SA Sx - Urinary 5

drraythe's version from 2017-09-22 03:45

Urethra (prolapse, ending notes on urethrostomy)

Question Answer
Urethral prolapse is most common in who?Bulldogs
CSs of urethral prolapse?Aside from seeing it, there will also be leaking, moving abnormally, excitement.
When surgically treating a urethral prolapse of the penis, how can you help minimize bleeding from the highly vascular gland penis?Penrose drain around penis
How do you surgically correct a prolapsed urethra? (Often Sx bc tend to recur often)Insert catheter to act as a guideline. Can use Penrose drain as a tourniquet to minimize penile bleeding. Then cut/remove tissues by halves or quarters. Cut at level where its prolapsed. Apply simple interrupted stitches as cutting, all around the whole 360 degrees -.mucosa of urethra to mucosa of penis (interrupted suture & cut like a quarter at a time so you don't cinch off urethra) . Absorbable stitches.
How can you keep the urethra from sliding back into penis from prolapse while you are cutting/doing Sx?Crisscross w/ needles so maintains prolapse while youre cutting it (need to be sharp so can get through all the layers)
How concerned are you about the urethra structuring after a prolapse Sx? How can you help prevent this?Usually not super concerned bc the urine stream usually keeps things open. However, can keep a cath in for a few days to help
What is a fairly new thing you can now use to help prevent stenosis of the urethra?Stents
What drugs & precautions do you take to help PTx post-op after an urethrostomy?ABX, NSAIDS & ECOLLAR

Feline Lower Urinary Tract Dz (FLUTD)

Question Answer
What is FUS?Feline urologic syndrome
What is FLUTD?Feline lower urinary tract Dz
What is IFLUTD?Idiopathic feline lower urinary tract Dz
What is (F)IC?(Feline) Interstitial cystitis
What is FISC?Feline idiopathic sterile cystitis
FISC (feline idiopathic sterile cystitis) so, it's idiopathic, but what's our theory on what it happening?It is suggested that an over-activation &/or inadequate suppression of the sympathetic nervous system, together w/ a lack of cortisol production as a stress response, czs a neurogenic inflammation w/in the bladder
Why is it easier for sandy material & mucus plugs to accumulate in the male cat than in the male dog?Penile urethra tapers in cats
Most common age range for FLUTD?2-6yr
Which cat breed at HIGHER risk for FLUTD? Who’s at a LOWER risk?HIGHER = Persian & Burmese
LOWER = Siamese
FLUTD is a is a syndrome which is characterized by... (8 possible signs) [One other sign?]Dysuria, hematuria / crystalluria, licking of genitals, reduced emission, urethral obstruction, sandy material, "crying", constipation? (Crying w/ constipation is what the owner will tell you what they see, even tho not constipation)...lastly, possible [shock]
If you suspect FLUTD in ca cat, what should you be SUPER careful about?DO NOT PALPATE BLADDER ROUGHTLY - CAN RUPTURE
How is anatomy of the cat unique? What implications does it have?Penis aims downward & caudal - so, you must extrude penis & then direct penis DORSALLY (ELEVATE IT) to get a more straight shot through the urethra
How often does a UTI happen the 1st time? What inc the chances of a UTI (& by how much?)1st time: 3%. Turns to 20% after catheterization due to obstruction
What are 3 examples of things you can use to cath a cat?Tom cat catheter
Slippery Sam Cath
Osborne cannulas
How can you try to non-surgically unblock a cat? What do you do after this?Place cath (ELEVATE PENIS! LUBE WELL!) & then try to FLUSH to break into smaller pieces. If this is the 1st time the cat has been blocked, after you unblock place a more permanent cath for a while
If you unblock a cat w/ a cath & flushing & the fluid released is the color of red wine, what do you think is going on?Tinged w/ blood bc of severe distension of the bladder
Theories on etiology of blocked cat?Bacteria → does not play a 1° role. Possible virus (mucoprotein). Possible diet? (Mg).
How do you Dx FIC? (Feline) Interstitial cystitisDx of EXCLUSION (ruled out all other possible options)
How can you try to non-surgically Tx FLUTD?Medical Tx (cath & flush, or urohydropropulsion) & special diets (like c/d)
When would you consider Sx Tx of FLUTD?(2)(1) When medical/diet Tx fail
(2) for RECURRENT urethral obstruction (30% have a 2nd episode)
What is urohydropropulsion?Stand cat up, try to massage w/ both hands & gently squeeze & try to dislodge little stones. If all else fails, Sx time.
After how many times of medical management of FLUTD w/ cath & flush would you start to consider Sx? Why?If recurrent & cath & treated medically, you get a frayed urethra during Sx bc of all the medical manipulation - so after 2nd block, consider Sx
Explain Urethral plug Vs Urolith?Urethral plug: matrix of gelatinous structure, amorphous, friable or doughy. Urolith: structure organized internally, non-deformable, solid (usually Struvite or Ca Ox) [note: the 2 can be concurrent & mix together in urethra, causing a cement-like plug. Also careful if palpating gritty feeling urethra, thats like sandpaper in there]
Some precautions you should take if you are going to perform a cystostomy on a FLUTD cat?Look out for URINE SCALDING! If dont take good care to put baby oil around to protect skin. Also cats have floppy fat reservoir there...that needs to be cleaned w/ antiseptics (prevent irritation & contamination)
If it is just a urethral plug which is causing the blockage, what might you be able to do?Massage penis from side to side & squeeze-can sometimes dislodge. ((Careful - if gritty material also in there, you are like sandpapering the inside of the urethra)
What can you do to help the urethra heal from it's various damage due to FLUTD ordeals?Bypass urethra while it heals - cystostomy. Remember; drain never exits through 1° incision.
About how often should you check the cystostomy bandage & why?Bandage should be checked at least 1x a day. Feel how tight it is. Put padding on it. If its wet, change it out.

