Journal of Feline Medicine and Surgery

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Vaginourethroplasty as a Salvage Procedure for Management of Traumatic Urethral Rupture in a Cat

Zoeë J Halfacree, Michael S Tivers and Daniel J Brockman
Journal of Feline Medicine and Surgery 2011 13: 768
DOI: 10.1016/j.jfms.2011.05.013

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Journal of Feline Medicine and Surgery (2011) 13, 768e771
doi:10.1016/j.jfms.2011.05.013

CASE REPORT
Vaginourethroplasty as a salvage procedure for
management of traumatic urethral rupture in a cat
Zoë J Halfacree MA, Vet MB, CertVDI, CertSAS, DipECVS*, Michael S Tivers BVSc, CertSAS, DipECVS,
Daniel J Brockman BVSc, CertSAO, Cert VR, DipACVS/ECVS

Department of Veterinary Clinical
Sciences, Royal Veterinary College,
Hawkshead Lane, North Mymms
Hatfield, Hertfordshire, UK
Date accepted: 13 May 2011
This report describes a cat that suffered pelvic urethral rupture associated with
multiple pelvic fractures. A vaginourethroplasty was performed as a salvage
procedure, via intrapelvic anastomosis of the proximal urethra to the caudal
vagina, following failure of a primary urethral anastomosis. Urinary diversion
was achieved via tube cystostomy and a vagino-urethral catheter was
maintained for 3 days postoperatively. Anterograde cystourethrography was
performed at 7 days and 14 days postoperatively. Absence of contrast leakage
from the vagino-urethral anastomosis was documented at 14 days
postoperatively and the tube cystostomy was removed. An Escherichia coli
urinary tract infection was treated following removal of the tube cystostomy and
subsequent urine culture revealed no evidence of urinary tract infection. The cat
retained normal urinary continence and elimination behaviour during the
7-month follow-up period. Vaginourethroplasty could be considered as a salvage
option for management of traumatic pelvic urethral rupture in the neutered
female cat.
Ó 2011 ISFM and AAFP. Published by Elsevier Ltd. All rights reserved.

U
rethral rupture may occur following vehicu-
lar trauma, bite wounds, penetrating in-
juries, urethral calculi or iatrogenic injury
during urethral catheterisation or surgery.1e4 Manage-
ment of urethral rupture requires patient stabilisation,
correction of metabolic disturbances and provision of
urinary diversion. There are three options for the
management of urethral rupture: temporary urinary
diversion via a tube cystostomy or urethral catheter
and second intention healing of the urethra, perma-
nent urinary diversion via a urethrostomy or primary
urethral repair.5 Second intention healing of the ure-
thra is only appropriate when the urethral defect is
small.4 Primary urethral repair is challenging due to
the small size of the feline urethra and is associated
with complications of urethral dehiscence and stric-
ture.5,6 Permanent urethrostomy may provide a satis-
factory outcome, however, the rate of complications
can be greater following urethrostomy at more cranial
sites. Prepubic and transpubic urethrostomy achieve
permanent bypass of urethral lesions of the pelvic ure-
thra, however, a relatively high rate of complications,
*Corresponding author. E-mail: zhalfacree@RVC.AC.UK
including urinary incontinence and peristomal skin
irritation and necrosis, are documented.7
This case report describes the use of an end-to-end
vagino-urethral anastomosis (‘vaginourethroplasty’)
to achieve permanent urinary diversion in a cat follow-
ing traumatic urethral rupture and failure of primary
urethral anastomosis.
A 9-year-old female neutered domestic shorthair cat
(3 kg) was referred for management of pelvic fractures,
following a road traffic accident. Plain and contrast radi-
ography revealed a right iliac shaft fracture, multiple pu-
bic and ischial fractures and rupture of the pelvic urethra
(Fig 1). A tube cystostomy was placed to achieve urinary
diversion on the day of presentation using a standard
technique.8 Surgical exploration of the pelvic urethra
on the fourth day, documented complete urethral tran-
section, 3 cm from the bladder neck, and a primary ure-
thral anastomosis was performed. The right iliac shaft
fracture was stabilised using a 2.0/2.7 mm lateral veter-
inary cuttable plate (Synthes, Welwyn Garden City, UK)
on the sixth day following presentation. Anterograde
cystourethrography performed 20 days following ure-
thral anastomosis revealed a stricture and persistent
contrast leakage at the anastomosis site (Fig 2), necessi-
tating surgical revision.

