Cystotomy, partial cystectomy, and tube cystostomy

Knowledge of the regional anatomy and healing characteristics of the urinary bladder are crucial to successful surgical intervention in common disorders of the bladder. Innervation and blood supply enter the neck region of the bladder on the dorsal surface. Surgical approach to the bladder is via a ventral midline incision. Cystotomy is most commonly performed on the ventral surface of the bladder and the incision is closed using absorbable suture material in a single-layer, appositional closure. Removal of urinary calculi is the most common indication for cystotomy and should be accompanied by mucosal biopsy and culture. After cystotomy for removal of calculi, a lateral radiograph should be made to confirm removal of all calculi. Partial cystectomy is indicated for bladder trauma, neoplasia, patent urachus, and urachal diverticula. A large percentage of the bladder wall can be excised with gradual return to near normal function when the trigone region is preserved. Complete cystectomy is not recommended because of the patient morbidity and client dissatisfaction with these procedures. Tube cystostomy is performed routinely for temporary or permanent urinary diversion. Temporary diversion may be performed concurrently with surgical repair of urethral trauma or to relieve acute urethral obstructions. Permanent cystostomy may be performed in cases of neurogenic bladder atony or bladder cancer.     

The use of pneumatic impact lithotripsy and a retrieval pouch to create a closed system for removal of cystic calculi in standing male horses

Multiple techniques exist for removal of cystic calculi in the male horse, some of which use a perineal urethrotomy (PU) to facilitate access to the urinary bladder for removal of small uroliths in the standing, sedated horse. These techniques have limited efficacy in the removal of uroliths that have a diameter larger than the PU site, typically 4–5 cm. Pneumatic lithotripsy as reported in this article provides a novel way to fragment these larger uroliths while containing the fragments and protecting the urethra and urinary bladder. Ten geldings and one stallion underwent a lithotripsy procedure to remove one (n = 10) or several (n = 1) uroliths ranging in diameter from 4 to 9 cm. A PU was performed and a laparoscopic retrieval bag was inserted into the urinary bladder through the PU site. The urolith was manipulated into the bag using blind transrectal manipulation or endoscopic guidance and the opening of the bag was exteriorised out of the PU site. A pneumatic lithotrite was used to fragment the stone. When the urolith was adequately fragmented, the fragments were removed by the use of sponge forceps and by flushing the fragments from the bag with obstetrical lube. This was continued until the bag could smoothly be withdrawn from the urinary bladder. All uroliths were successfully removed. The PU sites healed without complication and none of the horses had recurrence of presenting clinical signs. This article also discusses the difference between two types of laparoscopic retrieval bags. Pneumatic impact lithotripsy in combination with a retrieval pouch offers a safe alternative to other methods for removal of cystic calculi in the horse.     

Use of Electrohydraulic Lithotripsy in 28 Dogs with Bladder and Urethral Calculi

Background: Electrohydraulic lithotripsy (EHL) has been used as an alternative to cystotomy in human medicine to remove urinary calculi. This prospective study evaluated the efficacy and safety of EHL to remove urinary calculi in dogs. Hypothesis: EHL is an efficient and safe method of treatment of bladder and urethral calculi in dogs. Methods: Dogs presented between January 1, 2005 and June 1, 2007 with lower urinary tract calculi diagnosed by radiographs or ultrasound examination were included in the study. Physical examination, CBC, biochemistry, urinalysis, and urine culture were performed at presentation. EHL and voiding urohydropulsion were performed under general anesthesia. Patients received IV fluids for 12 hours after which they were rechecked by ultrasound examination and discharged with antibiotics and anti‐inflammatory drugs for 5 days. All patients were reevaluated 1, 3, and 6 months after presentation by physical examination, urinalysis, and ultrasonography. Results: Twenty‐eight dogs (19 males, 9 females) presented with bladder or urethral calculi or both underwent lithotripsy. Their median weight was 8.3 kg. Calcium oxalate calculi were present in 22 dogs, struvite in 4, and mixed calculi in 2. Fragmentation was done in the bladder (23 dogs) and in the urethra (12 dogs). Calculus‐free rate was higher for urethral than for bladder calculi in males and higher for bladder calculi in females than in males. No major complications were reported. Twelve dogs relapsed within 6 months. Conclusions: Results of this study support the use of EHL as a minimally invasive treatment for bladder calculi in females and for urethral calculi in male dogs.     

