SA Sx - Urinary 2

drraythe's version from 2017-09-15 14:24

Ectopic ureters Sx procedures/ more ureter stuff

Question Answer
What are the 2 correctional Sx Tx for ectopic ureters?(1) Neoureterostomy (creating new stoma for the ureter)
(2) Ureteroneocystostomy (ureteral relocation) (create a new stoma in the bladder for the ureter)
What procedure is this? Explain what is going on Neoureterostomy (creating a new stoma for the ureter) so make new stoma & then close up rest of unnecessary ureter → are you concerned about that extra urethra? No, bladder contracts w/ enough force to not worry about backflow there
***If you incise the bladder, which way to you want to cut & why?ALWAYS CUT TOWARDS APEX, NEVER TOWARDS NECK bc dont wanna mess w/ innervation & BLOOD SUPPLY WHICH IS CA TO CR (neck to apex) - & THERE IS NO OTHER SOURCE
Explain neoureterostomy procedure (1: OPENING)Ventral midline approach. Cut ventral portion of bladder open so that you can see the inside back (dorsal) wall of the bladder (dont wanna cute dorsal part & risk damaging trigone). ALWAYS CUT TOWARDS APEX, NEVER TOWARDS NECK (dont wanna mess w/ unique blood supply). Palpate into bladder & feel ureter running submucosally. When ID ureter, make incision into ureter - Use #11 blade, don't go too deep or you'll damage back wall of ureter, (don't wanna do that).
Explain neoureterostomy procedure (2: ONCE URETER INCISED - PROCEDURE)Sew new stoma of urethra open w/ simple interrupted sutures (more on this in other card). Then place retrograde cath & flush (make sure stoma is good), then place in antegrade manner into other portion of ureter that goes into the urethra. This will be your stint. Then place some sutures & then remove the cath....will allow you to place sutures blindfolded so you cant see it but going around cath..Place sutures, pull out cath, then tie sutures closed. Tie them CLOSE to the opening into the urethra. If you tie too far down, then it'll start to get a little pocket which is bad.
*Wwhat is the technique for sewing the new stoma you have created for the ureter in your neoureterostomy? (Suture size?)(5-0-6-0 suture) ALWAYS SUTURE FROM MUCOSA OF URETER & TOWARDS MUCOSA OF BLADDER - & NEVER THE OPPOSITE. FROM INSIDE OUT - BC WANNA EVERT MUCOSA & HAVE A GOOD OPENING. Otherwise will block new stoma. Once finished, make sure urine can pass through the stoma
Do you use stay sutures in bladder?Yep
What procedure is this? Explain what is going on (What's the red line about?) Ureteroneocystostomy (ureteral relocation) this is for extramural ectopic ureters. Cut the ureter at the level it enters the bladder & then transpose it into the bladder (so, cystostomy). Once into lumen, ureter is a TINY thing. So this is the end (not the side like the intermural one) so do FISH MOUTH (to prevent stricture). Tie off the rest of the ureter at the level of the RED LINE, not where the pic shows, or you'll get a dilation there (bad)
When transposing the ureter into the bladder in an ureteroneocystomy, how do you deal w/ the fact that the ureter's lumen is so super tiny?Fishmouth it!!
Explain the ureteroneocystostomy procedure a bitIncise bladder same as in neoureterostomy. Ligate ureter at level of entrance into urethra. Cut ureter. Stay suture on end of ureter then grab w/ tool to drive into bladder, then fish mouth it. Simple interrupted only. *Suture mucosa of ureter over mucosa of bladder!
What is an Ureterocele?Intraluminal cystic structures in the vesicoureteral region of the bladder (uncommon in vetmed) can happen due to duplicated ureters w/ 1 having dilation at opening - act like a little cavity keeping urine inside. Gotta elim the cele (reconstruction opening) can elim duplicated ureter. Might need to remove kidney if bad enough..
For all bladder stuff, what kinda suture patterns? Why?*For bladder stuff, simple interrupted. Not enough room & not good idea for it to turn into purse string. Also simple continuous will tend to make mucosa go inward
Trauma to the ureters is MOST COMMONLY where? Czd by?Most commonly in initial 4 cm - usually IATROGENIC DUE TO OVH!!!! (Ligate on accident) - look how close it is to everything else for a spay:
Even accidental PARTIAL entrapment of ureter via ligation during spay can lead to what problems?Granuloma/hydronephrosis
Best way to ID a ureter from a BV?Touch ureter gently & it will do a peristaltic wave
If a ureter is severed, how do you sew it together? (Cautions?)Make sure there is no tension!! Suture by trying to enlarge both ends via fishmouth technique. (You can also cut obliquely but fishmouth is preferred he said) try to use contrast to see where you are placing your stitches. Suture used is like 7-0, 8-0, 9-0...very challenging to fix
What’s a nephrostomy? Why do you do it?Open hole in kidney is what it literally means. Used to bypass ureter when you've done Sx on ureter to let it rest. From dilated pelvis - bring tube through abd wall into kidney against pelvic wall & urine will collect into bag outside body. finger trap. When take out - will heal 2nd intention
What is a pigtail cath? What procedure do we like to use them in & why?Cath w/ a little spiral on the end - good for nephrostomy bc you straighten out, place in kidney & then spirals back (will not occlude) so it stays more firmly in the pelvis of the kidney (self-retaining)
What’s a pyelotomy?Open pelvis/dilated ureter, remove whats in there & suture it back (simple apposition, try not to get into lumen - might act as nidus for new stone formation)

