Affections of Urinary System

AFFECTIONS OF
URINARY SYSTEM
DR.D.VISHNUGURUBARAN
ASSISTANT PROFESSOR
DEPT OF VSR
28/05/2023 DR.D.VISHNUGURUBARAN 1
DEFINITIONS AND TERMS
• Nephrectomy is excision of the kidney;
• Nephrotomy is a surgical incision into the kidney.
• Nephrostomy is the creation of a permanent fistula leading into the pelvis of the kidney
• Temporary nephrostomy tubes (nephropyelostomy) are occasionally used to divert
urine when obstructive uropathy occurs or when the proximal ureter has been avulsed
from the kidney.
• Pyelolithotomy is an incision into the renal pelvis and proximal ureter
• Ureterostomy is an incision into the ureter
• Neo ureterostomy is a surgical procedure performed to correct intramural ectopic
ureters;
• Ureteroneocystostomy involves implantation of a resected ureter into the bladder.
RENAL FAILURE
• CKD Vs CRF
• ARF or AKI
• ACUTE ON CRF
• CKD - markers of structural or functional kidney damage of longer
than 3 months’ duration.
• CRF - patients with CKD with significant clinical signs (polyuria,
polydipsia, weight loss, decreased appetite) and laboratory findings
(azotemia, anemia, proteinuria).
PRE-OPERATIVE CONSIDERATION
• Renal profile, Haematology, Calcium, Phosphorus, TP, Electrolytes, Urine analysis, BP
• Metabolic derangements, azotemia, dehydration, oliguria, polyuria
• Pre-operative fluid therapy – Judiciously
• Diuretics – hydrated?
• 50 ml/kg/day or more than 2 ml/kg/hr.
• Hyperkalemia or hypokalemia – cardiac arrhythmia
• Hypermagnesemia or hypomagnesemia – cardiac conduction disturbances & CNS aberrations
• Anemic – why?
• Gastric ulceration, bleeding, or increased red cell fragility
• hydrated animals with a packed cell volume (PCV) below 20% or a hemoglobin level less than
5 g/dl may benefit from preoperative blood transfusions
SURGICAL ANATOMY
• Kidney – retroperitoneal space
• Right Kidney – T13 to L3
• Left kidney – L4/L5
• Renal pelvis – Ureter
• Ureter to bladder @ Dorsal surface
SURGICAL TECHNIQUE
• Ventral midline incision – xiphoid to caudal to the umbilicus or extend
to the pubis if needed
• Balfour retractor is used to retract the other organs
• Right kidney – elevate the duodenum and retract the intestine to the
left
• Left kidney – elevate the mesocolon and retract the intestines to the
right
NEPHRECTOMY
• Neoplasia
• Uncontrollable haemorrhage
• Persistent urine leakage
• Pyelonephritis resistant to medical therapy (e.G.,Associated with
nephroliths), hydronephrosis, and
• Ureteral abnormalities that defy surgical repair (e.G., Avulsion,
stricture, rupture, obstruction due to calculi).
• Grasp the peritoneum over the kidney and incise it. Using a combination of
blunt and sharp dissection, free the kidney from its sub lumbar
attachments.
• Elevate the kidney and retract it medially to locate the renal artery and
vein on the dorsal surface of the renal hilus.
• Identify all branches of the renal artery. Double ligate the renal artery with
absorbable suture (e.g., polydioxanone, Polyglyconate, glycomer 631,
poliglecaprone 25) or nonabsorbable suture (e.g., cardiovascular silk)
close to the abdominal aorta to ensure that all branches have been ligated.
• Identify the renal vein and ligate it similarly.
• Ligate the ureter near the bladder. Remove the kidney and ureter and, after
procuring appropriate culture specimens, submit them for histologic
examination.
PARTIAL
NEPHRECTOMY
NEPHROTOMY
• Caliculi and exploration of kidney
• Mobilize the kidney to expose the convex lateral surface.
• Make a sharp incision along the midline of the convex border of the kidney capsule, then bluntly dissect through
therenal parenchyma, ligating renal vessels as necessary
• Culture the renal pelvis. Remove the calculi and flush the kidney with warm saline or lactated Ringer’s solution.
• Assess the ureter for patency by placing a 3.5 French soft rubber catheter down the ureter and flushing it with
warm fluids.