Cystoscopy

Cystoscopy is a diagnostic and therapeutic procedure commonly employed in human medicine but that has received limited application in small animal practice. Readily applicable, cost-effective instruments are available for use in the dog and cat. The urethral opening, urethra, bladder, and ureteral openings can be effectively assessed, and samples can be collected for histopathology, cultures, and stone analysis. Cystoscopy is indicated for assessment of chronic cystitis, hematuria, tenesmus, increased frequency of urination, urinary incontinence, alteration of urinary stream, trauma, and cystic and urethral calculi. Most cases can be evaluated transurethrally; the rest can be assessed by prepubic percutaneous cystoscopy.     

Laparoscopic Splenectomy for Treatment of Splenic Hemangiosarcoma in a Dog

Objective: To report laparoscopic splenectomy in a dog. Study Design: Clinical report. Animals: Mixed breed dog (n=1). Methods: Hemangiosarcoma was diagnosed by ultrasound‐guided fine‐needle aspiration of a splenic mass in an 11‐year‐old, 30 kg, mixed breed dog. No metastatic disease was identified during complete staging (chest radiographs, echocardiogram, and abdominal ultrasonography); however, cystic calculi were identified. Laparoscopic splenectomy using Ligasure V was performed through 3 portals and the calculi were removed by laparoscopic‐assisted cystoscopy. Results: Total surgical time was 2 hours and for laparoscopic splenectomy, 65 minutes. The celiotomy incision for splenic removal was 7 cm. The dog recovered uneventfully and was ambulatory 2 hours postoperatively. Conclusion: Laparoscopy with Ligasure V facilitated successful removal of a spleen with a 3 cm mass. Clinical Relevance: Laparoscopic splenectomy in dogs is feasible for removal of a normal‐sized spleen with a moderate‐sized mass.     

Endoscopic-assisted disruption of urinary calculi using a holmium:YAG laser in standing horses

OBJECTIVE: To describe a technique for endoscope-assisted disruption and removal of urinary calculi using a holmium:YAG laser in sedated, standing horses. STUDY DESIGN: Retrospective study. ANIMALS: Six horses with urinary calculi. METHODS: A holmium:YAG laser was used to disrupt naturally occurring urinary calculi in horses (4 geldings, 1 stallion, 1 mare). Ischial urethrotomy was performed in male horses to provide a portal for the endoscope and laser fiber. Calculus fragments were removed by a combination of lavage, transendoscopic basket snare removal, forceps, and digital manipulation. Ischial urethrotomies healed by second intention. Follow-up was obtained by recheck examination and telephone interview of owners. RESULTS: No major operative or postoperative complications occurred. Two calculi (1 stallion and 1 mare) were fragmented by a combination of laser ablation and manual disruption with a lithotrite. Postoperative dysuria occurred in the mare, but resolved after 1 month. Mean (+/- SD) follow-up was 306 +/- 149 days; no other complications were reported. CONCLUSIONS: Calcium carbonate urinary calculi (up to 15 cm in diameter) in horses can be effectively fragmented with a holmium:YAG laser. It is not known if this technique would be completely effective for larger calculi or extremely dense calculi. CLINICAL RELEVANCE: Calculus disruption by an endoscopically assisted holmium:YAG laser offers a minimally invasive method that can be performed in standing horses and that minimizes patient risk.     

Failure of holmium:yttrium-aluminum-garnet laser lithotripsy in two horses with calculi in the urinary bladder

Holmium:yttrium-aluminum-garnet (Ho:YAG) laser lithotripsy was attempted in a mare and a gelding with calculi in the urinary bladder. The procedure was unsuccessful in producing adequate fragmentation of the calculi. In the gelding, pulsed dye laser lithotripsy was subsequently used to fragment the urolith. Manual removal of the urolith via the urethra was performed in the mare.     

