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SA Sx - Urinary 1

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drraythe's version from 2017-09-15 14:19

General/ Nephrectomy

Question Answer
Which gender is less likely to have obstruction & why?Females, bc short & wide urethra
Most urinary procedures are elective, UNLESS...UT is OBSTRUCTED or INJURED (then emergency)
*****What's the Cullen sign?Classic of trauma in sublumbar region-hematoma descents & collects around the umbilicus. Maybe free fluid (esp blood) inside abdomen. (Cullen's sign is superficial edema & bruising in the subcutaneous fatty tissue around the umbilicus) [So hematoma around umbilicus = trauma]
**If trauma to spleen, should you be aggressive or conservative?Conservative
If there is traumatic damage to the UT, what sign might you see?Cullen sign
If there is traumatic damage to the UT, what must you ALWAYS do before Sx?STABILIZE! if cant, OPTIMIZE
What are the 2 kinds of contrast rads you can do on the UT? (Basic idea of how you do them?)(1) Antegrade (via IV)
(2) Retrograde (place cath & squirt contrast backwards)
***If you suspect uroperitoneum & you get the fluid, would you want to base your Dx off of the creatinine or the BUN content of the fluid?CREATININE! BUN is a smaller molecule & is more easily balanced, so SRT is more reliable
If there is an uroperitoneum, what must you do to help prevent a chemical peritonitis?LAVAGE, yo
2 approaches for nephrectomy? Do you want a bigger or smaller incision & why?Celiotomy (ventral approach)
Laparotomy (flank approach - prolly GRID approach)
Want a bigger incision bc sometimes kidneys can be way down. Esp if deep chested dog. R kidney CR & can even be touching liver
Which kidney is easier to access?Left (its left behind) - more moveable & more easily exposed.
2 types of nephrectomys?Total or partial
Should you strum the suspensory lig?No - more likely to get a hematoma
Basic steps for doing a nephrectomy?(1) Lots of fat around kidneys - ID vessels
(2) Find kidney capsule, separate it from the kidney w/ your finger.
(3) 3 clamp technique (2 clamp if REALLY can't fit 3) the vessels & ligate, ligate ureter
What should you know about renal vasculature variation?Might have more than 1 renal artery, maybe more than 1 renal vein (usually renal a is duplicated)
Where might you wanna look for porto-systemic shunts? What is special about the L renal vein?Around the renal aa/vv & the phrenicoabdominal veins is where you should look for shunts. NOTICE THAT L gonadal vein empties into the L renal vein, not into the ca vena cava
How should you ligate the renal vasculature? Why?NEVER LIGATE TOGETHER!! Can develop artero-renal fistulas (leads to abnormal circulation). So separate aa from vv. Can use Halsted or bulldogs to try to prevent thrombus formation (atraumatic clamps). Then dissect & separate vessels.
If you see an animal w/ blunt trauma like a HBC, or the femur is Fx, what should you check & how?CHECK PATENTCY OF URETHRA! Put in a cath
***WHERE along its length should you dissect the ureter in a nephrectomy? (How do you wanna ligate?)As much of it (as far down) as you can (near the **trigone) don't want a ureter not attached to a kidney floating around in the abdomen czs adhesions & stuff & dilates backwards & czs a nidus for stone formation/Infnxn/cystitis. Place 2 ligs on side of ureter staying & 1 on side going out
Exs of some indications for nephrectomy?Severe damage/ infarct/ neoplasia (nephroblastoma)/ severe pyelonephritis
What is an excellent reason to separate & keep intact the capsule of the kidney in a partial nephrectomy?If partial nephrectomy, you can close the capsule over the newly resected section **DONT FORGET TO CLOSE RENAL PELVIS 1ST - OR URINE LEAKING INTO CAPSULE! Ok to let some clots form here, mother nature fixing it - if not enough, can use some oxidized cellulose
If the animal is aged & the capsule has adhesions onto the kidney (normal for age) so you can't use it to close over your partial nephrectomy, what else can you use?Omentum (just sew it to the edges of resected kidney)
Whats a Rummel tourniquet? Explain this techniqueAtraumatic way to temporarily occlude kidney vasculature - start by having vessel dissected out. Place 1 end of umbilical tape through tube, around 1 side of vessel & then circle around the vessel w/ the tape. Then place both ends of tape through tubing. Then take hemostat & w/ 1 hand pull gently on the tape & w/ other hand push down tubing & hemostat & that will choke the vessel. Gently. Wont damage. (Better to use umbilical tape bc then vessel cant get inside tubing & more surface area = less cutting force on vessel). Then close clamp & that will maintain vessel occluded.
How long can you occlude blood from the kidney w/o causing hypoxic damage? What if you want a little more time?Hypoxia time of kidney is about 15-20 min. (plenty of time he said). You can relax a bit, let more blood flow, clamp again, have 5 more min.
W/ a partial nephrectomy, how much are you usually removing?Usually remove 1/2 or 1 pole of kidney.
Do you want to Rummel tourniquet the renal aa & vv separate or together? What order do you want to do them in?Prepare a tourniquet 1 for artery & 1 for vein separately, then clamp both at same time, regardless of which 1 you start to ligate 1st.
Do you want to open the artery Rummel tourniquet or the vein Rummel tourniquet 1st & why?1st open vein & then artery!!!! Or will be engorged w/ lots of blood that has to go into venous system.
Is the kidney a low or high-pressure system?100-120 mmHg high-pressure system of kidney. So close things as you go.
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Nephrolithiasis