• Close the nephrotomy by apposing the cut tissues and applying digital pressure for approximately 5 minutes
while restoring blood flow through the renal vessels (suture less technique).
• As an alternative, appose the capsule with a continuous pattern of absorbable suture material.
• If adequate hemostasis is not achieved, or if urine leakage is a concern, place absorbable sutures through the
cortex in a horizontal mattress fashion
• Then, suture the capsule in a continuous pattern with absorbable suture. Replace the kidney in its original
location.
PYELOLITHOTOMY
• Dissect the kidney from its sub lumbar attachments and expose the dorsal surface. Identify the ureter and
renal vessels.
• Make an incision over the dilated pelvis and proximal ureter, and remove the calculi.
• Flush the renal pelvis and diverticula with warm saline to remove small debris. Next, flush the ureter to
ensure its patency. Close the incision in a continuous pattern with 5-0 or 6-0 absorbable suture
URETEROTOMY
• Make a transverse or longitudinal incision in the dilated ureter proximal to the
calculi and remove them .
• Place a small, soft rubber catheter into the ureter proximal and distal to the
incision, and flush the ureter with warm fluid.
• Make sure that all calculi have been removed and that the ureter is patent.
• Close the incision in a simple interrupted pattern with 5-0 to 7-0 absorbable suture.
• As an alternative, if the ureter is not dilated and if stricture formation seems likely,
make a longitudinal incision over the calculi and close the incision in a transverse
fashion.
• If the ureter has been damaged, perform a resection and anastomosis or a proximal
urinary diversion via a nephropyelostomy tube
ECTOPIC URETER
• Ectopic ureter, or ureteral ectopia, is a congenital anomaly in which one or both ureters empty
outside the bladder.
• Extraluminal (extramural) ectopic ureters are those that completely bypass the bladder;
intraluminal (intramural)
• Ectopic ureters course submucosally in the bladder to open in the urethra or vagina
• Ectopic ureters are more commonly diagnosed in female than in male dogs.
• Breed susceptible
• Siberian Huskies,
• Golden Retrievers,
• Labrador Retrievers,
• Newfoundlands,
• English Bulldogs,
• Miniature
• Poodles,
• Briards,
• Appenzellers, and some Terrier breeds
Clinical signs and physical examination
findings
• Intermittent urine dribbling
• Incontinence, dysuria, haematuria, chronic
UTIs, and complete or partial urinary
obstruction
Diagnosis
• Excretory urography
• Cystoscopy probably is the most reliable,
sensitive, and specific method for
diagnosing ectopic ureters in females
• CT
• Intramural ectopic ureters can be corrected with neoureterostomy,
ureteroneocystostomy, or laser ablation.
• If the ureter is extraluminal, ureteroneocystostomy must be performed
by resecting the ureter as distal as possible and reimplanting in the
bladder lumen.
• Nephroureterectomy may be performed for unilateral ectopic ureters if
significant morphologic or functional abnormalities of the kidney and
ureter are present.
RENAL AND URETERAL CALCULI
• Urolithiasis refers to the condition of having urinary calculi or uroliths (kidney,
ureter, bladder, or urethra).
• The condition of having renal or ureteral calculi (i.e., nephroliths or ureteroliths)
is nephrolithiasis or ureterolithiasis, respectively.
• Nephrolithotomy is performed to remove renal calculi from the renal pelvis by
incising through kidney parenchyma;
• Pyelolithotomy is an incision into the renal pelvis and proximal ureter.
• Ureterolithotomy is the removal of calculi from the ureter by incision
(ureterotomy)
RENAL AND URETERAL NEOPLASIA
• Nephroblastomas are rapidly
developing, malignant mixed
tumors that arise from
embryonal elements of the
kidney.
• They are also called embryonal
adenomyosarcoma, nephroma,
and Wilms’ tumor.
SURGERY OF BLADDER AND
URETHRA
• Cystotomy is a surgical incision into the urinary bladder, whereas urethrotomy is an incision into the
urethra.
• Cystectomy is removal of a portion of the urinary bladder.
• Cystolithiasis and cystolithectomy refer to urinary bladder calculi and their removal, respectively.
• Cystostomy is the creation of an opening into the bladder
• Urethrostomy is the creation of a permanent fistula into the urethra; it is generally performed for
irreparable or recurrent urethral stricture, or to prevent repeated obstruction
• Obstruction to urinary flow may cause a distended urinary bladder, postrenal azotemia, and
hyperkalemia
• Urinary leakage into the abdominal cavity causes uremia, dehydration, hypovolemia, hyperkalemia,
and death if undiagnosed or untreated.