Electrohydraulic Shock-wave Lithotripsy in Experimental Canine Struvite Bladder Stone Disease

Electrohydraulic shock-wave lithotripsy (EHL), the fragmentation of urinary stones with hydraulic shock waves, was performed through a cystoscope in two female dogs with surgically implanted struvite bladder stones. Stone fragmentation was achieved after about an hour, but complete removal of fragments by irrigation through the cystoscope sheath was not successful. After the procedure, small stone fragments and pieces of the shock-wave electrode remained in the bladders of both dogs. All stone fragments and electrode pieces were spontaneously voided by one dog; further cystoscopy was required in the other dog to remove three larger stone fragments with a stone basket, and pieces of the electode with grasping forceps. Bladder-stone removal in the female dog by EHL, irrigation, and using a stone basket is technically feasible, but requires expensive equipment.     

Modified parainguinal approach for cystic calculus removal in five equids

This report describes a modification of the parainguinal approach for removal of cystic calculi: a ventral midline laparotomy‐guided parainguinal laparocystotomy. The ventral midline approach to the abdomen is rapid and routinely used by equine surgeons. With an arm introduced to the abdomen via the ventral midline, the surgeon is able to select the ideal parainguinal laparotomy incision location that allows bladder exteriorisation with the minimum amount of tension. Because the surgeon's hand is introduced via the ventral midline incision, the parainguinal incision can be sized to just allow exteriorisation of the urinary bladder and urolith, increasing extra‐abdominal bladder security during cystotomy while reducing incision size in the parainguinal region. Finally, an assistant's hand via the ventral midline incision can maintain bladder stability within the parainguinal incision during cystotomy closure.     

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.     

Resection of inflammatory polyps in dogs using laparoscopic-assisted cystoscopy

Inflammatory polyps in the urinary bladder of two dogs were removed via laparoscopic-assisted cystoscopy. In addition, one dog had a calculus removed and liver biopsies taken using the same two trocar sites. The laparoscopic-assisted cystoscopic technique provided clear surgical margins and permitted a thorough examination of the inside of the bladder and urethra. The technique was minimally invasive, produced little abdominal injury, and limited urine contamination of the abdomen.     

Standing urogenital surgery

Caslick's, episioplasty, urethroplasty, cervical, and rectovestibular laceration repair are, by preference, performed in the standing patient. Normal castration is performed routinely uneventfully in the standing patient. The duration of the procedures and the ease with which they are accomplished in a standing horse of normal temperament make general anesthesia unnecessary. More invasive procedures, such as removal of urinary bladder calculi in male horses or removal of a neoplastic ovary in a mare, can be accomplished in a standing patient but serious consideration should be given to the use of general anesthesia. For these procedures, the potential complications are increased while the ability to effectively deal with those complications is diminished in a standing patient. For instance, imagine a mare that lays down in the stocks during a standing flank removal of an ovary or a stallion that defecates during a Gokel's approach to the bladder. Only extenuating circumstances justify these risks when general anesthesia is available.     

Laparoscopic-assisted cystotomy for urolith removal in geldings

OBJECTIVE: To describe a technique for laparoscopic-assisted removal of cystic calculi in geldings and report outcome. STUDY DESIGN: Clinical report. ANIMALS: Four geldings with cystic calculi. METHODS: Laparoscopic-assisted cystotomy and urolith retrieval was performed in 4 anesthetized geldings positioned in dorsal recumbency. With a laparoscope portal located at the umbilicus, the abdomen was insufflated and then the surgical table was tilted (30 degrees head-down position) before an instrumental portal was created parallel and 2-3 cm medial to the left external inguinal ring. Laparoscopic grasping forceps were inserted to grasp the cranial aspect of the bladder and elevate it to the ventral abdominal wall. With the instrumental portal as mid-point, the parainguinal skin incision was longitudinally extended cranial and caudal (approximately 8-10 cm) to accommodate the size of the urolith. The apex of the bladder was exteriorized and sharply incised, the urolith extracted, and after cystotomy closure, the bladder was repositioned. The mini-laparotomy and trocar incisions were closed in layers. RESULTS: There were no intra- or post-operative complications. All horses had minor incisional swelling for 3-4 days. No signs of abdominal or incisional pain were observed. Hematuria and slight stranguria occurred until the 3rd or 4th day. Surgical time (skin incision to skin closure) was 35-40 minutes. On long-term follow-up (up to 12 months) no recurrence of clinical signs associated with cystic calculi occurred. CONCLUSION: Uroliths (6-8 cm diameter) can be removed by laparoscopic-assisted cystotomy in geldings. CLINICAL RELEVANCE: Laparoscopic-assisted cystotomy combines the advantages of the parainguinal laparocystotomy with laparoscopic technique for removal of cystic calculi while avoiding their disadvantages.     

