Reconstruction of the urethra by use of an inverse tubed bipedicled flap in a dog with hypospadias

CASE DESCRIPTION: A 1-year-old castrated male German Shepherd Dog was evaluated because of a history of hematuria and stranguria secondary to recurrent urinary tract infections. CLINICAL FINDINGS: Physical examination revealed hypospadias with penile and preputial aplasia. The urethral orifice was just ventral to the ventral aspect of the anocutaneous junction. Ascending urinary tract infections, secondary to fecal contamination of the urethral orifice, were the presumed source of recurrent bouts of cystitis that developed despite periodic antimicrobial treatment. TREATMENT AND OUTCOME: A 1-cm-diameter urethral extension was constructed from the urethral mucosal remnant located along the midline of the perineum (urethral trough). Two parallel 4-cm incisions (3 cm apart) were made lateral to that urethral trough. The borders were sutured to form an inverted, epithelium-lined tube (bipedicled flap) attached to the dorsal urethral orifice. The lateral skin margins were sutured over the reconstructed urethral extension, completing the procedure. Postoperative swelling necessitated temporary catheterization of the urinary bladder. After closure of a small fistula from the reconstructed urethral segment, the dog subsequently had only 2 episodes of cystitis during a 3-year period. To minimize skin irritation secondary to urine exposure, the dog's owner regularly trimmed the hair around the new urethral orifice. CLINICAL RELEVANCE: In dogs, correction of perineal (subanal) hypospadias via urethral reconstruction should be considered among treatment options. By use of an inverse tubed urethral extension, direct fecal contamination to the lower urinary tract may be effectively eliminated, dramatically reducing the incidence of ascending urinary tract infections in dogs with hypospadias.     

Single stage urethroplasty for perineal hypospadias in a foal

The incidence of hypospadias is increasing in man, but the condition is rarely reported in horses. There are few available data regarding the surgical management of this disorder in horses, with no previous published report of urethral reconstructive surgery and only two reports documenting phallectomy procedures. This case report documents hypospadias repair, not previously reported in the horse, in a Thoroughbred foal with proximal hypospadias. The indication for surgery was contact dermatitis of the hind leg, which was impairing the foal's ambulation and had the potential to impair the foal's racing ability. Preoperative examination revealed a proximal hypospadias with a wide urethral plate. The anus was normal. The foal was otherwise thriving. A single stage urethroplasty was performed, during which the urethral plate was tubularised in two layers and the urethral meatus was successfully relocated distally to open upon the glans. The urethroplasty was covered with dartos fascia and the penile shaft skin and prepuce were reconstructed. Minor superficial dehiscence of the wound was successfully managed conservatively. Post‐operatively, urine was voided through the opening created on the glans penis, resolving the contact dermatitis. Follow‐up after 3 years confirmed that the horse continues to void through the re‐sited meatus without complication and had gone on to race successfully. In conclusion, we present the first report of reconstructive urethroplasty for the treatment of a horse for proximal hypospadias with good functionality and long‐term outcome.     

Long-Term Efficacy of a Percutaneously Adjustable Hydraulic Urethral Sphincter for Treatment of Urinary Incontinence in Four Dogs

Objective— To evaluate the efficacy of a surgically placed, static hydraulic urethral sphincter (SHUS) for treatment of urethral sphincter mechanism incompetency (USMI).
Study Design— Prospective study.
Animals— Spayed female dogs (n=4) with acquired USMI.
Methods— Urinary incontinence was assessed using a subjective continence score before and after implantation of an SHUS on the proximal urethra via ventral median celiotomy. Dogs were assessed for urinary continence, urinary tract infections, and implant-associated complications for 30 months. Residual incontinence was treated with percutaneous inflation of the SHUS with sterile saline solution through a biocompatible subcutaneous administration port.
Results— At last follow-up (26–30 months after surgery), continence scores improved from a median preoperative score of 3/10 to a median postoperative score of 10. One dog developed wound drainage over the subcutaneously placed administration port but remained continent after port removal. Three occluders were percutaneously filled with additional saline (median, 0.18 mL; mean, 0.16 mL) to improve continence after surgery.
Conclusions— Application and adjustment of an SHUS provided sustained improvements in continence score in all dogs.
Clinical Relevance— In this pilot study, 3 of 4 dogs with hydraulic urethral sphincter implantation had successful percutaneous adjustment and maintained improved continence scores for 2 years after surgery. Continence was maintained in the 4th dog even after administration port removal. Based on this pilot study, the SHUS warrants further clinical evaluation for treatment of dogs with USMI unresponsive to medical management.     

