Urinary Tract Surgery

Question 1

• Crusty Jones is a 6 month old female domestic short haired cat
• She is normally seen at another practice but her owners weren’t very happy with the service there so have bought her to you
• She is bright, happy and healthy with a 1cm umbilical hernia BUT her abdomen began to look swollen about a month ago and has got bigger since then.
• She weighs 3kg
• On palpation you can feel what seems to be a soft tissue mass.
• She has no other abnormalities on clinical examination.
• Using ultrasound you identify a large fluid filled structure cranial to the bladder but cannot characterise it further
• List what would you ideally do next?

Answer 1

–Cystocentesis – ultrasound guided

–Radiography and contrast study?

–Biochem (protein, electrolytes, general health)

Question 2

• Crusty Jones is a 6 month old female domestic short haired cat
• She is normally seen at another practice but her owners weren’t very happy with the service there so have bought her to you
• She is bright, happy and healthy with a 1cm umbilical hernia BUT her abdomen began to look swollen about a month ago and has got bigger since then.
• She weighs 3kg
• On palpation you can feel what seems to be a soft tissue mass.
• She has no other abnormalities on clinical examination.
• Using ultrasound you identify a large fluid filled structure cranial to the bladder but cannot characterise it further
• After discussion with Mrs Jones and in consideration of the costs of further tests, they ask you perform an exploratory laparotomy without haematology and serum biochemical profile. They want to know if you can spay her at the same time.
• Are you willing to do this? (what are the pros and cons of this)

Answer 2

–Linking 2 major surgeries (more surgery time, higher risk)

–Is on table (already open, saves more incisions)

–Depends on what you find?

Question 3

• Crusty Jones is a 6 month old female domestic short haired cat
• She is normally seen at another practice but her owners weren’t very happy with the service there so have bought her to you
• She is bright, happy and healthy with a 1cm umbilical hernia BUT her abdomen began to look swollen about a month ago and has got bigger since then.
• She weighs 3kg

Would you like to do a pre-operative biochemistry and haematology screen?

Answer 3

–Ideally especially as pathology not routine, but is young.

Question 4

• Crusty Jones is a 6 month old female domestic short haired cat
• She is normally seen at another practice but her owners weren’t very happy with the service there so have bought her to you
• She is bright, happy and healthy with a 1cm umbilical hernia BUT her abdomen began to look swollen about a month ago and has got bigger since then.
• She weighs 3kg
• You will also need to choose an anaesthetic protocol for her – calculate the drug dose rates and fluid therapy rates for Crusty

Answer 4

–Pre – med – butorphanorphine (10-20mg/kg) plus ACP? (0.03 - 0.125 mg/kg)

–Leave for 20 mins

–Induction – propofol (6mg/kg)

–Maintenance – isoflurane

Fluids – Hartmann’s at maintenance (2-4ml/kg/hr)

Question 5

• She is given a buprenorphine premedication 20 minutes before the surgery
• You plan on anaesthetising her with propofol and isoflurane.
• However when the nurse goes to get her out of the cage she doesn’t appear at all sedated and is quite stressed (are you surprised by this)

What else can you/could you give her? Can she have another dose of buprenorphine?

Answer 5

•ACP lower dose (0.03 - 0.125 mg/kg). Would depend on original dose of buprenorphine.

Question 6

•You ask the nurse to set up an intravenous fluid infusion for the surgery – the nurse is a new trainee and wants to know which fluid and how many seconds per drops per minute she should set the giving set at (your pumps are all occupied with other cases)

Weight 3kg

20 drops/ml

Answer 6

–Take gtt as 20.

–20drops/ml

–4ml/kg/hr x 3 kg = 12ml/hr.

–20drops/ml x 12ml/hr = 240drops/hr

–=4drops/min, or 1 drop every 15 seconds

Question 7

You discover a very enlarged hydronephrotic right kidney her left kidney appears normal

• You have a busy surgery list for the afternoon and the nurse can’t get hold of Mrs Jones on the phone. You are still scrubbed in and the cat is still anaesthetised. You have in-house biochemistry testing available
• You now have to make a decision as to what you should do next make two lists for your notes.

Answer 7

• things you need to consider
• why is it hydronephotic
• blockage?
• Infection
• Congenital
• your options
• Remove the kidney
• Euthanise
• Close and leave

Question 8

•The kidney has a soft tissue mass;

–How could you biopsy this mass and what are the complications of this?

Answer 8

• Tru-cut.
• Incisional – eliptical, wedge
• Excisional

Complications - bleeding and seeding neoplastic cells

Question 9

• You contact the owners and get permission for blood tests and nephrectomy. You are feeling very gung-ho today and proceed with the nephrectomy and spay yourself. Owners cannot afford histopathological analysis of kidney.
• She recovers from her anaesthetic normally but is disoriented and seems painful afterwards. She uses her litter tray that evening and produces about 30 ml of urine
• Crusty’s intra-operative blood test results are on the following slides:
• If you had known these results prior to commencing surgery would it have affected your decision to go to surgery or your anaesthetic protocol?

Pct - low

MPV - low

BUN - high

Answer 9

–Small platelets, clotting issues. Mucosal clotting test first?

–Otherwise fine

Question 10

•What surgical techniques could you have used for the nephrectomy (read the section in Fossum/Tobias on this). Could you do this operation with the standard SVMS surgery kits or would you have needed special equipment?

Answer 10

–Ventral midline abdominal approach, from just behind the xiphoid, extending just caudal to the umbilicus. Retract the intestines, to expose the kidney and its vessels. Incise the peritoneal membrane, to enter the retroperitoneal space. Expose the lateral (convex) surface of the kidney, by blunt and sharp dissection through the retroperitoneal fat. Mobilize the kidney by continued dissection around its cranial, caudal, and dorsal surfaces, until the convex lateral surface can be rotated 90 degrees toward midline. Locate the renal vessels Using hemoclips, or monofilament absorbable suture, double ligate (or clip), and transect, the renal artery Similarly, double ligate and transect the renal vein(s) Incise the retroperitoneum overlying the ureter, and dissect the ureter free over its entire length Routine abdominal closure

Question 11

•What discharge instructions and long term prognosis will you give her owners after nephrectomy?

Answer 11

–Depends on histo and function of other kidney