Bladder intro & anatomy

Question Answer
**Blood supply of bladder is special how?Goes Ca-to-Cr (from neck to apex)
How is it that when the bladder empties, it doesnt shoot urine back up the ureter?
4 ways to palpate the bladder?Abdominal palpation
Perineal palpation
Rectal palpation (can palp trigone rectally)
Vaginal palpation
So there's a bunch of urine sitting in a bag called the bladder that just sits does it not get Infxns ALL the time?Bladder is lined by transitional epithelium, which is bacteriostatic due to a glycosaminoglycan secretion that impairs bacterial adhesion to the epithelium
What’s urachus?Remnant from embryo phase - at apex of bladder - can have urachus be patent
2 diff ways lithiasis of bladder?Either kidney sending down stones into bladder, or stones forming in bladder
Most common neoplasia of bladder? (Who? what? how bad?)Elderly PTxs - TCC - invasive & destructive
What are some possible reasons for urinary incontinence of bladder?Chronic cystitis or Dz that effect bladder or weak sphincter
*How much of the bladder can you remove & still be ok (what structures need to be avoided tho?)Can take up to 75% of bladder & will be ok -stay away from trigone. Blood supply is from caudal to cranial
**Which ligaments of the bladder can be severed? Which cannot be? Why?Ventral ligament can be severed. Lateral/collateral ligaments cannot be touched bc structures pass through there.
Blood to bladder comes from which vessels?Internal pudendal & internal iliac aas.
Do you use stay sutures in the bladder? Where would you put them?Yes you can use stay sutures. Place suture in apex-most cranially - take big bites - not small bites so dont rip suture out & hole in bladder.
If you wish to manipulate bladder w/o stay sutures, what are your 2 options?Hands or Babcock’s
How would you make an incision in the bladder? Where?Incision in bladder - ventrally approach - work toward apex-stay away from neck of bladder. Look for hypovascular area for incision. Place 2 stay sutures each on each side of incision/proposed incision - so will have 3 locations where there are stay sutures total (bc also 1 on apex for general manipulation)
Pic for bladder & urethral innervation
What do hypogastric nerves innervate/do?SyMPATHETIC so cz bladder relaxation & urethral contraction (URINE RETENTION)
What do pelvic nerves innervate/do?PARASYMP so cz bladder contraction & urethral relaxation (bladder emptying)
What does the pudendal nerve innervate/do?SOMATIC nerve controls the VOLUNTARY urethral contraction (outer sphincter) (urine retention)
Bladder muscle that will contract bladder's name?Detrusor mm
Explain how the mm is set up in the urethra to allow both involuntary & voluntary controlUrethra itself is smooth mm & then periurethral mm is striated

