Use of cystoscopic-guided laser ablation for treatment of intramural ureteral ectopia in male dogs: four cases (2006-2007)

OBJECTIVE: To describe and evaluate the outcome of cystoscopic-guided laser ablation of intramural ureteral ectopia in male dogs. DESIGN: Retrospective case series. ANIMALS: 4 incontinent male dogs with intramural ureteral ectopia. PROCEDURES: Intramural ectopic ureters were diagnosed via preoperative computed tomography-IV urography and subsequent cystoscopy. Transurethral cystoscopic-guided laser ablation (diode laser [n = 3 dogs] and holmium:yttrium aluminum garnet laser [1]) was performed to proximally relocate the ectopic ureteral orifice to the urinary bladder. Fluoroscopy was used during the procedures to confirm that the ureteral tract was intramural and the ureteral orifice was intravesicular after the procedure. In 1 dog with bilateral ureteral ectopia, staged laser ablation was performed at 6-week intervals because of difficulty viewing the second ureter on the first attempt. All ureteral orifices were initially located in the middle to proximal portion of the prostatic portion of the urethra. Six weeks after surgery, imaging was repeated in 3 of 4 dogs. RESULTS: Postoperative dysuria or hematuria did not develop. All dogs were immediately continent after laser treatment and remained so at a median follow-up period of 18 months (range, 15 to 20 months) without medical management. Conclusions and CLINICAL RELEVANCE: Ureteral ectopia can cause urinary incontinence in male dogs and is usually associated with other urinary tract abnormalities. Cystoscopic-guided laser ablation provided an effective and minimally invasive alternative to surgical management of intramural ureteral ectopia.     

ULTRASONOGRAPHIC FINDINGS IN 14 DOGS WITH ECTOPIC URETER

To evaluate ultrasonography as an alternative to contrast radiography for diagnosis of ectopic ureter in dogs, ultrasonography of the urinary tract was performed prospectively in a series of urinary incontinent dogs anesthetized for contrast radiography. Fourteen dogs had ectopic ureter based on surgical, necropsy or unequivocal contrast radiographic findings. There were eight females and six males of a variety of breeds; five were Labrador retrievers. Mean (range) age at the time of diagnosis was 1.2 (0.2–4) years for females and 3.5 (0.3–5) for males (p < 0.05). Ectopic ureters were unilateral in five dogs (2 left; 3 right) and bilateral in nine dogs. Both ultrasound images and contrast radiographs were positive for 21 (91%) ectopic ureters; the same two ectopic ureters were not detected using either modality. The termination of each of the five normal ureters was visible on ultrasound images; two (40%) were visible on radiographs. Other ultrasonographic findings included dilatation of the ectopic ureter and/or ipsilateral renal pelvis in ten (43%) instances, evidence of pyelonephritis in two dogs (with enlargement of the contralateral kidney in one dog), and urethral diverticuli in one dog. Ultrasonography is a practical diagnostic test for ectopic ureter in dogs. In this series there was close correlation between the ultrasonographic and contrast radiographic findings for each ectopic ureter, but ultrasonography enabled more accurate determination of normal ureteral anatomy.     

Ureteral Function and Healing Following Microsurgical Transureteroureterostomy in the Dog

An oblique end-to-side anastomosis of one ureter to the contralateral ureter (transureteroureterostomy) may permit salvage of a kidney whose middle or distal ureter is not salvageable by standard repair techniques. This procedure was done with intraoperative magnification and microsurgical techniques in 5 experimental dogs. Animals were euthanized for healing studies at 1, 3 and 5 weeks, and the results correlated with postoperative and preterminal excretory urograms. Healing of the anastomosis was organized by layers and completed both grossly and histologically in all animals at 5 weeks. Ureter function was retained except for short-term, mild, postoperative hydroureter. Potential clinical indications for transureteroureterostomy are: 1) middle or distal ureteral transection due to trauma; 2) delayed recognition of iatrogenic intraoperative severence or ligation; 3) distal ureteral neoplasia; and 4) selected cases of ectopic ureter. Complications include dehiscence, stricture, or the dissemination of infection or neoplasia which would compromise proximal ureters and both kidneys.     

