25% 75%
Ureteral ectopiaRelatively common in many breedsTraditionally treated by neoureterostomyfor most intramural casestrue extramural cases are extremely rarebut can be treated by ureteral implantationSurgery has been main treatment to resolveincontinence and prevent progression ofhydroureter and hydronephrosis
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Literature -Diagnostic imaging
IVU: No association exists between the shape ofthe ureterovesicular junction and the surgicaldiagnosis of EU (Canizzo 2003).
-only 32% had double contrast usedRetrograde vaginourethrogram: EU were
diagnosed in only 47% of dogs with the disease inone study using this modality (Samii 2004)
Abdominal ultrasonography: User dependent anddifficult to tell which side affected (Mantis 2008)
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Contrast-enhanced CT: Correct diagnosis of EUin 16 of 17 dogs (Samii et al. 2004) Cystoscopy: Diagnosed EU in 24 of 25 affected
dogs (Cannizzo et al. 2003)
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Neoureterocystostomy with distalureteral tunnel ligation or excision(trigonal reconstruction)
Cystoscopic evaluation
video courtesy of J. Westropp
100% sensitivity and 75% specificity ina population of 24 dogs suspected ofhaving EU. (Samii et al. 2004).
Combine with other modality thatevaluates upper tract
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Cystoscopic laserablation ofectopic ureters.
Images and videos courtesyA. Berent
CLA technique video
12 weeks post CLA ofectopic ureter
What is the post-operativeincontinence rate for surgeryversus CLA for EU
Neoureterostomy with distal ureteralligation
- 42-78% (Holt et al. 1982, Stone & Mason 1990, Holt & Hotson-Moore 1995).
Neoureterostomy with distal tunnelexcision (trigonal reconstruction)
- 71% remained incontinent (Mayhew 2006)
CLA-EU technique - 53-68% (Smith et al. 2009, A. Berent – personal
communication).
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Cystoscopic-guided collagenimplantation
Hydraulic occluder placement
Any Questions?
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