Some bladder procedures / Congenital abnormalities

Question Answer
Cystotomy → what approach do you do? How do you elevate bladder? How do you prep for Sx?Ventral midline from umbilicus to pubis. Use stay sutures or Babcock forceps to elevate bladder from cavity. Pack off bladder w/ lap sponges
Before & after you incise bladder for cystotomy, how do you empty it of urine?Can manually compress (before incision), or aspirate urine w/ a needle & suction unit (before or after opening)
Where do you place stay sutures for cystotomy?Stay sutures placed at the apex of the bladder & lateral to the incision
For performing cystotomy, how should you deal w/ the prepuce?Prepuce should have lavaged 3x - BEFORE scrub. & prepuce must be pushed to side under drapes & prepuce towel clamped. & must catheterize
You should always make your incision of the cystotomy big enough when removing stones bc...Need to get them out w/o tearing tissue bc incision not big enough.
If you're doing a cystotomy to deal w/ stones, what should you do before Sx?Place cath!
***Which layers do you go through when closing the bladder?***DO NOT GO THROUGH MUCOSA
What type of suture do you use for closing cystotomy? What pattern(s) do you use?Use ABSORBABLE suture material. You can use 3 types of suture patterns:
(1) Simple continuous
(2) Simple interrupted
(3) Cushing & Lembert (NO CONNELS - BC NO MUCOSA PIERCING)
If you wish to close the bladder in 1 layer, what pattern do you use?Simple apposition - simple continuous or simple interrupted. Simple continuous needs certain tension after a couple bites have to pull suture tight to make sure enough apposition & no holes
When do you wanna do a 2 layer closure on a bladder & what patterns do you use?Save 2 layer closures for really big bladders - do a Cushing & Lembert (not Connell!! Bc DONT WANT TO PIERCE MUCOSA!!!)
Explain how you do a water test on the bladderCant clamp w/ forceps - occlude where? Occlude urethra. Occlude w/ 1 finger & the floor of the pelvis. Dorsal to trigone, insert finger into pelvic cavity & pushing up on finger against floor of pelvis, the lumen will be occluded. Now inject & then squeeze gently from sides & see if leakage. (DONT FORGET TO LAVAGE ABDOMEN AFTER YOU ARE DONE)
How well does the bladder heal? How much regain of strength in how long?SUPER WELL!! Great regeneration capability!! Recovers almost ***100% of its original strength in 14-21 days (everything else can only do like 80% so this is special) → & total re-epithelialization in 1 mo
The bladder tolerates cystectomies of up to...(what must be preserved tho?)75-80%. As long as the trigone remains intact, 75% of the bladder can be removed & the bladder will still heal & regain normal size & Fxn over time
What are the 3 (well, 4) salvage procedures & how often are they used?Trigonal-colonic anastomosis, Ureteral-colonic anastomosis, Urethral-colonic implantation ← basically making a cloaca. He said not gonna go into these. SA not adapted for this. & might have pyelonephritis bc of ascending Infnxn. these are not curative - just buying time for pet & owner. (*Most feasible salvage procedure is the cystostomy where you just make a whole new opening for the bladder)
Congenital abnormalities → patent urachus → what is going on here?In fetus, Urachus opens externally at umbilicus. If persists once born, patent urachus (bad). (c) is patent urachus
How do you Dx a patent urachus?Physical examination reveals urine dripping from umbilicus
How do you Tx patent urachus?Surgical excision of urachus
Whom is patent urachus more common in? (Gender)Females he said
What is A, B, C? (a) Urachal cysts, also nidus for recurrent cystitis if communication
(b) Urachal diverticulum - still small cavity w/i big cavity - nidus for bugs - recurrent cystitis
(c) This is patent urachus - normal communication where fetus expels bladder. Dripping of urine @ level of umbilicus
Vesicourachal diverticulum usually seen in who, how?Often seen radiographically in cats w/o signs of UTI (B on diagram)
How do you usually Sx Tx Vesicourachal diverticulum?Just resect by taking that whole part out (bladder will be fine!)