Removal of cystic calculi using a transinguinal laparoscopic‐assisted technique in two stallions

A 12‐year‐old donkey and a 6‐year‐old Connemara pony, both sexually intact males, were admitted for surgical removal of urinary calculi. Both underwent a laparoscopic‐assisted cystotomy technique to exteriorise the bladder and remove uroliths via the inguinal canal after hemi‐castration. Both surgeries were successful and no complications occurred. This modified technique, which is minimally invasive, may be a safe and efficient way to remove bladder stones from adult stallions.     

Massive obstructive urolithiasis in a bull used for artificial insemination

A seven-year-old Jersey bull used for artificial insemination showed clinical signs of obstructive urolithiasis. This was confirmed by catheterisation and subsequent urethrotomy over the site of obstruction distal to the sigmoid flexure. Although urine flow was elicited after removal of the calculi, this was only temporary and the animal had to be killed 24 hours later. On post mortem examination about 2 kg of round, smooth, pearl-like calculi were found in the urinary bladder and the urethra of the sigmoid flexure was studded with similar calculi. It was concluded that urethrotomy at the sigmoid flexure or penectomy post scrotally would not have alleviated this condition.     

Canine urolithiasis: epidemiology and analysis of urinary calculi

The incidence of canine urolithiasis was found to lie between 0–5 to 1 per cent of the canine population. Epidemiological and analytical data were collected for 1731 urinary stones, and causal relationships investigated. Calculi were found in 72 breeds. While they were relatively common among dachshunds, dalmatians, cocker spaniels, Pekingese, bassets, poodles, schnauzers and small terrier breeds, urinary stones were relatively rare among German shepherd dogs, boxers, collies, chow chows, old English sheepdogs, spitz and rottweiler breeds. Struvite, which was found in 55-6 per cent of all calculi, proved to be the most common constituent, followed by cystine (22-5 per cent) and ammonium urate (6-6 per cent). Xanthine calculi were rare (six cases), while silicium dioxide calculi were present in only one case. The likelihood of calculi in male animals was twice that of bitches, although the latter were found to be more prone to infection of the urinary tract. Adiposity was present in 29 per cent of all dogs with calculi. The average age of the animals was seven years. In 98-7 per cent of all cases the calculi were found in the lower urinary tract, and surgical removal of the stones was required in 87-5 per cent of cases. The main types of calculi appear among specific breeds, which indicates that a careful breeding programme may help to reduce the frequency of urinary calculi.     

Ultrasonographic evaluation of abdominal distension in 52 camels (Camelus dromedarius)

