Small Ani. Sx- Urinary 1

kelseyfmeyer's version from 2016-03-05 14:38

general/ nephrectomy

Question Answer
which gender is less likely to have obstruction and why?females, bc short and 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 and collects around the umbilicus. maybe free fluid (esp blood) inside abdomen. (Cullen's sign is superficial edema and 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 two 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 and squirt contrast backwards)
***If you suspect uroperitoneum, and 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 and is more easily balanced, so crt is more reliable
if there is a uroperitoneum, what must you do to help prevent a chemical peritonitis?LAVAGE, yo
two approaches for nephrectomy? Do you want a bigger or smaller incision and 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 and can even be touching liver
which kidney is easier to access?L- more moveable and more easily exposed.
two 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 with your finger. (3) Three clamp technique (2 clamp if REALLY can't fit 3) the vessels and ligate, ligate ureter
what should you know about renal vasculature variation?might have more than one 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 and 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 vaculature? 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 and separate vessels.
If you see an animal with blunt trauma like a HBC, or the femur is fx, what should you check and 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 causes adhesions and stuff, AND dilates backwards and causes a nidus for stone formation/infection/cystitis. Place 2 ligs on side of ureter staying, and one on side going out
exs of some indications for nephrectomy?severe damage/ infarct/ neoplasia (nephroblastoma)/ severe pylonephritis
what is an excellent reason to separate and 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 FIRST-- 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 and 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 one end of umbillical tape through tube, around one side of vessel and then circle around the vessel with the tape. Then place both ends of tape through tubing. Then take hemostat, and with one hand pull gently on the tape and with other hand push down tubing and hemstat and that will choke the vessel. gently. wont damage. (better to use umbilical tape bc then vessel cant get inside tubing and more surface area=less cutting force on vessel). then close clamp and that will maintain vessel occluded.
how long can you occlude blood from the kidney without 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 bloodflow, clamp again, have 5 more min.
with a partial nephrectomy, how much are you usually removing?usually remove 1/2 or one pole of kidney.
Do you want to rummel tourniquet the renal aa and vv separate or together? what order do you want to do them in?prepare a tourniquet one for artery and one for vein separately, then clamp both at same time, regardless of which one you start to ligate first.
Do you want to open the artery rummel torniquet or the vein rummel torniquet first, and why?first open vein and 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.


Question Answer
5 main clinical signs 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 and 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 one kidney at a time if at all able-- so nephrotomy on one (preferably worse one), close it up, let it heal for like 15-20d or a month later, and then do other kidney.
how might nephrotomy affect renal fxn?can DEC up to 20-50% :(
two 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 and exposed. Pack all around with lap sponges. On Side opposite hilus, make incision from one pole to the other. (long incision.) wont reach pelvis on first cut-- will need to keep cutting without filleting kidney (stay on same plane you started incision with) more cuts--> more dead nephrons. Go till you see whiteish 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 and tearing
why is suction very important to have with a nephrotomy?(aside from fact you're cutting through arcuate vessels and there will be a lot of blood obscuring) there might still be urine in the pelvis/still being produced- don't want this scarring parynchyma
(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, and then place a red rubber cath into pelvis and flush into ureter. This will displace any potential sandy material that might have been left over, and 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 and squeeze it with 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 with a nephrotomy, and what should it be?maintian good fluid therapy before/during/after procedure- should get 1-2ml/kg/hr- indicate good renal function
Can you use horizontal mattress closure with a nephrotomy?AVOID. Used to do horizontal but not much anymore bc when you cut into the kidney, there is gonna be huge inflammation...and then tension on the sutures. So, if not tight enough horz. mattress, blood seeps out, and too tight, sutures cut through kidney parenchyma and cause damage. (just hold kidney 5-10 min to let coag and then you will have good closure)...try to avoid horiz mattress. (dont forget to suture pelvis first.
how does a percutaneous nephrolithotomy work?through skin make incision, through kidney, place endoscope with 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 which can freely pass

Hydronephrosis/ Ectopic Ureters intro

Question Answer
what's going on here? hydronephrosis- leads to enlargement of ureters and kidneys bc they are full of fluid (also ureters are usually a straight line)
who is most prone to hydronephrosis?dogs
4 main causes 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) and urinalysis (eggs in urine)
etiology of ectopic ureters unknown. is there one 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 extopic 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 extopic ureter can open into?may open into urethra, vagina, uterus
what does it mean if the ectopic ureter is taking a 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 complcation?60% continent post-op-- might have a hypoplastic bladder
what is a med that might help with incontinence post-op of fixing a ectopic ureter?PPA (Phenylpropanolamine)
main clinical sign of ectopic ureter?INCONTINENCE!
two 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 with air) <---together this is a DOUBLE CONTRAST STUDY
what does the uretral 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 and why?foley- little blow up balloon to prevent backflow (red circle is blown up foley balloon)