SA Sx Urinary III
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. What would you like to do?
where is best approach for removing urolith? What are other options?
- scrotal (and castrate)
- perineal (salvage in cats)
- prepubic (salvage)
what procedure creates a permanent opening of urethra to exterior? indications?
- -nondisplacable stones
- -chronic stone formation
- -urethral stenosis
- -penile trauma
for urethrostomy, is prepuce included in the draped field?
yes! so need to flush when scrubbing pt
for urethrostomy, which muscle is displaced to see urethra? then what is done?
- retractor penis m.
- palpate os penis edge, put in vertical position before cutting down to urethra --> remove stones/flush w catheter in place
How do you close urethra? what are post op treatments for urethrostomy?
- can heal by 2nd intention, or close w/5-0 absorbable, taper needle
- fluids + NSAIDS + Abs +catheter for 1-2d
When suturing urethra to skin, what order are layers sutured? What size should opening be for urethrostomy?
- inside-out (mucosa to skin) --> bridge cavernosous to control oozing
- stoma of 2.5-3cm
What is wilson and harrison technique?
- perineal urethrostomy for CATS only
- requires partial amputation of penis
What are some etiology of urethral laceration and rupture?
- pelvic or os penis fracture
- penile trauma
- iatrogenic from catheter
How are urethral laceration/ruptures diagnosed? treatement?
- + contrast urethrography or US
- minor can heal spontaneously
- soft catheter or urethral splint
- simple apposition w/3 to 5-0 (end to end anastm)
What is involved in the salvage procedure prepubic anastomosis?
anastamose remnants of penis to bladder and hope innervation still works
what salvage procedure creates a urethrostomy on the ventral body wall, cranial to pubis? what are indications for this procedure?
- antepubic urethrostomy
- -salvage for stricture, neoplasia, trauma to urethra
- -recurrent stricture of perineal urethrostomy
What are some disadvantages associated with antepubic urethrostomy?
- urine scald (can tx w/baby oil or vasoline)
- ascending UTI
- potential for urinary incontinence
If amputation of urethral prolapse is indicated, how is hemostasis maintained for the sx? what type of suture to close? Post op concerns?
- rummel turniquit around penis ->catheter to maintain patency during sx and after to monitor output
- close w/simple interrupted (short tags) and REST/isolate
- C/S for antibiotic choice; NSAIDS + ecollar
What are some anatomical considerations that make the cat more prone to FLUTD?
- no prescrotal area
- conical/tapered urethra
what age cat is most susceptible to FLUTD? breed?
- 2-6 yr (both genders, esp males)
- increased risk for Persian and Burmese
- (decr. risk for Siamese)
FLUTD is a SYNDROME. what are some of the clinical signs?
- dysuria, hematuria, crystalluria
- licking genitals; "crying"
- reduced emission, urethral obstruction
- sandy material
- can appear to o' like straining to defecate (r/o constipation via palpation)
Patients w/ FLUTD often present in shock. What would chemistry reveal? What can you do to initially relieve the pt?
- elevated BUN/Creatinine (from backflow of urine)
- cystocentesis to decompress bladder
What % of patients develop a UTI from being catheterized to treat obstruction? What % had UTI before being catheterized?
- 20% (make sure to use aseptic tools and clean technique)
- (only 3% before cath.)
what is medical option for treated FLUTD patients? when is sx indicated?
- prescription diets (like C/D); in early stage can try urohydropropulsion = massage abdomen to allow urine to pass
- sx when medical tx fails or recurrent urethral obstruction
Does bacteria play a primary role in development of FLUTD?
no, but not completely sure of etiology; diagnosis of rule outs
What is difference between urethral plug and urolith?
- plug: matrix of gelatinous, friable, doughy, amorphous
- urolith: organized internally, non-deformatble, solid (struvite or Ca oxalate)
What procedure is salvage for male cat w/recurrent urethral blockage or one with irreversible mural lesions causing obstruction?
perineal urethrostomy (wilson and harrison technique)
for wilson & harrison technique, which part of urethra is opened to be sutured to skin?
pelvic urethra (penis partially amputated)
with cat in perineal position, what suture do you place before starting the sx? After that, what do you do if cat is intact?
- purse sting around anus
- castrate and scrotal ablation--> then make elliptical incision around scrotum and prepuce
for PU, how far do you dissect ventral to the penis?
to ischial arch (see ischiocavernosus mm. that connects to arch --> scrape to detach)
After you sever the retractor penis m., you pull the penis to disengage from any connective tissue. How do you know you have disengaged adequately?
visualize bulbourethral glands --> stays in incision site even if not pulling on penis (then incise urethra up to this point)
After incising the urethra up to bulbourethral gland, how do you check that you've established a good opening?
Halsteds inserted up to instrument's joint w/no resistance
When closing PU, where are first sutures placed?
- suture 11, 12 and 1 oclock from inside - out
- then stagger sutures rest of the way down, leaving 2-3cm open --> then clamp and amputate rest of penis using circumferential ligature
what suture is used for PU?
- (monocryl, PDS, monofilament nylon, vicryl)
What change to the mucosa do you expect to see at first after PU?
redder and metaplasia
What are post op consideration for PU? should catheter be left in place?
- indwelling catheter only if urethral tear is present
- remove sutures in 7-10d
- E collar
- use paper litter, popcorn, etc
what are common post op comlications following PU?
- recurrent FLUTD and bacterial cystitis (10-19%)
- urethral stricture due to sx technique (11.5%)
- urolithiasis (6%)
what is number 1 post op complications of PU due to?
- surgeon's technique!
- -fail to fully separet from pelvic attachment
- -wrongly incise urethra
- -nerve damage from rough handling
- -suture technique/dehiscence
- -excessive catheterization
What post op complication of PU is possibly secondary to severe vascular damage at sx?
What post op complication of PU is due to excessive dorsal dissection that penetrated rectum?
urethrorectal fistula (place catheter to maintain patency)
What should you do if post op PU leads to stricture/stenosis?
redo the surgery (this is an emergency!)
What would you like to do?
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