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URI 2 > Principles of urinary surgery > Flashcards

Principles of urinary surgery Flashcards

1
Q

List Some surgical indications for the kidney and ureter?

A

Kidney & ureter:

  • biopsy
  • neoplasia
  • nephrolithiasis
  • hydronephrosis
  • ectopic ureter
  • trauma
  • pyelonephritis
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2
Q

List Some surgical indications for the bladder?

A

Bladder:

  • urolithiasis
  • uroabdomen
  • biopsy
  • cystostomy tube placement
  • neoplasia
  • ectopic ureters
  • incontinence
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3
Q

List some surgical indications for Prostate and urethra?

A

Prostate and urethra:

  • Prostatic/para-prostatic cysts
  • Prostatic neoplasia
  • Prostatic abscessation
  • Urethral obstruction
  • Urethral prolapse
  • Urethral rupture
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4
Q

List Common Presenting Signs for urinary problems?

A
  • Polyuria
  • Dysuria
  • Haematuria
  • Stranguria
  • Anuria
  • Anorexia
  • Lethargy
  • Urinary incontinence
  • Painful/swollen abdomen
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5
Q

How should you Investigate before surgery?

A
  • Clinical exam
  • Blood work
  • Urinalysis
  • Radiography
  • plain
  • contrast
  • Ultrasound
  • Cystoscopy
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6
Q

Remember Common things occur commonly. And these are?

A
  • Cystolithiasis (mot common site bladder) /FLUTD (fat indoor cats)
  • Uroabdomen (caused commonly by RTAs)
  • Neoplasia
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7
Q

Case study: Rascal

  • 10 year old, ME Dalmatian
  • Recurrent dysuria and haematuria
  • Lethargic compared to normal
  • Previous history of “mixed” uroliths
  • Tender bladder on palpation
  • Unable to pass urinary catheter
  • Pyrexic

D/dx?

A

Think in dalmation think urolithiasis most commonly urates because dalmations lack the enzyme that converts urate to alontoin in the liver. Bulldogs also suffer from this as well.

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8
Q

Discuss cystotomy pre-op?

A
  • Consider patient electrolyte status
  • Hyperkalaemia leading to —> Cardiac arrhythmia – potentially life threatening!!!! (disproportionately low HR in light of situation they are in)
  • Monitor ECG for bradycardia (in bradycardia will see spiky tall T waves, QRS complex wider than usual and P waves are small or absent)
  • Correct hyperkalaemia if present
  • dilution (majority cases)
  • sodium bicarbonate (severe-rare)

•Post renal azotaemia

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9
Q

Discuss fluid therapy in cystostomy pre-op?

A

Instigate IVFT – 0.9% saline (majority)

  • 5% dextrose saline (not if hyponatraemic as may make problem worse by diluting sodium further)
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10
Q

What is our aim pre-op?

A

Aim get stable so can GA and fix problem

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11
Q

Discuss antibiosis pre-op cystotomy?

A

•Antibiosis (hold off if want bladder biopsy for culture and sensitivity) Pick something good for LUT such as amoxicillin, clavulanic acid, TMPs. Fluroquiniolones (marbofloxicin and enrofloxicin) are good for LUT but should only be reaching fro them if you have a C &S that indicates so.

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12
Q

Discuss placing a urinary catheter pre cystotomy?

A

Place urinary catheter and drain bladder. In case of obstruction may not be able to pass one if you can have a go and drain before you start cutting.

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13
Q

List Halstead’s principles?

A
  • Gentle handling of tissue
  • Meticulous haemostasis
  • Preservation of blood supply
  • Strict aseptic technique
  • Minimum tension on tissues
  • Accurate tissue apposition
  • Eliminate deadspace
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14
Q

Discuss the approach to cystotomy?

A
  • Ventral midline coeliotomy
  • Caudal umbilicus to pubis (wounds heal side to side)
  • In males paraprepucial incision required. Be careful of branches of caudal superficial epigastric vein at the cranial end of the prepuce really obvious and need to ligate them to enable you to continue then reflex the penis to one side.
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15
Q

Discuss exposure after skin incision for cystotomy?

A
  • USE RETRACTORS e.g. Balfour
  • Expose bladder and pack around with moist laparotomy sponges to prevent bladder drying out and to prevent any urine spillage
  • Monofilament simple interrupted stay sutures in apex so can lift bladder up out of bladder when you make your incision
  • Perform cystocentesis with syringe & needle or stab incision and suction
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16
Q
A
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17
Q

Discuss approach to entry into the bladder in cystotomy?