Question Answer
5 main CSs of nephrolithiasis?Depression, anorexia, hematuria, pain on the flank, INC IN BUN IF BILATERAL!
What might confirm your Dx of nephrolithiasis?Radiographs (can see most - not all tho) [*dont forget to take AT LEAST 2 VIEWS - you might think a stone is a GI FB & vice versa]
What procedure will you do to remove stones from renal pelvis?Nephrotomy (tomy = cut)
Nephrotomy can be unilateral or bilateral - if you need to do bilateral bc stones in both pelvises, how should you do this?Do 1 kidney at a time if at all able - so nephrotomy on 1 (preferably worse one), close it up, let it heal for like 15-20d or a mo later & then do other kidney.
How might nephrotomy affect renal Fxn?Can DEC up to 20-50% :(
2 techniques to perform nephrotomy?(1) Classic technique
(2) Non-atropic technique
If cutting into kidney for nephrotomy/stone removal, when you are closing, NEVER FORGET TO...CLOSE THE PELVIS!!! - Prevent backflow of urine into kidney parenchyma - can scar glomeruli
Nephrotomy technique - OPENINGPeel off perirenal fat, once kidney exposed, kidney brought up, clamp the vessels (atraumatic!)
Also keep kidney elevated & exposed. Pack all around w/ lap sponges. On Side opposite hilus, make incision from 1 pole to the other. (Long incision.) Won’t reach pelvis on 1st cut - will need to keep cutting w/o filleting kidney (stay on same plane you started incision with) more cuts → more dead nephrons. Go till you see whitish structure - thats the renal pelvis (or feel like its cutting over a gritty surface) then enter pelvis... (looks like this:)
Why do you want to make sure your nephrotomy incision is from pole to pole?Want to make sure it's long enough to get the stone out!! Otherwise if trying to pull it out of too small of incision → lots of damage & tearing
Why is suction very important to have w/ a nephrotomy?(Aside from fact you're cutting through arcuate vessels & there will be a lot of blood obscuring) there might still be urine in the pelvis/still being produced - don't want this scarring parenchyma
(Nephrotomy) What should you do once the stone is out, but the closure has not yet begun?Once stone out, flush pelvis, clear up, look for other stones/fragments & then place a red rubber cath into pelvis & flush into ureter. This will displace any potential sandy material that might have been left over & then clean up the renal pelvis. Then HOLD OFF the kidney's bleeders by pressing the sides together firmly but gently. Then check again for bleeders. If none, let go. Now ready for closure
Nephrotomy technique - CLOSUREAfter making sure no bleeders left by applying pressure (squeeze halves together), run a simple continuous suture pattern on capsule. Can also attach part of capsule to vertebral gutter to make sure not just flopping around in abdomen since you removed the kidney from its attachment.
What is the "sutureless method" of closing the kidney?Let kidney bleed a little bit & squeeze it w/ a little tension - blood comes through incision coagulates so u have a nice firm clot. (Should take at least 5-10min)
When should you be doing fluid therapy w/ a nephrotomy & what should it be?Maintain good fluid therapy before/during/after procedure - should get 1-2ml/kg/hr - indicate good renal Fxn
Can you use horizontal mattress closure w/ a nephrotomy?AVOID. Used to do horizontal but not much anymore bc when you cut into the kidney, there is gonna be huge inflammation...& then tension on the sutures. So, if not tight enough horz. mattress, blood seeps out & too tight, sutures cut through kidney parenchyma & cz damage. (Just hold kidney 5-10 min to let coag & then you will have good closure)...try to avoid horiz mattress. (Dont forget to suture pelvis 1st.
How does a percutaneous nephrolithotomy work?Through skin make incision, through kidney, place endoscope w/ grabby basket attachment to pull out the stones
How might you be able to remove a stone in the renal pelvis from the pelvis via the ureter?Via grasping scope from ureter
What is a non-invasive way to help remove stones from bladder?Use ultrasound to break large immoveable stone into smaller pieces that can freely pass
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Hydronephrosis/ Ectopic Ureters intro

