Ectopic Ureters

Question 1

ectopic ureters risk factors
- sex, breed
- obervations

Answer 1

• Female dogs +++
• Breeds
  > Siberian Huskies, Mini and Toy Poodles, Labrador Retrievers, Fox Terriers, West Highland White Terriers, Collies, Welsh Corgis
• Rare in cats (males+++)
• Constant/intermittent dribbling of urine since birth or weaning

Question 2

what is an ectopic ureter

Answer 2

normal goes to trigone, ectopic goes somewhere else eg. urethra

Question 3

Types of Ectopic Ureters

Answer 3

• Unilateral/bilateral
• Intra/extramural
  > With extramural ectopic ureters, the ureter completely bypasses the bladder before opening distally into the urethra or vagina. With intramural ectopic ureters, the ureter enters the bladder wall in the normal location, but then tunnels distally within the bladder wall before opening into the urethra or vagina.

Question 4

urinary incontinence in puppies Ddx

Answer 4

• Urethral sphincter mechanism incompetence (75-89%)
• Urinary tract infection (65-85%)
• Persistent paramesonephric septal remnants (90%)
• Hydroureter (50%) and hydronephrosis (25%)
• 90% of male dogs with EU
• Short urethra (20%)
• Vaginal septum/dual vaginas (10%)
• Renal agenesis (5%)
• Renal dysplasia (10%)
• Vaginal strictures
• Pelvic bladder
• Patent urachus
• Female pseudohermaphroditism

Question 5

Paramesonephric vaginal remnant - what is it, why is it an issue?

Answer 5

• normally, vestible is free of tissues
• in PVR, paramesonephric membrane is still present and pulls on vestibule wall, keeping urethral hole open

Question 6

Incontinence in Puppies - how do we notice on PE

Answer 6

• Perineum stained with urine
• Perivulvar dermatitis

Question 7

Incontinence in Puppies
Work-up

Answer 7

• Blood work: unremarkable
• Urine culture: positive in 64% cases
• Vaginal palpation : stricture?
  > If doubtful: vaginography/vaginoscopy
• Imaging studies
  > Urogenital tract ultrasound
  > Excretory urography
  > CT-Scan
  > Cystoscopy

Question 8

Incontinence in Puppies - Ultrasound
- what can we evaluate?
- drawbacks?

Answer 8

Evaluates if:
* Intrapelvic bladder
* Ureteral jet visible (but not sensitive)
* Ureteral distension
* Pelvic distension
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Drawbacks:
* Entire urethra not visible
* Ectopic ureters not followed

Question 9

what might we see if we ultrasound a puppy with an ectopic ureter?

Answer 9

Possible
* Ureteral distension
* Hydronephrosis
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* ureterocele??????

Question 10

Radiographs: Excretory Urography
- what is this technique?
- pros and cons?

Answer 10

Technique
* Under anesthesia
* IV injection of contrast agents
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Advantages
* Equipment easily available
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Drawbacks
* Extramural or intramural ureter ??
* Superimposition of pelvic bones, GI tract
* Diagnostic for only 70 to 78% of ectopic ureter

Question 11

CT-Scan Excretory Urography
- is it useful? drawbacks?

Answer 11

• In the past= gold standard
• Drawbacks:
  > $$$$
  > Experienced operator required

Question 12

Cystoscopy of incontinent puppies:
- technique
- pros and cons

Answer 12

Technique
* Endoscopic visualisation of urethra and bladder
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Advantages
* Direct visualisation of ureteral papillas
* Distinction intra and extramural
* Eval entire urethra and vagina
* Treatment (laser) at the same time
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Drawbacks
* Experienced operator required

Question 13

Imaging studies for ectopic ureters
- rank from lowest to highest sensitivity

Answer 13

Ultrasound: poor
excretory urography: 70-78%
CT-scan: 91%
Cystoscopy: 100%

Question 14

Treatment of Congenital Disorders
* Patent urachus or urachal diverticulum

Answer 14

Surgery

Question 15

Treatment of Congenital Disorders
* Ectopic ureters

Answer 15

• Extramural: surgery (reimplantation)
• Intramural: laser removal

Question 16

when treating a congential urinary tract diorder, should we guarantee continence afterward? Eg. for:
* Patent urachus or urachal diverticulum
* Ectopic ureters

Answer 16

Do not guarantee continence (possible urethral incompetence)

Question 17

ectopic ureter surgery
- ureteral re-implantation
> complication rates? what can happen? continence?

Answer 17

• Overall complication rates:16-50%
• 25-50% worsening hydroureter
• 14% uroabdomen
• Continence rate for females low: 25-70%
• Continence rate for males >90%

Question 18

Cystoscopic Laser ablation of Ectopic Ureters
- what is this process?
- what do we do?
- contraindication?

Answer 18

• Simultaneous diagnosis and treatment
• Diagnosis
  > Ectopic ureters (intra vs extramural)
  > Other abnormalities (vaginal septal remnants…)
• No opened surgery
• Ablation of the medial ectopic wall
• Reposition of the opening
• Contraindication: extramural ectopic ureter
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  For intramural ectopic ureter:
• zap medial part with laser, open up ureter in trigone

Question 19

what happens if we try Cystoscopic Laser ablation of Ectopic Ureters on an extramural ectopic ureter?

Answer 19

uroabdomen

Question 20

Laser Ablation Ectopic Ureters
- outcomes
- complications

Answer 20

females: 77% continence
males: 85% continence
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Complications
* Proliferative reaction along the laser tract +/-
obstruction (3%)
> Recheck US 6 weeks post procedure

Question 21

ectopic ureters prognosis overall, and things we can do to help

Answer 21

• Persistent incontinence in 44 -67% patients
  > Medical management
  > Urethropexy or colposuspension
  > Periurethral injection of collagen
• Hydroureter and hydronephrosis partial or complete resolution