• Urinary obstruction and uroperitoneum are medical emergencies, not surgical emergencies.
• Hyperkalemia associated with these conditions makes the animal prone to cardiac arrhythmias;
therefore fluid and electrolyte abnormalities should be corrected before anesthesia
SURGICAL ANATOMY
• The urinary bladder location varies depending on the amount of urine it currently contains; when
empty, it lies primarily within the pelvic cavity.
• In a 12 kg dog, the bladder holds up to 120 ml of urine without becoming overly distended.
• The bladder is divided into the trigone, which connects it to the urethra, and the body.
• The bladder receives its blood supply from the cranial and caudal vesical arteries, which are
branches of the umbilical and urogenital arteries, respectively.
• Sympathetic innervation is from the hypogastric nerves, whereas parasympathetic innervation is
via the pelvic nerve.
• The pudendal nerve supplies somatic innervation to the external bladder sphincter and striated
musculature of the urethra.
• The urethra in male dogs and cats is divided into prostatic, membranous (pelvic), and penile
portions
SURGICAL TECHNIQUE
• Umbilicus to pubis – Bladder and proximal urethra
• Pelvic osteotomy or symphysiotomy is required for adequate exposure of
the membranous urethra
• The penile urethra begins at the ischial arch and extends to the external
urethral penile orifice.
• The penile urethra may be approached in the perineal (perineal
urethrotomy) or scrotal (scrotal urethrotomy) region, or between the
scrotum and the external urethral orifice (prescrotal urethrotomy)
• If the prepuce is to be left in the surgical field, a preputial flush with
chlorhexidine or dilute Betadine should be part of the surgical preparation
CYSTOTOMY
• Cystic and urethral calculi
• Neoplasia
• Repair ectopic ureter
• Isolate the bladder from the rest of the abdominal cavity by placing moistened laparotomy pads beneath it.
• Make a longitudinal incision in the ventral or dorsal aspect of the bladder, away from the ureters and urethra,
and between major blood vessels.
• Remove urine by suction or perform intraoperative cystocentesis
• Close the bladder in a single layer using a continuous suture pattern with absorbable suture material. For a
two-layer closure, suture the seromuscular layers with two continuous inverting suture lines (e.g., Cushing,
followed by Lembert;).
• If the dog has severe bleeding tendencies, consider suturing the mucosa as a separate layer with a simple
continuous suture pattern.
CYSTOSTOMY (PREPUBIC
CATHETERIZATION)
URETHROTOMY
• Urethrotomy is performed in male dogs to remove urethral calculi that cannot be
retrohydropropulsed into the bladderand to facilitate placement of catheters into
the bladder. Occasionally, urethrotomy is performed for a biopsy of obstructive
lesions (i.e., strictures, scar tissue, and neoplasms). Prescrotal or perineal
urethrotomy may be performed depending on the level of the obstructive lesion.
BLADDER AND URETHRAL CALCULI
• Most canine uroliths are found in the bladder or urethra. Struvite (magnesium ammonium phosphate) and
calciumoxalate calculi are the most common canine uroliths, followed by urate, silicate, cystine, and mixed
types
• Urinary tract infections with urease-producing bacteria are an important cause of struvite calculi in dogs.
• Female dogs tend to have more struvite-containing calculi than male dogs, most likely owing to the association
with urinary tract infection
• Calcium oxalate calculi occur most commonly in dogs with transient, postprandial hypercalcemia and
hypercalciuria.
• Although rare, these calculi may also occur in dogs with defective tubular resorption of calcium, primary
hyperparathyroidism, lymphoma, vitamin D intoxication, decreased urine concentrations of citrate, or increased
dietary oxalate.
• Acidic urine favors calcium oxalate crystal formation. Dogs eating canned diets with a high amount of
carbohydrate were found to be at increased risk for calcium oxalate urolith formation; dogs fed dry diets
formulated to contain high concentrations of protein, calcium, phosphorus, magnesium, sodium, potassium, and
chloride appeared to have fewer calcium oxalate calculi.