Surgical treatment of a duplicated and ectopic ureter in a dog

An eight‐month old female bull mastiff was referred for evaluation of urinary incontinence. Contrast‐enhanced computed tomography identified complete duplication of the left ureter with ectopic insertion of the duplicate ureter into the proximal urethra. Ureteroneocystostomy was performed, which improved but did not resolve urinary continence. To the authors’ knowledge, this report details only the second reported case of duplicated ectopic ureter in the dog and the first documenting surgical reimplantation; thus, double‐system ureteral ectopia should be considered as a possible differential diagnosis for urinary incontinence.     

URETERAL DIVERTICULA IN TWO DOGS

We describe ureteral diverticula in two dogs and briefly review the related literature. The diagnosis of this condition is radiographic and based on the excretory urographic observation of multiple ureteral outpouchings. Pathologically, ureteral transitional cell hyperplasia and mucinous metaplasia result in submucosal proliferation of the urothelium and the formation of crypts and small cysts. Ureteral diverticulosis in humans is associated with an increased risk of urothelial malignancies, such as transitional cell carcinoma of the urinary bladder. Clinically, both dogs were older, small breed neutered females. Both had a history of chronic urinary obstruction. One dog died during surgery to remove an adrenal mass, and the other was euthanized at the owner's request because of an inoperable bladder neoplasm. Histopathologic diagnosis of ureteral lesions confirmed the radiographic diagnosis of ureteral diverticula in both dogs.     

Management of ureteral obstruction.

The most common cause of ureteral obstruction in dogs and cats is ureteral calculi. Common clinical signs associated with ureteral obstruction include abnormalities in urination, persistent urinary tract infection, abdominal pain, vomiting, anorexia, weight loss,and depression or lethargy. Medical management of ureteral obstruction includes fluid diuresis, muscle relaxants, and treatment of azotemia using nephrostomy tubes or hemodialysis. Surgical techniques used to restore patency to the ureter include ureterotomy,partial ureterectomy and ureteroneocystostomy, and ureteral resection and anastomosis. Lithotripsy has been used in dogs to remove ureteral calculi. Renal function can be preserved if complete ureteral obstruction is relieved within several days of onset.     

Urinoma (para-ureteral pseudocyst) as a consequence of trauma in a cat

A two-year-old cat was involved in a road traffic accident. Survey abdominal radiographs and urinary function were considered unremarkable. Six weeks later the cat presented with a palpable dorsal abdominal mass. Radiography revealed a soft tissue opacity mass caudal to the right kidney. Ultrasonography revealed a cyst-like structure with moderately echogenic contents, and right-sided hydronephrosis. There was no excretion of contrast medium from the right kidney after intravenous urography. Surgery revealed a disrupted right ureter adherent to the retroperitoneal mass. The mass contained serosanguineous fluid consistent with extravasated urine. Ureteronephrectomy was performed. The majority of the mass was excised and the cavity ablated. Histopathology of the excised tissue revealed a thick fibrous wall with no epithelial lining, consistent with a urinoma, which is thought to have developed as a consequence of ureteral trauma. The cat was clinically well three months postoperatively.     

Nephroliths and ureteroliths: a new stone age

Nephroliths may obstruct the renal pelvis or ureter, predispose to pyelonephritis, or result in compressive injury of the renal parenchyma leading to progressive chronic kidney disease. Indications for removal of nephroliths in dogs include obstruction, recurrent infection, progressive nephrolith enlargement, presence of clinical signs (renal pain), and patients with nephroliths in a solitary functional kidney. The most common indication for removal of upper tract uroliths in cats is ureteral obstruction caused by ureteroliths. Nonobstructive nephroliths in cats are not usually treated unless they move into the ureter resulting in ureteral obstruction.