FLUTD perineal urethrostomy

Question Answer
**What makes the perineal urethrostomy different in the cat than in the dog?CAT ALSO REQUIRES PARTIAL AMPUTATION OF PENIS - Wilson & Harrison technique
When do you use perineal urethrostomy in the cat? (3 indications)(1) This is a SALVAGE procedure used to treat recurrent FLUTD & calculi in the male cat
(2) Irreversible mural or extramural lesions causing recurrent or persistent obstruction
(3) Frequent recurrence of urethral obstruction despite appropriate medical therapy
In SHORT, what are you doing in a Perineal Urethrostomy in the Cat?The pelvic urethra is opened & sutured to the skin → The penis is partially amputated → The remaining skin incision is closed
PU (step 1) positioning, prep & initial incision for this?Place cat in perineal position (Trendelenburg but on stomach)! Clip WIDE margins - from sacrum to tuber coxi to middle aspect of thigh. Dont want any fur! Also place a purse string around the anus to help prevent contamination. If the cat is intact, castration & scrotal ablation are done before PU. Make an elliptical skin incision around the scrotum & prepuce (use an 11/12/15 blade, not a 10) & you can remove skin & take testicles out at this time.
PU (step 2) after initial incision, how do you start to manip/work w/ tissues?After initial elliptical incision around penis & testes, start bluntly dissecting SQ & CT that holds prepuce to skin. Dissect 360° around penis, trying to separate. Once the penis is freed, you should see 2 bellies of attachment from penis to ischial arch - 1 on each side, the ischiocavernosus mm on both sides!!!!! You want to release these attachments. However, just severing the mm will lead to much bleeding. So instead, he uses the back of the scalpel to scrape at the attachment of the ischiocavernosus to the ischial arch. (Back arrow pointing to attachment point)
PU (step 3) *Once the attachments of the ischiocavernosus have been freed, what do you do to fully free up the penis & know you are ready for the procedure?Next cut retractor penis mm. then penis can move freely 180 degrees. Lift penis & then bluntly, while working against penis (not pelvis) free it from any other CT that might attach penis to floor of pelvis. Careful not to damage innervations. Now attach Halsted to tip of prepuce & let it hang by itself, you should see bulbourethral glands near skin incision w/o needing to apply tension. (Glands make urethra narrow, shorter & not as wide as you need) if see this, mean you have enough area to create the stoma & do all the shit you wanna do.
PU (step 4) How do you begin procedure after the penis is freed & bulbourethral glands are exposed?W/ Steven Tenotomy scissors (bluntly tipped but finely pointed). Cut & split urethra up to the level of the bulbourethral glands. (Doesnt bleed that much if you cut like how he said) sometimes when split the urethra might have more of an oozing or bleeder if cat cathed several times due to inflammation, but usually just some slow oozing. You CAN use traumatic forceps for stabilization, bc the penis being stabilized will be removed anyway
PU (step 5) What do you do once the urethra & penis have been split up the midline?Once the urethra is split in half, insert curved Halsted hemostat & push up to the box joint of the instrument (there should be no pressure), then you know you have the optimal opening.