1098-612X/11/100768+04 $36.00/0 Ó 2011 ISFM and AAFP. Published by Elsevier Ltd. All rights reserved.

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 Vaginourethroplasty for management of urethral rupture
Fig 1. Retrograde vaginourethrocystogram performed on
the day of presentation. This demonstrates contrast leakage
from the pelvic urethra, consistent with urethral rupture.
Under general anaesthesia the cat was prepared for
a vaginourethroplasty surgery via a ventral midline
laparotomy and pubic symphysiotomy, including anti-
septic lavage of the vulva which was draped within the
sterile field. An 8 Fr nylon catheter was passed nor-
mograde, via a stab incision in the urinary bladder,
through the proximal urethra allowing improved visu-
alisation of the site of urethral stricture. A 5 Fr Foley
catheter was inserted in a retrograde fashion per va-
gina. The vagina was then transected and spatulated
at the level adjacent to the previous urethral anastomo-
sis, allowing the tip of the Foley catheter to exit the dis-
tal vagina at this point. The cervical remnant and
proximal portion of the vagina were resected. A
5 mm portion of urethra, at the site of previous anasto-
mosis, was resected and the distal urethra was ligated
using an encircling ligature of 3e0 polydioxanone. The
proximal urethra and distal vagina were then apposed
Fig 2. Anterograde cystourethrogram performed via the
tube cystostomy 20 days following primary repair of the
complete pelvic urethral rupture. This demonstrates leakage
of contrast material and the presence of a stricture at the
anastomosis site.
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769
by advancing the Foley catheter into the distal opening
of the proximal urethra (Fig 3). The anastomosis was
sutured using a simple interrupted pattern of 5e0 pol-
ydioxanone on a round bodied needle circumferen-
tially; eight sutures were placed and surgical Loupes
(3.5) were used for magnification. The vagino-
urethral anastomosis site was omentalised prior to rou-
tine abdominal closure.
Continued urinary diversion was provided via the
tube cystostomy and the vagino-urethral Foley cathe-
ter was closed and left in situ for 3 days post-
operatively. Anterograde cystourethrography was
performed under general anaesthesia at 7 days and
14 days postoperatively by injection of a 2 ml/kg bo-
lus of iohexol (Omnipaque; GE Healthcare AS, Oslo,
Norway, 300 mg I/ml) diluted in a 1:1 ratio with ster-
ile saline via the tube cystostomy. Leakage of contrast
agent was documented from the vagino-urethral anas-
tomosis site at 7 days postoperatively but was not
present by 14 days (Fig 4) and the tube cystostomy
was, therefore, removed. Urinalysis and culture at
this time revealed an active urine sediment and a pro-
fuse growth of Escherichia coli. A 4-week course of en-
rofloxacin (5 mg/kg po q 24 h) was prescribed on the
basis of sensitivity testing.
The cat was re-examined 4 and 16 weeks postoper-
atively. The owners observed that she urinated nor-
mally with no evidence of dysuria and that she
retained normal urinary continence. There was no ev-
idence of perineal urine scald or vulval inflammation.
A urine sample was obtained via cystocentesis 1 week
following cessation of antibiotic treatment and the
urine sediment was unremarkable and culture yielded
no bacterial growth. The cat was represented at
24 weeks postoperatively following a 2-week history
of vomiting. Abdominal ultrasonography revealed
a grossly thickened gastric wall with complete loss
of layering. The owners declined further investiga-
tions and the cat was euthanased 1 month later due
to progression of her disease; post-mortem examina-
tion was not performed.
The majority of published literature regarding man-
agement of feline urethral rupture describes the con-
dition in the male cat.1e5 Literature regarding
urethral rupture in the female cat is very limited.1,9
Extrapolating from the canine literature, the optimal
management of transection of the pelvic urethra is pri-
mary urethral anastomosis over a urethral stent with
concurrent urinary diversion.5,10,11 Following failure