The treatment approach to nephroliths and ureteroliths is different for dogs versus cats. Surgical removal of nephroliths or ureteroliths by nephrotomy and ureterotomy respectively is associated with potential for complications in more than 30% of cats treated by ureterotomy; therefore, minimally invasive options should also be considered. Extracorporeal shock wave lithotripsy (ESWL) treatment of nephroliths results in small “passable” stone fragments in most dogs, whereas ESWL does not work effectively in cats. Ureteral stents are effective for relief of ureteral obstruction by ureteroliths in both dogs and cats. Ureteral stents may be left in place long-term to relieve ureteral obstruction by ureteroliths. Post-operative morbidity and mortality are substantially lower for ureteral stent placement compared to open surgical ureterotomy in cats.     

Ureteral mast cell tumor in a dog

A 6-year-old, castrated male, mixed-breed dog was diagnosed with partial unilateral ureteral obstruction secondary to a ureteral mass. The ureteral mass was surgically resected, and an ureteroneocystostomy was performed. Histopathology of the ureteral mass was consistent with a poorly differentiated mast cell tumor (MCT). The patient recovered well but was euthanized 5 months postoperatively for central nervous system signs. A choroid plexus tumor was diagnosed during necropsy examination. There was no evidence of recurrence or dissemination of the ureteral MCT. Extracutaneous MCTs are rare in dogs, and primary MCT associated with the urinary tract has not previously been reported in the veterinary literature.     

Ureteral obstruction after ureteroneocystostomy in dogs assessed by technetium TC 99m diethylenetriamine pentaacetic acid (DTPA) scintigraphy

OBJECTIVE: To use technetium Tc 99m diethylenetriamine pentaacetic acid (99mTc-DTPA) renal scintigraphy to monitor ureteral obstruction after ureteroneocystostomy in a canine model of partial ureteral obstruction. STUDY DESIGN: Experimental study. ANIMALS: Eight normal adult dogs. METHODS: Partial ureteral obstruction was created in 8 dogs by incomplete ligation of the terminal right ureter. Two weeks later, ureteroneocystostomy was performed in 7 dogs with unilateral partial ureteral obstruction and in 1 dog that had developed bilateral partial ureteral obstruction. 99mTc-DTPA scintigraphy was performed intermittently for 2 weeks after ureteroneocystostomy. Renal transit time of each kidney, as assessed by the time to maximal uptake (time of peak), and glomerular filtration rate, as assessed by percentage of kidney uptake of the radiopharmaceutical between 1 and 3 minutes, were estimated. Comparison between affected and nonaffected kidneys was performed with the Wilcoxon rank sum test. RESULTS: Unilateral partial ureteral obstruction was induced successfully in 7 dogs. In 1 dog, bilateral partial obstruction was induced inadvertently. After ureteroneocystostomy, percentage of kidney uptake of 99mTc-DTPA was low in 4 affected kidneys. The uptake returned to within normal limits in 2 of the kidneys during the observation period. The time activity curve had a more rounded appearance or was increasing continuously for all affected kidneys. A significant increase in renal transit time was observed 2 and 4 days after ureteroneocystostomy. Transit time progressively returned to normal by 4 to 11 days for all affected kidneys except 1. CONCLUSION: Ureteroneocystostomy resulted in persistent partial ureteral obstruction for 4 to 11 days as determined by 99mTc-DTPA scintigraphy. CLINICAL RELEVANCE: 99mTc-DTPA scintigraphy may be a useful procedure for monitoring renal function and ureteral obstruction after ureteroneocystostomy. Persistent partial ureteral obstruction may be seen 1 to 2 weeks after ureteral reimplantation in dogs with previously existing dilated ureters.     