A case of hypospadias in a dog

: This clinical case report described a three-month-old mongrel dog that had the urethral orifice opening 3 cm from the tip of the penis and lacked a completely formed preputial sheath. It was presented to the clinic with an exposed penile shaft that was dry. The dog had urinary incontinence that was not of neurological origin. It also had unilateral agenesis of the right testicle. The preputial sheath was successfully reconstructed. Urinary incontinence stopped soon after surgery, suggesting that it had been probably due to an ascending urethritis. A large preputial opening was left because of the location of the urethral opening.     

Use of a preputial circumferential mucosal flap for hypospadias management in a Boston terrier

An eight-week-old male Boston terrier presented for penile desiccation and urine pooling in the prepuce due to congenital hypospadias. An advancement flap was created from the dorsal mucosa of the incompletely formed prepuce and sutured circumferentially to construct a longer distal preputial mucosa. V- to Y-plasty of the ventral abdominal skin was utilised to create the preputial skin overlying the mucosal flap. Urethrostomy and partial penile amputation were also performed. Following surgery, the clinical signs of penile desiccation and preputial urine pooling resolved and acceptable cosmetic appearance was achieved. This technique may be considered for glandular or penile hypospadias or following resection of the ventral aspect of the distal prepuce when inadequate tissue is present for a simple two-layer closure of the preputial mucosa and skin.     

Prevalence of bacterial urinary tract infection after perineal urethrostomy in cats.

It has been reported that the prevalence of bacterial urinary tract infection (UTI) increases after perineal urethrostomy in male cats. Perineal urethrostomy, using a surgical technique preserving striated urethral sphincter function, was performed on 2 groups of cats. The first group consisted of healthy castrated cats. The second group of cats had recurrent or persistent urethral obstruction. All cats had normal urethral sphincter function after surgery, as measured by urethral pressure profilometry and electromyography. Long-term periodic urinalysis and bacterial culturing of urine was performed on all cats. Twenty-two percent of the previously obstructed cats had recurrent bacterial UTI, compared with none of the healthy cats. On the basis of these findings, we suggest that perineal urethrostomy per se does not predispose cats to bacterial UTI, but surgical alteration of the urethral meatus combined with an underlying uropathy may increase the prevalence of ascending bacterial UTI after surgery.     

Perineal urethrostomy versus dietary management in prevention of recurrent lower urinary tract disease

The frequency and cause of recurrent lower urinary tract disease was compared prospectively in three groups of 10 male cats during a one year period following correction of obstructive urethropathy caused by matrix-crystalline plugs. One group of cats was managed by perineal urethrostomy, one group with a calculolytic diet, and the third group by perineal urethrostomy and the calculolytic diet. Ten episodes of bacterial urinary tract infection developed in five of 10 cats with perineal urethrostomies; six episodes of bacterial urinary tract infection developed in four of 10 cats with perineal urethrostomies and consuming the calculolytic diet. Bacterial urinary tract infections were not observed in cats managed only with the calculolytic diet. Staphylococcal-induced struvite urocystoliths developed in two cats with perineal urethrostomies. Vesicourachal diverticula detected in nine cats at the time of diagnosis of urethral obstruction healed spontaneously following restoration of urethral patency and remission of clinical signs. Transient microscopic haematuria was observed in approximately 25 per cent of the cats in all three treatment groups during the one year study. Results of this study confirm the effectiveness of dietary management in prevention of recurrent urethral obstruction caused by struvite-containing urethral precipitates, and verify that recurrent signs of lower urinary tract disease in cats may be caused by agents that are different from those that initiate the problem. They also confirm that perineal urethrostomies predispose cats to recurrent ascending bacterial urinary tract infections.     