A
  • Stab incision in ventral midline incision into lumen
  • Extend incision with Metzenbaum scissors
  • Remove uroliths with Volkmann spoon.
  • Or can sterilise tea spoon in charity practice
  • Can see surgical assistant holding stay sutures
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18
Q
A
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19
Q

During removal of calculi from bladder what else must you ensure you do?

A
  • Place retrograde urinary catheter to check for patency and can also flush any uroliths stuck in the urethra
  • FLUSH URETHRA, THEN FLUSH IT AGAIN!
  • Check bladder again! Make every effort to make sure have got them all out.
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20
Q

What after closure of bladder what else needs to be done?

A
  • Flush abdomen through with sterile saline if think have spilt urine but good to do routinely anyway don’t want any nasty uroabdomen consequences after surgery.
  • Close abdomen routinely
  • ANALYSE UROLITHS… So you can advise owner on diet and ph of urine post surgery (think Hills offer this as a free service)
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21
Q

Discuss suturing the bladder?

A
  • Bladder is one of the weakest organs in body
  • But it heals quickly if you suture it appropriately. Regains nearly 100% strength in 14-21days
  • Submucosa is surgical holding layer as this where the collagen lives which enables the stitches to stay in place securely. Always engage the submucosa but no deeper than that as can be a nidus for infection if in lumen.
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22
Q

Discuss suture use in the bladder?

A
  • Avoid non-absorbable as nidus for calculi
  • Avoid suture placement through mucosa (occurs commonly so use absorbable)
  • Monofilament- polydioxanone (PDS)
  • poliglecaprone 24 (Monocryl)
  • Braided- polyglactin 910 (Vicryl) Avoid if suspect there is an infectious process as it is braided
  • PDS retains 71% strength and Vicryl 59% strength after 28days
  • If infection or delayed healing anticipated eg. significant trauma for blood supply or immunosuppressed animal, I tend to use PDS
23
Q

Discuss suture placement?

A

One or two layers

•One layer:

-simple appositional

•Double layer:

  • double simple continuous
  • appositional or inverting
24
Q

Discuss testing your sutures?

A
  • Studies have shown no difference in bursting strengths between appositional v inverting so why complicate?
  • Trust your stitches don’t weaken them by squeezing
  • Do NOT test the bursting strength yourself
  • Tap layer of omentum over surgical site for insurance policy against leakage
25
Q

Discuss post-op care?

A
  • Monitor urination closely (mls/kg/hr if IDUC)
  • Ideally want more than 1ml/kg/hr if you have relieved an obstruction
  • Maintain IVFT to encourage it to produce urine
  • Monitor electrolytes especially K+ to ensure not gone from hyper to hypo
  • Elizabethan collar in patient with indwelling urinary catheter
  • ANALGESIA
  • Continue antibiotics if bacteria isolated in urine initially
26
Q

When is Partial Cystectomy indicated?

A
  • Most commonly done for resection of neoplasia in bladder
  • Fewer than 1% of canine and feline neoplasms
  • transitional cell carcinoma
  • leiomyoma/leiomyosarcoma

•Non neoplastic

  • polyp
27
Q

Discuss partial cystectomy surgery?

A
  • 60-75% bladder can be resected with minimal clinical signs (pollakiuria) , with time will regain original size
  • Avoid trigone to reduce need for ureteral re-implantation (are techniques but this is referral level. Can re-implant in colon which predisposes to tracking infections and urine scold)
  • Something at apex of the bladder it is easily resectable
  • To prevent seeding of neoplasia changes gloves and surgical kit once removed and closing.
28
Q

Discuss total cystectomy?

A
  • For neoplasia
  • Avoided due to high post-op morbidity
  • Vomiting, anorexia, neurological abnormalities, pyelonephritis
  • Metastases
29
Q

What treatment for non-resectable bladder neoplasias are there?

A

Chemo:

Piroxicam (may see vets use metacam instead of this as it is a similar drug to piroxicam but only proof in vivo that it works not in vitro. Piroxicam has been shown to be useful in vivo and in vitro but is not licensed and is very hard to get hold of and the safety threshold is very low whereas metacam has a better safety threshold so make sure owner is aware of all this), mitoxantrone, doxorubicin, cisplatin

30
Q

What can be seen here?