Polypoid cystitis in 17 dogs (1978-2001)

Polypoid cystitis is a rare disease of the urinary bladder in dogs characterized by inflammation, epithelial proliferation, and development of a polypoid mass or masses without histopathologic evidence of neoplasia. Medical records of 17 dogs with polypoid cystitis were reviewed to determine the clinical and laboratory features of this disorder and to assess treatment and outcome. Most affected dogs (15/17) were female and presented for evaluation of hematuria or recurrent urinary tract infection (UTI). Proteus spp were the most common bacterial isolates (12/52 or 23.1%) identified when all urine samples obtained for culture at any time during the course study were considered. Other commonly isolated organisms included Escherichia coli , Staphylococcus spp, and Enterococcus spp. Several dogs (7/17) also had cystic calculi at some time during the course of their disease. Most of the masses (11/14) were located cranioventrally in the bladder as opposed to transitional cell carcinoma, which has a predilection for the bladder neck or trigone area. It is unknown whether persistent or recurrent UTI predisposes to polyp formation or if polyps predispose to UTI. Surgery and removal of all polyps was the most efficacious treatment in dogs of this study. The question of whether or not polyps represent preneoplastic lesions remains unanswered and constitutes an area for future investigation.     

Reduction of hydronephrosis and hydroureter associated with ectopic ureters in two dogs after ureterovesical anastomosis

Severe hydronephrosis and hydroureter associated with ectopic ureters were diagnosed in 2 dogs. Surgical transplantation of the ectopic ureters into the urinary bladder resulted in urinary continence in both dogs. Intravenous urography revealed a marked decrease in the size of hydronephrosis and hydroureter in both dogs 28 to 35 weeks after surgery. In 1 dog with bilateral ureteral ectopia, kidney size and renal function remained normal for 5 years after surgery. A dog with one ectopic ureter and an associated ureterocele had a marked reduction in size of the affected kidney and an apparent decrease in function of that kidney, as indicated by decreased opacification on an intravenous urogram.     

Delayed-onset urinary incontinence in five female dogs with ectopic ureters

This case series describes five female dogs with congenital ectopic ureter presenting with delayed-onset urinary incontinence out of 22 female dogs diagnosed with ectopic ureter over a 102-month period at a veterinary teaching hospital. All five dogs improved following surgical treatment of ectopic ureter, but only three remained continent long-term without further intervention. Delayed-onset urinary incontinence in female dogs with ectopic ureters may be more common than the current literature suggests. Congenital ectopic ureter should be considered and investigated as a possible contributing factor in female dogs presenting with delayed-onset urinary incontinence.     

Plasma and urinary trypsinogen activation peptide in healthy dogs, dogs with pancreatitis and dogs with other systemic diseases

OBJECTIVE: To determine the specificity and sensitivity of plasma and urinary trypsinogen activation peptide (TAP) concentrations in diagnosing pancreatitis in dogs. DESIGN: Retrospective analysis of clinical cases. PROCEDURE: Dogs were classified into three groups: healthy animals, dogs with confirmed pancreatitis and dogs with nonpancreatic disease, which clinically or biochemically resembled pancreatitis. This last group was further subdivided into dogs with renal and those with nonrenal disease. The plasma and urinary TAP concentration was determined by a competitive enzyme immunoassay. Clinical cases additionally had serum trypsin-like immunoreactivity concentration measured, as well as radiography and ultrasound of the abdomen and further diagnostic procedures. Nonparametric analysis of variance (Kruskal-Wallis test) was performed using Statistix 4.0 program. RESULTS: There was a wide range of urinary TAP concentration in healthy dogs (mean 52.30 nmol/L, standard deviation 55.25) that made interpretation of urinary TAP concentrations difficult in the other groups. There was a narrow reference range for plasma TAP (mean 2.67 nmol/L, standard deviation 0.93). Plasma and urinary TAP concentrations, as well as urinary TAP to creatinine ratio, were all increased in dogs that died with necrotising pancreatitis. Values were not increased in mild, interstitial pancreatitis. Increased plasma TAP concentrations were also present in dogs with severe renal disease. CONCLUSION: Plasma TAP concentration is a good prognostic indicator in naturally occurring pancreatitis in dogs. The failure of TAP to increase in mild pancreatitis, and the increase present in severe renal disease, suggests its measurement has limited application as a sole diagnostic tool for canine pancreatitis. Further investigations are required in order to explain the large variability of urinary TAP concentration and the presence of circulating TAP in healthy dogs.     