of this technique, revision of the urethral anastomosis
was considered unfeasible due to the risk of tension at
the anastomosis site following excision of the stric-
ture. Vaginourethroplasty was performed as an
alternative salvage option to prepubic,7 subpubic12
or transpelvic13 urethrostomy, to maintain greater ure-
thral length and normal elimination behaviour.
The vaginourethroplasty technique employed in
this cat was modified from that previously described
for management of urethral neoplasia in the bitch14,15
to account for anatomical species differences. In the
770
Fig 3. A schematic diagram of the caudal abdomen and pelvis of the cat demonstrating the stages of the vagino-urethral
anastomosis procedure to create the vaginourethroplasty.
bitch, the luminal disparity between the vagina and
urethra necessitates resection of the ventral vaginal
wall and closure over a catheter to create a narrow
‘vaginourethra’15; however, in contrast, the narrow lu-
men of the feline vagina allowed a direct anastomosis
of the proximal urethra to the distal vaginal. In fact,
the end of the distal vagina was spatulated in this
cat to increase the luminal diameter of the vagina.
The small size of the feline urethra and vagina pres-
ents a technical challenge during both primary ure-
thral anastomosis and vaginourethroplasty; however,
magnification was used to ameliorate this problem.
Whilst the primary urethral anastomosis failed, suc-
cessful healing of the vagino-urethral anastomosis
was achieved. This is likely to be due to improved
urethral tissue characteristics following a delay post-
trauma, in addition to use of the non-traumatised dis-
tal vagina which provided a tension free site for
anastomosis.
Following the vaginourethroplasty procedure, con-
tinued urinary diversion was employed via the tube
Fig 4. Anterograde cystourethrogram 15 days following
vaginourethroplasty demonstrating the healed anastomosis
between the cranial vagina and distal portion of urethra.
There is slight narrowing at the anastomosis site but no
evidence of contrast leakage.
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ZJ Halfacree et al
cystostomy and an indwelling closed vagino-urethral
catheter was left in place as a stent for 72 h. Urinary
diversion to bypass the anastomotic site is associated
with improved urethral healing and reduced inci-
dence of dehiscence and stricture.16,17 The period for
which a catheter was used for vagino-urethral stent-
ing was similar to the previous canine case series in
which the catheter was retained for 48 h.15 The ratio-
nale for use of a catheter as a vagino-urethral stent
is based upon a canine experimental study in which
minimal urethral stricture was demonstrated follow-
ing suturing of a urethral anastomosis over a catheter
compared to other non-sutured anastomoses, or those
without an indwelling catheter.10 It has been demon-
strated in experimental dogs that urothelial regenera-
tion occurs rapidly across urethral defects if some
mucosal continuity is present,16 however, it is unclear
how mucosal healing would occur at the vagino-
urethral interface.
A urinary tract infection was documented in this
cat, however, resolution occurred following antibiotic
treatment and it is recognised that the use of a tube
cystostomy18 and indwelling urethral catheter19 pre-
dispose to urinary tract infection. There was no indi-
cation that the cat was predisposed to urinary tract
infection during the follow-up period; however, lon-
ger term follow-up of this technique in additional
cats is required.
This report describes the modification of an existing
technique of vaginourethroplasty for permanent uri-
nary diversion in a female neutered cat with a trau-
matic pelvic urethral rupture associated with pelvic
fractures. The technique allowed retained continence
and elimination behaviour and was not associated
with any complications. This report highlights an al-
ternative salvage option to urethrostomies in neutered
female cats for management of urethral trauma.
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