A

Bladder tumours. TCC at the trigone and can see filling deficit at neck of the bladder.

31
Q

What can be seen here?

A

Bladder tumours (leiomyoma at the apex which you could remove in its entirity and stitch up and be fine)

32
Q

Discuss Urinary Diversion?

A
  • Allows diversion of urine through the urethra
  • Most commonly done with a Tube cystostomy which bypasses the LUT
  • Allows urine drainage in ill patient prior to definitive urological surgery
  • Allows diversion of urine from bladder for months to years due to neoplasia or detrusor dysfunction (other options including stenting now available where you insert a metal mesh tube into bladder neck or urethra it is expensive make owners aware about half the cases are likely to have complications such as: chewing own tube out, leakage of urine around tube, infection, haematuria)
  • Aids healing of urethra after surgical repair
  • Percutaneously placed or via caudal laparotomy
33
Q

Discuss Tube Cystostomy?

A
  • Surgical method less demanding than percutaneous as the surgical method you can see what you’re doing
  • General anaesthetic
  • Caudal ventral midline incision
  • Locate bladder and place purse string suture in body, leave untied
  • Stab incision in centre purse string
  • Insert Foley or de Pezzer (mushroom tipped) catheter and inflate bulb saline
  • Tighten purse string
  • Perform cystopexy (suture bladder to body wall on inside)
  • Attach catheter to closed system and bandage
34
Q

Discuss tube placement in cystotomy?

A

Tube placement
Attention to the slight kink where the tube emerges from the bladder runs along inside of body wall and along then out through muscle and skin this helps prevent leakage whilst tube is in place but also when you pull tube out there is less of a chance of stoma (permanent hole) forming. If they were all in a line the wound may not heal and a stoma may occur.
Normally leave in place 5-7 days to remove deflate the bulb and removed and allow wounds to heal by secondary intention.

35
Q

Discuss Complications of Bladder Surgery?

A

Uroperitoneum

–Dehiscence (don’t rule this out if they are still producing urine, can still produce some urine with a significant bladder tear)

–Abdominal ultrasound

–Abdominocentesis; creatinine/k+ exceed serum values (K+ abdo fluid:blood ratio of >1.4:1=definitive for uroabdomen, elevated 92% cases)

–Not normally associated with bacterial peritonitis as urine is normal sterile only happen from bacterial contamination

–Bloods

–Do not rule out dehiscence because some UOP remains

36
Q

Discuss the anatomy of the urethra?

A
37
Q

What are the indications for Urethral Surgery?

A
  • Traumatic tears (idiopathic!)
  • Obstruction – urolith (most common) (recurrent & non responsive to med Tx)
  • stricture (consider stent)
  • Urethral rents in horses
  • Neoplasia
  • Congenital disorders – hypospadias (their urethra opens at the wrong point rather than being at tip it opens ventral and caudal anywhere along its length and in more than one place)
38
Q

Discuss Urethral Trauma causes and diagnosis?

A
  • Pubic fractures
  • Uroabdomen or urine collects in subcutaneous tissues
  • Partial tears-normal urination or some haematuria
  • Uraemia
  • Positive contrast urethrocystography
39
Q

Discuss Treatment of Urethral Rents in equids?

A
  • Associated with over the top mating behaviour and reproductive rest often indicated
  • Incomplete lacerations will often heal if intraurethral catheter placed for 3 weeks
  • Large stricture risk
  • Large tears or avulsion require surgery (diff surgery consider referral)

–Caudal celiotomy +/-pubic symphysiotomy/pubic osteotomy if intrapelvic

–Catheterize urethra , occasional cystotomy necessary to do this

–Debride ends

–Suture with 5-0 monofilament suture, simple interrupted pattern

–Try to avoid tension as increases stricture risk

–Rectus abdominis or obturator flaps can be raised to reinforce

–Leave urinary catheter in place for 7-10 days

40
Q

Discuss indications urethrostomy?

A
  • recurrent obstructive episodes
  • urethral stricture
  • urethral or penile neoplasia/trauma
  • preputial neoplasia requiring penile amputation
41
Q

Discuss the various techniques for Urethrostomy?

A

–Prescrotal (more common in dogs as obstruction near os penis)

–Scrotal

–Prepubic

–Perineal (most common way to do it in cats, in dogs avoid that as you’ll get scalding and at that perineal site dogs have a lot of cavernous tissue and lies deep in dogs)

42
Q

Discuss Feline Perineal Urethrostomy indications?