Question Answer
What’s going on here? Hydronephrosis - leads to enlargement of ureters & kidneys bc they are full of fluid (also ureters are usually a straight line)
Who is most prone to hydronephrosis?Dogs
4 main czs of hydronephrosis?(1) Lithiasis (stone blocks ureter → urine cant go to bladder → distension)
(2) Stenosis (from either inside or outside of system)
(3) Compression (wrongly placed spay ligature)
(4) Parasite (Dioctophyme renale)
Is male or female D. renale the bad one?FEMALE is the killer of kidneys, male just floats around in abdomen
How do you Dx D. renale (parasite)IVP (intravenous pyelogram - won't see filtering of contrast material bc female worm eats kidney parenchyma) & urinalysis (eggs in urine)
Etiology of ectopic ureters unknown. Is there 1 gender that gets them more?FEMALES get them more, 25:1
WHO is prone to unilateral ectopic ureters? Who is prone to bilateral ectopic ureters?DOGS are prone to unilateral (80%), CATS prone to bilateral
Which dog breeds are predisposed to ectopic ureters?(Remember dogs usually UNIlateral!!!)
Poodle
Husky
Labrador
What are Normal ureteral openings into trigone look like? Why does it look this way?When bladder is fully expanded-presses against ureter putting pressure against it - so prevent backflow.
What are 4 different types of ABNORMAL ureteral openings into the trigone?Can have an intramural course, or extramural (B is extramural)
What are some of the places that the ectopic ureter can open into?May open into urethra, vagina, uterus
What does it mean if the ectopic ureter is taking an intramural course?Runs submucosally
What does it mean if the ectopic ureter is taking a extramural course?Bypasses bladder completely
What is the prognosis of ectopic ureter post-op? What is a possible complication?60% continent post-op - might have a hypoplastic bladder
What is a med that might help w/ incontinence post-op of fixing an ectopic ureter?PPA (Phenylpropanolamine)
Main CS of ectopic ureter?INCONTINENCE!
2 radiographic techniques to help Dx ectopic ureter?(1) Excretory urogram (also known as intravenous pyelogram)
(2) + pneumocystography (radiography of the urinary bladder after it has been injected w/ air) ← together this is a DOUBLE CONTRAST STUDY
What does the urethral opening into the trigone look like NORMALLY?Little slits bc entering intraluminally
When doing retrograde contrast study of bladder/ureters, what cath do you wanna use & why?Foley - little blow up balloon to prevent backflow (red circle is blown up Foley balloon)
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