Cystoscopy: techniques and clinical applications

Cystoscopy is a powerful tool for characterization of lower urinary tract disease in dogs and cats. Current applications of cystoscopy include diagnostic and interventional techniques. This article reviews cystoscopy equipment, procedures, and common applications of cystoscopy. A review of normal anatomy and common lower urinary tract lesions identifiable with cystoscopy is also presented.     

Treatment of ureteral calculus obstruction with laser lithotripsy in an Atlantic bottlenose dolphin (Tursiops truncatus)

An adult female bottlenose dolphin (Tursiops truncatus) presented with acute anorexia secondary to progressive azotemia (blood urea nitrogen = 213 mg/dl, creatinine [Cr] = 9.5 mg/dl) and electrolyte abnormalities (K = 7.4 mEq/L). It was later diagnosed with postrenal obstruction secondary to bilaterally obstructing ureteral calculi seen on ultrasound. Treatment of the obstruction required two endoscopic procedures, cystoscopy for ureteral stent placement and ureteroscopy to perform intracorporeal lithotripsy on the obstructing calculi. Before the first procedure, the dolphin's azotemia was stabilized with aggressive fluid therapy, peritoneal dialysis, and treatment for acidosis. Diuresis subsequent to the fluid therapy enabled passage of the right obstructing urolith. For both endoscopic procedures, the dolphin was placed in left lateral recumbency due to the peritoneal dialysis catheter in the right retroperitoneal region. For the first procedure, a 12-French (Fr) flexible cystoscope was inserted retrograde into the bladder via the urethra, whereupon a calculus was seen obstructing the left ureteral orifice. A 4.8-Fr, 26-cm double-pigtail ureteral stent was placed up the left ureter to relieve the postrenal obstruction. Inadvertent proximal migration of the left ureteral stent occurred during the procedure. However, renal parameters (serum Cr = 5.8, K = 5.4) improved significantly by the next day. For the second procedure, 28 hr later, ureteroscopy was performed to treat the calculus and replace the existing stent with a longer stent. The left ureteral calculus was pulverized into tiny fragments by using a holmium:yttrium-aluminum-garnet laser inserted through a 6.9-Fr semirigid ureteroscope. The migrated stent was visualized in the distal left ureter and replaced with a 90-cm single-pigtail ureteral stent that was sutured exterior to the urogenital slit and removed 3 days later. Renal function normalized over the next several days, and the dolphin recovered over the next 2 mo.     

Effect of partial ureteral obstruction on results of renal scintigraphy in dogs

OBJECTIVE: To use scintigraphy to determine the effects of partial ureteral obstruction on renal transit time and induction of diuresis in dogs. ANIMALS: 8 adult dogs. PROCEDURE: Scintigraphy was performed, using technetium Tc 99m diethylenetriaminepentacetic acid (Tc 99m-DTPA), before and within 2 weeks after surgical induction of unilateral partial ureteral obstruction. Time of peak (TOP) for the parenchyma (pTOP) and whole kidney (wTOP) and mean-transit time (MTT) for the parenchyma (pMTT) and whole kidney (wMTT) were determined by evaluation of renal time-activity curves before and after deconvolution analysis. Percentage uptake for each kidney between 1 and 3 minutes after injection of Tc 99m-DTPA was determined and used to indicate glomerular filtration rate. The effect of diuresis was determined by measuring the slope of decrease in activity after i.v. administration of furosemide. Obstruction was documented by direct inspection of the ureter. RESULTS: There was a concomitant increase in pTOP, wTOP, pMTT, and wMTT of the kidney with the partially obstructed ureter in all dogs at various times between 2 and 9 days after surgery. Concurrently, renal time-activity curves changed shape. Percentage renal uptake of the affected kidney was decreased in 2 dogs. Response to furosemide injection was inconsistent for kidneys before surgery and for kidneys with obstructed and nonobstructed ureters after surgery. CONCLUSIONS AND CLINICAL RELEVANCE: Scintigraphy may be a useful procedure for the evaluation of renal function in dogs with ureteral obstruction. Induction of diuresis appears to be of little value for differentiating renal function in dogs with obstructed and nonobstructed ureters.     