Proximal Urethral Reconstruction Using a Distally Based Ventral Bladder Tube Flap An Experimental Study

Reconstruction of the proximal urethra using a distally based tube flap mobilized from the ventral bladder wall was performed on 12 clinically normal dogs after total prostatectomy and resection of 2 cm of membranous urethra. One dog was euthanized at 6 hours and one at 36 hours after surgery because of surgical complications. Five dogs were euthanized at 10 days, two dogs at 6 weeks and three dogs at 12 weeks. Advancement of the tube flap allowed for tension-free anastomosis to the membranous urethra. Vascular integrity was maintained in all flaps. Intermittent to continuous postoperative urinary incontinence occurred in 7 of 10 dogs. The incontinence was transient in all 6 and 12 week dogs except one in which a persistent stress incontinence developed. Mild to severe dysuria was noted in 8 of 10 dogs, but was also transient in all of the 6 and 12 week dogs, with the exception of one dog. Postoperative urethral closure pressure profilometry revealed decreased tone in the membranous urethra in all 6 and 12 week dogs. It was concluded that proximal urethral reconstruction, using a ventral bladder tube flap, is a viable technique that may permit functional urodynamic recovery in dogs with significant proximal urethral loss.     

A technique for resection of invasive tumors involving the trigone area of the bladder in dogs: preliminary results in two dogs

Objective— To describe a surgical technique for resection of the entire bladder neck, including the trigone and proximal urethra in dogs with invasive tumors causing life-threatening urinary tract obstruction.
Study Design— Clinical case reports.
Animals— Dogs (n=2) with bladder tumors.
Methods— Circumferential excision of the bladder neck and proximal urethra with preservation of the neurovascular pedicles was performed to remove a rhabdomyosarcoma (dog 1) and a transitional cell carcinoma (dog 2) involving the trigone and bladder neck that were causing urinary tract obstruction. Reconstruction of the bladder and proximal urethra included bilateral ureteroneocystostomy. Adjuvant chemotherapy was administered postoperatively to both dogs.
Results— Postoperatively, dogs 1 and 2 were continent after 7 and 17 days, respectively, and regained normal urinary function after resolution of a transient pollakiuria. Dog 1 had no evidence of local or regional recurrence; however, a large solitary pulmonary metastatic lesion was diagnosed 8 months later. The dog was euthanatized despite a lack of clinical signs. Dog 2 had at least 1 metastatic lesion in the abdominal wall 6 months later and was euthanatized at 580 days because of renal failure.
Conclusion— En-bloc removal of the bladder neck and proximal urethra with preservation of the dorsal vascular and nervous pedicles, although a technically challenging procedure, can be performed without associated urinary incontinence or bladder wall necrosis.
Clinical Relevance— In dogs with invasive bladder tumors causing life-threatening urinary tract obstruction, resection of the bladder neck and proximal urethra should be considered as a promising surgical alternative to urinary diversion.     

Wedge meatoplasty as a treatment for stricture of the urethral meatus in a cat

A three-and-a-half-year-old male neutered Siamese cat presented with idiopathic feline lower urinary tract inflammation and dysuria, which appeared to be caused by stricture of the urethral meatus. Wedge meatoplasty was performed, which relieved the cat's dysuria and restored a normal urine stream. To my knowledge, this is the first report of meatoplasty as a treatment for stricture of the urethral meatus in a cat.     

Iatrogenic proximal urethral obstruction after inadvertent prostatectomy during bilateral perineal herniorrhaphy in a dog

Proximal urethral obstruction was diagnosed 2 days after bilateral perineal herniorrhaphy in a 12-year-old male Pomeranian-cross dog. The obstruction was caused by ligation of the proximal urethra during resection of a presumed paraprostatic cyst. Surgical repair involved reconstruction of the urethra and bladder wall, but urinary incontinence persisted.     