A
  • FLUTD
  • Obese, indoor cat
  • MALE
  • Recurrent obstructive episodes (2nd or 3rd)
  • Urethral stricture post obstruction/catheterisation
  • Stabilise as previously discussed
  • Idea is to remove narrow section of urethra where plugs tend to form
  • Constant recurrent episodes are life threatening to cat and need to be treated.
43
Q

How is Feline Perineal Urethrostomy surgery done?

A
  • Sternal recumbency
  • Purse string suture in anus
  • Catheterise penis if possible
  • Elliptical incision around scrotum and prepuce
  • Blunt dissect penis free from attachments in pelvic canal
  • Identify ischiocavernosus muscles
  • Don’t dissect too dorsally as that is where the pudendal nerve is and if you dissect it they become faecally incontinent
  • Ischiocavernosus muscles cut, bleed
  • Dissect fibrous tissue attaching penis to pubis
  • Minimal dorsal dissection due to penile innervation
  • Dissect cranially until bulbourethral glands identified
  • Incise urethra in dorsal midline to level of bulbourethral glands, diameter here 4-5mm
  • Suture wall of urethra to skin using 4-0 or 5-0 monofilament absorbable or non-absorbable suture, interrupted pattern
  • Transect penis

(pic) Finished Urethrostomy (creating a permanent stoma in urethra which is more proximal than it’s original opening)

44
Q
A
45
Q

Discuss Complications of Perineal Urethrostomy?

A
  • Haemorrhage
  • Stricture formation theoretical risk if you don’t make stoma large enough
  • know anatomy
  • make incision large enough
  • Bacterial cystitis (owner needs to be aware that the animal is more prone to this)
  • Urinary/faecal incontinence if pudendal nerve damage-but rare
  • Urine leakage into subcutaneous tissues which may lead to dehiscense of wound
46
Q

What are the instructions to the owners after feline perineal urethrostomy?

A
  • Buster collar whilst healing
  • Non-absorbent litter eg newspaper
  • Some haemorrhage expected for 5-7 days post op in urine
  • Vaseline good idea ventral to surgical site to prevent some of the scalding you may get
  • ?Urine culture (2-4 times a year even if asymptomatic is ideal to keep on top of UTI)
47
Q

Discuss how to do a renal biopsy?

A

•Percutaneous ultrasound guided, laparoscopic or surgical

DO NOT do it blindly…

  • Surgical method allows direct visualisation of both kidneys
  • Needle, Tru-cut, Wedge
48
Q

What are the complications of renal biopsy?

A

Complications:

  • fatal haemorrhage
  • renal failure
  • urinary leakage
  • hydronephrosis
49
Q

What are the contra-indications for percutaneous renal biopsy?

A

•Contraindications for percutaneous include:

  • coagulopathy
  • hypertensio
  • abscess/cyst/pyelonephritis
  • end stage CRF
  • inexperience
  • lack of equipment
50
Q

How should you manage fluid for renal biopsy?

A
  • Use IVFT to avoid hypotension and prior to provide mild diuresis reducing risk clot formation
  • Spring loaded device e.g. Tru-Cut
  • Apply pressure to site
  • Avoid biopsy of renal pelvis leading to urine leakage
51
Q

How do you do a wedge biopsy of the kidney?

A
  • Incise renal parenchyma
  • Make second incision at angle to first
  • Include cortex
  • Close with 3-0 mattress suture, absorbable material
52
Q

What are the Indications for Nephrectomy?

A
  • Neoplasia
  • Trauma leading to haemorrhage or urine leakage/idiopathic renal haemorrhage
  • End stage kidney disease
  • Resistant pyelonephritis
  • Ureteral abnormalities e.g. stricture, calculi
  • Ureteral rupture
53
Q

Discuss how to perform a nephrectomy?

A

•Must ensure other kidney is functional!

e.g. scintigraphy, excretory urogram

  • Caudal laparotomy
  • Incise peritoneum over kidney
  • Free kidney from sublumbar attachments
  • Elevate and retract medially
  • Locate renal artery and vein (beware extra arteries!)
  • Double ligate vessels individually close to aorta
  • Ligate ureter close to bladder
  • Remove kidney and ureter and submit for histology.

URI 2 (44 decks)

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