• Dalmatians have defective hepatic transport of uric acid, resulting in decreased
production of allantoin and increased urinary excretion of uric acid. Dalmatians also
have decreased proximal tubular resorption and distal tubular secretion of uric acid,
making urate urolithiasis common in this breed.
• Dogs with hepatic insufficiency (e.g., congenital portosystemic shunts) may form
ammonium acid urate stones as the result of increased renal excretion of ammonium
urates.
• Silicate uroliths are often jack shaped and probably are related to increased dietary
intake of silicates, silicic acid, or magnesium silicate
• Male German Shepherd dogs and old English Sheepdogs are at increased risk for
formation of silica-containing urinary calculi.
• Cystine uroliths occur because of an inherited disorder of renal tubular transport.
Cystine stones usually occur in acidic urine.
• Although dissolution of some stones is possible, surgical removal is often necessary
initially to allow a diagnosis of stone type.
• Appropriate medical management may help decrease the recurrence of canine uroliths
Bladder distention, abdominal pain, stranguria, perceived incontinence due to partial
obstruction, and/or signs due to postrenal azotemia (i.e., anorexia, vomiting, and depression)
may develop. Occasionally the bladder ruptures, causing uroabdomen
DIAGNOSIS
• Survey abdominal radiographs or ultrasonography is indicated in any animal with urolithiasis.
• In addition to defining the numbers and locations of bladder and urethral calculi, these procedures may detect
calculi in the kidney and/or ureter.
• Calcium-containing uroliths (i.e., calcium phosphate and calcium oxalate) are the most radio-opaque,
whereas cystine and urate uroliths are the least radio-opaque.
• Struvite calculi are normally radio-opaque and usually are observed with survey radiography
• Doublecontrast cystography and/or retrograde urethrography may identify radiolucent stones in the bladder or
urethra; however, ultrasonography can detect calculi and can evaluate the kidneys and ureters for concurrent
abnormalities.
MEDICAL MANAGEMENT
Urethral caliculi
Retrohydropropulsion Catheterization failed
Medical management Surgery Surgery
SURGICAL TECHNIQUE
• Surgery should be considered if concurrent or predisposing anatomic abnormalities
(e.g., urachal diverticula) are present, if medical dissolution is not possible or is
inadvisable, if a bladder mucosal culture is required, or if the stones are large enough
that attempting voiding hydropropulsion is likely to cause urethral obstruction.
• Although medical dissolution of struvite, urate, and cystine calculi is possible, surgical
removal of calcium oxalate, calcium phosphate, and silicate stones is necessary.
• Cystotomy should be performed preferentially over urethrotomy if stones can be
flushed into the bladder preoperatively or intraoperatively.
• Cystotomy plus scrotal urethrostomy may be the most effective treatment in
preventing recurrence of clinical signs in Dalmatians with urate calculi. Recurrence is
common when a cystotomy alone is performed
URETHRAL PROLAPSE
• Urethral prolapse is a protrusion of the urethral mucosa beyond the end of the
penis.
• Urethral prolapse is uncommon. It may occur after excessive sexual excitement or
masturbation, or it may be associated with genitourinary infection.
• A small, reddened mass may be visible protruding from the tip of the penis when
the penis is extruded from the preputial orifice.
• Penile erection may cause the protrusion to enlarge.
• Necrosis of the prolapsed urethra may occur secondary to drying or self-inflicted
trauma.
• Concurrent infection of the genitourinary tract should be treated. If the urethral mucosa
is not necrotic, the prolapse can occasionally be reduced by gently manipulating it with
a sterile cotton swab or by placing a lubricated catheter into the urethral orifice.
• A purse-string suture of 5-0 or 6-0 suture material can be placed in the penis around
the orifice and tightened to prevent the prolapse from recurring without obstructing
urination.
• The suture should be removed after 5 days and the patient monitored for recurrence.
• Spontaneous recovery has not been reported.
• Surgical resection of the prolapsed urethra is usually the treatment of choice.
• If the prolapse can be reduced, placing several mattress sutures from the urethral
lumen and tying them on the external penile surface may cause fibrosis and prevent
recurrence.
• The sutures should be left in place for 2 to 3 weeks.
• Bilateral orchiectomy should be performed, particularly in dogs that have prolapse
associated with erection or sexual excitement.

Affections of Urinary System

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AFFECTIONS OF

Retrohydropropulsion Catheterization failed

Medical management Surgery Surgery

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