Hypospadias in a Himalayan cat

A one-year-old male Himalayan cat was presented with a history of chronic cystitis. Physical examination revealed that the cat had hypospadias. It was postulated that the abnormal urethral opening on the ventral aspect of the penis permitted faecal contamination of the preputial area and gave rise to the ascending infection. The hypospadias was surgically corrected and a complete recovery was achieved.     

Vaginourethroplasty for Treatment of Urethral Obstruction in the Bitch

Vaginourethroplasty was performed in six bitches with infiltrative, obstructive urethral disease. The initial clinical signs included dysuria, hematuria, pollakiuria, and stranguria. Diagnosis was based on the clinical signs, plain radiography and contrast vagino-urethrogram examination, and urethral biopsy. Five dogs were diagnosed as having urethral neoplasia; the sixth dog had granulomatous urethritis. In all six dogs, up to 50% of the urethra and the urethral tubercle were resected to ensure adequate surgical margins. One dog was euthanatized 4 months after surgery for recurrence of a transitional cell carcinoma at the surgical site. Long-term resolution of the problem (minimum of 12 months) was achieved in the other five dogs. The frequency of serious complications, including urinary incontinence and ascending lower urinary tract infections, was low.     

Application of preputial tube-flap urethroplasty to establish a neourethra in a male dog with complications after preputial urethrostomy

A 14-year-old male poodle weighing 7.5 kg presented due to complications after preputial urethrostomy for management of preprostatic urethral rupture. Revision surgery was performed with preputial tube-flap urethroplasty via preputiotomy. A longitudinal flap was raised from the prepuce and anastomosed to the end of the previously cut urethra to create a neourethra and reduce tension at the urethrostomy site. Follow-up retrograde positive contrast urethrography performed 10 days and 6 months postoperatively showed no contrast leakage from either the neourethra tube flap or new preputial urethrostomy. A follow-up email questionnaire, based on the American Urological Association Symptom Index, was completed by the owner 6 months after surgery. The dog had excellent symptom scores, and urinated from the prepuce without difficulty in a manner resembling physiological urination.     

Vaginourethroplasty as a salvage procedure for management of traumatic urethral rupture in a cat

This report describes a cat that suffered pelvic urethral rupture associated with multiple pelvic fractures. A vaginourethroplasty was performed as a salvage procedure, via intrapelvic anastomosis of the proximal urethra to the caudal vagina, following failure of a primary urethral anastomosis. Urinary diversion was achieved via tube cystostomy and a vagino-urethral catheter was maintained for 3 days postoperatively. Anterograde cystourethrography was performed at 7 days and 14 days postoperatively. Absence of contrast leakage from the vagino-urethral anastomosis was documented at 14 days postoperatively and the tube cystostomy was removed. An Escherichia coli urinary tract infection was treated following removal of the tube cystostomy and subsequent urine culture revealed no evidence of urinary tract infection. The cat retained normal urinary continence and elimination behaviour during the 7-month follow-up period. Vaginourethroplasty could be considered as a salvage option for management of traumatic pelvic urethral rupture in the neutered female cat.     