PU (step 6) How do you close? (Material? technique?)He recc Monocryl, PDS, Maxon, or monofilament nylon for suture material on a reverse cutting needle (taper point prolly not strong enough to get through skin also). He does not recc braided suture (ok if have nothing else. if too stiff - wet fingers & slide braided suture btwn fingers). Suture from urethra mucosa to the skin (in to out). 11, 12, 1 oclock - most important stitches bc if those collapse you will not have good opening → strictures. Stagger the sutures on each side all the way down - then go fill back in. simple interrupted. Leave tags longer - don't want to act as bristles. Once you get to the bottom on the incision near where the penis was, you suture goes through skin under corpus cavernosum urethra & out through other skin (kind works like a mattress stitch) maintains tip of penis from pulling up & acts as hemostatic suture - bc going to amputate penis below that stitch. Amputate penis then finish suturing-sub q & then skin w/ simple interrupted (dotted red line in picture is where you do mattresses)
PU (step 7) after closure is done, how do you check your work?"Cath" again w/ curved hemostat up to joint box to make sure sutures ok & have a nice opening. Should go in w/ almost no pressure - very gently. Once you finish suturing the skin, remove suture around anus & then remove drapes. Carefully express the bladder manually to ensure that urine is not leaking into the subcutaneous tissue
What is the "S.A.F.E." approach for basic tips on how you should deal w/ FLUTD cats?S = Stabilize 1st (FLUIDS to help w/ HYPERKALEMIA)
A = Accurate Dx
F = FLUSH & DONT force caths through the urethra
E = extend the urethra dorsally when inserting caths to flush the urethra
When should you use a post-op catheter for a perineal urethrostomy? (What kinda cath, how long?)Use indwelling urethral catheter only if urethral tear is present. You should use a large cath French 8 & remove w/in 5-7d
When should you remove the sutures7-10d
What post-op precaution should you instruction owners to take?Remove regular litter box! (Use diff kind of litter & stuff that wont stick to them)
#1 cz of post op complications is...(others?)(#1) Poor surgical technique! Also, if you don't detach the penis enough where the bulb. Glands can show just by having Halsted’s weigh it down, you have not detached it enough & the penis will move inwards & cz tension on the sutures. The penile urethra could have been wrongly incised (not down the midline etc - see pic in that card), there could be neurological damage from you not being careful while dissecting penis out, the suturing technique could have been improper (always mucosa to skin), excessive tension of sutures, or excessive catheterization.
3 most common complications after a PU? (What are some less common complications?)(1) Recurrent FLUTD/FISC & bacterial cystitis
(2) Urethral stricture
(3) Urolithiasis (other complications incld: SQ urine leakage, Urine scald, Incontinence, Urethrorectal fistula, Perineal hernia, Rectal prolapse)
#1 cz of perineal hernia in cats?The PU procedure!! Bc your finger is moving around in there like a blender
Urethrorectal fistula might happen if...Excessive dorsal dissection resulted in penetration of rectum (scissors went up too far)
If the PU heals & there is a stricture of the will have toREDO SX
Explain how you would go about REDOING the PU procedure if the urethra healed into a strictureRecreate elliptical incision, free up penis (make sure it's fully dissected) ventral to penis there is also connective tissue needs to be freed up. Make sure bulbourethral glands come into incision - otherwise strictures. Create a new stoma in the penis urethra. You only get 1 redo!!
What is the transpelvic urethrostomy?A new approach to the PU procedure - cat in dorsal recumb, incision ventral, dissection of penis very similar, but w/ rongeur you're gonna eat/take out part of pelvis at level of symphysis. Expose ventral aspect of urethra. Free up penis, open penis, try to bring urethra mucosa to skin. Since opening into bone, can bring penis up & suture urethra to skin.. Could be salvage procedure if having a stenosis & it obstructed.