USE OF ULTRASOUND-GUIDED FINE-NEEDLE ASPIRATION BIOPSY AND AUTOMATED CORE BIOPSY FOR THE DIAGNOSIS OF GASTROINTESTINAL DISEASES IN SMALL ANIMALS

The purpose of this study was to evaluate the usefulness of ultrasound-guided fine-needle aspiration biopsy and core biopsy in the diagnosis of infiltrative gastrointestinal diseases. Six dogs and seven cats with clinical signs of gastrointestinal disease underwent ultrasonography and intestinal lesions were identified. One or more ultrasound-guided fine-needle aspiration biopsy and/or core biopsy procedures were performed in each patient. Each patient also underwent one of the following additional procedures for comparison of results: 1) surgery (n=4), 2) endoscopy (n=2), 3) post mortem exam (n=3), and, 4) for lymphoma diagnosed with ultrasound-guided procedures, response to chemotherapy (n=4). Correct diagnoses were obtained in nine of the 13 patients, incorrect diagnoses in two of the 13 patients, and inconclusive diagnoses in two of the thirteen patients. Of the 16 total ultrasound-guided procedures performed, ten were confirmed as correct, three as incorrect, and three were non-diagnostic. Intestinal lesions with bowel wall thickness greater than 2.0 cm had a higher percentage of correct diagnoses than lesions of lesser wall thickness. Gastric lesions had a higher percentage of correct diagnoses than small and large intestinal lesions. Malignant lesions had a higher percentage of correct diagnoses than benign lesions. There were no complications. Ultrasound-guided gastrointestinal fine-needle aspiration biopsy and core biopsy appears to be a safe, accurate, and rapid procedure for use in the diagnosis of infiltrative gastrointestinal disease.     

Ureteral fibroepithelial polyp in an owl monkey (Aotus nancymae)

Ureteral fibroepithelial polyps are benign mesodermal tumors in humans that occur predominantly in the proximal ureter. During a routine necropsy of a wild-caught, research na?ve, adult, male, Aotus nancymae, the left ureter just distal to the renal pelvis contained a pedunculated, lobulated neoplasm with a narrow stalk at the base projecting into the lumen. The left renal pelvis was found to be mildly dilated. The histologic characteristics of the ureteral mass were consistent with a fibroepithelial polyp. To our knowledge, this is the first report describing a ureteral fibroepithelial polyp in a nonhuman primate.     

The cytologic and histologic diagnosis of ureteral fibroepithelial polyp in a dog

A 6-year-old, intact male, brindled, 30-Lb English Bulldog presented to the Purdue University Veterinary Teaching Hospital with a recurrent history of hematuria, periuria, and lethargy that responded temporarily to antibiotic therapy. The work-up included a complete blood count, serum biochemical profile, complete urinalysis, diagnostic imaging (abdominal radiographs and ultrasound with contrast urography), and exploratory laparotomy. The diagnostic imaging findings and subsequent exploratory revealed a unilateral, intraluminal, right-sided, 3-cm ureteral mass extending from the proximal ureter into the renal pelvis. Subsequently, a unilateral right-sided ureteronephrectomy followed by biopsy with cytopathology/cytology (impression smears) and histopathology of the ureteral mass was performed. The cytopathologic interpretation was benign mesenchymal proliferation with mildly atypical urothelial cells. The association of this mass with vascular tissue and a benign nuclear appearance on cytology is similar to reports of fibroepithelial polyps (FEPs) and myxomatous tumors. Histopathology diagnosed the mass as an FEP. Cytopathology proved useful in the presumptive diagnosis of this benign urothelial polyp. To the authors' knowledge, this is the first report using cytopathology to depict and characterize FEPs in veterinary and human medical literature.