Minimally Invasive Inguinal Approach for Tube Cystostomy

Objective— To report a technique for tube cystostomy placement via a minimally invasive inguinal approach and outcome in 9 dogs and 6 cats with urinary tract obstruction or detrusor atony.
Study Design— Case series.
Animals— Dogs (n=9) and cats (6).
Methods— Medical records (January 2004–January 2008) of dogs and cats that had tube cystostomy via an inguinal approach were reviewed. Retrieved data included signalment, diagnosis, surgical technique, and complications. Access to the bladder was through a muscle splitting approach in the inguinal region with the cystostomy tube placed through a skin incision made several centimeters proximal to this incision and secured in the bladder by a purse string suture. Cystopexy during closure of the muscle layers ensured secure closure and minimized the likelihood of uroabdomen if tube dislodgment occurred.
Results— Cystostomy tubes were placed in 5 cats as an emergency procedure for treatment of acute urinary tract obstruction or urethral rupture, and as an elective procedure in 9 dogs and 1 cat. No complications occurred during cystostomy tube placement. Postprocedural complications were minor (peristomal irritation in 2 dogs with latex catheters, catheter laceration, premature removal) and only occurred when tubes were retained for >4 weeks. Urinary tract infection at catheter removal in 6 dogs resolved with antibiotic administration.
Conclusions— An inguinal approach for cystostomy tube placement facilitated rapid catheter placement into the bladder with minimal soft tissue dissection. Cystopexy during abdominal wall closure provided peritoneal protection should premature dislodgement of the cystostomy tube occur.
Clinical Relevance— An inguinal approach should be considered for rapid tube cystostomy particularly in metabolically compromised animals.     

Urinary incontinence in a dog with an ectopic ureterocele.

A 7-month-old, female English cocker spaniel was examined because of a complaint of urinary incontinence. Excretory urography revealed a small right kidney and right-sided hydroureter, ectopic ureter, and ureterocele. Ureteronephrectomy and ovariohysterectomy were performed, but the distal ureter and ureterocele were left in situ. Recurrent urinary tract infections and intermittent urinary incontinence persisted after surgery. Vaginourethrography demonstrated the presence of a urethral diverticulum associated with the ureterocele. Ureterocelectomy was performed, and the dog remains continent 4 years after ureterocelectomy. Persistent urinary incontinence and urinary tract infection were attributed to failure to resect the ureterocele.     

Use of a latissimus dorsi myocutaneous flap for one-stage reconstruction of the thoracic wall after en bloc resection of primary rib chondrosarcoma in five dogs

Objective— To describe a thoracic wall reconstructive technique using a latissimus dorsi myocutaneous flap after en bloc resection of primary rib chondrosarcoma and report outcome in 5 dogs.
Study Design— Retrospective study.
Animals— Dogs (n=5) with primary rib chondrosarcoma.
Methods— Medical records (2003–2005) were reviewed for signalment, staging investigations, surgical findings, complications, and outcomes. Owners and veterinary surgeons were contacted for outcome information.
Results— A latissimus dorsi myocutaneous flap provided an air-tight thoracic wall closure after chondrosarcoma resection. Paradoxical respiratory movement of the flap occurred; however, from physical examination and blood gas analysis (2 dogs), ventilation was adequate. All flaps survived, 1 had superficial skin necrosis distally and 2 had minor wound dehiscence. One dog without tumor-free margins died of tumor-related disease 56 days after surgery. Tumor recurrence did not occur in 4 dogs with tumor-free margins. One dog was euthanatized 10 months after surgery for unrelated disease; 3 dogs were alive at writing (median follow-up: 20 months; range, 18–27 months) and all had a satisfactory functional and cosmetic outcome.
Conclusions— Reconstruction of ventral thoracic wall defects using a latissimus dorsi myocutaneous flap yields a functional, cosmetic outcome.
Clinical Relevance— A latissimus dorsi myocutaneous flap can be used as a successful 1-stage reconstructive technique for ventral thoracic wall defects.     

Hypospadias in a Friesian gelding

Objective: To report clinical signs and management of hypospadias in a horse. Study Design: Clinical report. Animal: A 6‐year‐old, Friesian gelding. Methods: Partial phallectomy was performed to resolve contact dermatitis of the pelvic limbs and abnormal behavior during urination. Subsequent urethral meatal stenosis was treated by revision. Results: Hypospadias and chordee caused altered direction of urine flow, contact dermatitis of the pelvic limbs, and abnormal behavior. Partial phallectomy and subsequent revision after meatal stenosis resolved urine direction, flow and abnormal behavior. Conclusions: Abnormalities of the urinary tract associated with hypospadias can result in urine‐induced, contact dermatitis and distress during urination, but these complications can be resolved by partial phallectomy.