The purpose of this study was to assess the diagnostic value of ultrasonography in the evaluation of abdominal distension in 52 camels (Camelus dromedarius). The conditions included trypanosomiasis (n=35), intestinal obstruction (n=12) and ruptured urinary bladder (n=5). Fifteen clinically normal camels were included as controls. Transabdominal and transrectal ultrasonography was carried out on all camels. In animals with trypanosomiasis, ultrasonographic findings included accumulation of massive amounts of hypoechoic abdominal fluids where liver, intestine, kidney, spleen and urinary bladder were imaged floating. Except in two cases of bile duct calcification and one of hepatic abscessation, no detectable abnormal sonographic lesions were detected while imaging the hepatic and renal parenchyma, and the heart and its valves and major blood vessels. In camels with intestinal obstruction, ultrasonographic findings included distended intestinal loops with markedly reduced or absent motility. In one camel, the intestinal lumen contained localised hyperechoic material that was consistent with a foreign body. Hypoechoic fluid with or without fibrin was seen between intestinal loops. In camels with ruptured urinary bladder, ultrasonographic findings included collapsed and perforated bladder, echogenic blood clots within the urinary bladder and peritoneal cavity, increased thickness of the bladder wall, floating intestines in hypoechogenic fluid and echogenic calculi within the urethra. Ultrasonography was considered a useful tool for the evaluation of dromedary camels with abdominal distension.     

Cystinuria in a cat

A 10-month-old male Siamese cat with dysuria was determined to have cystine crystalluria. Many small calculi composed entirely of cystine were found in the urinary bladder. Measurement of serum and urine amino acids and calculation of fractional reabsorption of amino acids indicated reabsorption defects for cystine, ornithine, lysine, and arginine. Urinary acidification, fractional reabsorption of glucose, and fractional reabsorption of electrolytes were normal. Diagnoses of cystinuria and cystine urolithiasis were made on the basis of low fractional reabsorption of cystine and dibasic amino acids and the detection of cystine calculi in the urinary bladder.     

Radiographic features of suspected suture‐associated cystic calculi in dogs

This retrospective case series describes the radiographic features of suspected suture‐associated cystic calculi in six dogs with a history of at least one or multiple prior cystotomies. One of the dogs presented twice. Suspected suture‐associated cystic calculi were multifocal, short, predominantly linear mineral opacities localized in the center of the urinary bladder on abdominal radiographs. One patient (n = 1) presented with multifocal round, pin point, and linear radiopaque calculi. The calculi were all calcium oxalate in composition. On gross examination, the calculi had a hollow center. Six cystotomies used monofilament absorbable suture material (polydioxanone [n = 4] or poliglecaprone 25 [n = 1]) in prior cystotomies. Suture material in two of the cases was unknown. Suspected suture‐associated cystic calculi are a rare occurrence in veterinary medicine but should be considered in dogs that have a history of prior cystotomy, hollow core on gross analysis, and radiographic evidence of mineral opaque, predominantly linear, cystic calculi.     

Colonic seromuscular augmentation cystoplasty following subtotal cystectomy for treatment of bladder necrosis caused by bladder torsion in a dog

CASE DESCRIPTION: A 5-year-old Labrador Retriever was evaluated because of a 3-day history of lethargy, anorexia, vomiting, stranguria, and anuria after routine ovariohysterectomy. CLINICAL FINDINGS: On initial examination, signs of abdominal pain and enlargement of the urinary bladder were detected. Clinicopathologic abnormalities included leukocytosis, azotemia, and hyperkalemia. Radiography and surgical exploration of the abdomen revealed urinary bladder torsion at the level of the trigone; histologically, there was necrosis of 90% of the organ. TREATMENT AND OUTCOME: After excision of the necrotic wall of the urinary bladder (approx 0.5 cm cranial to the ureteral orifices), the remaining bladder stump was closed with a colonic seromuscular patch. Eleven weeks later, cystoscopy revealed an intramural ureteral stricture, for which treatment included a mucosal apposition neoureterocystostomy. Thirteen months after the first surgery, the dog developed pyelonephritis, which was successfully treated. By 3 months after subtotal cystectomy, the dog's urinary bladder was almost normal in size. Frequency of urination decreased from 3 to 4 urinations/h immediately after surgery to once every 3 hours after 2 months; approximately 4 months after the subtotal cystectomy, urination frequency was considered close to normal. CLINICAL RELEVANCE: Urinary bladder torsion is a surgical emergency in dogs. Ischemia of the urinary bladder wall may result from strangulation of the arterial and venous blood supply and from overdistension. Subtotal resection of the urinary bladder, preserving only the trigone area and the ureteral openings, and colonic seromuscular augmentation can be used to successfully treat urinary bladder torsion in dogs.