Page 553 - WSAVA2018
P. 553

by corpus cavernosum urethra, which is in turn surrounded by tunica albuginea. Because of the blood filled corpus cavernosum urethra and the tough fibrous connective tissue tunica albuginea, the urethra can withstand tremendous pressure (e.g., as with aggressive retropulsion) without the fear of urethral rupture.
The urinary bladder consists of the following layers; serosa, muscular, submucosa and mucosa. The bladder is lined with transitional epithelium.
Positioning: Patients are positioned in dorsal recumbancy for retropulsion, cystostomy tube placement and routine cystotomy.
Urethrostomy: Urethrostomy is generally performed
in patients that are recurrent stone formers. It
provides a permanent opening that is large enough to accommodate passage of most urethral calculi, crystals and mucoid debris.
Perineal urethrostomy; perineal approach: The perineal urethra is the location of choice for urethrostomy in
cats. It is a convenient location for surgical manipulation, the urethral diameter will accommodate passage
of most urethral calculi and there is less urine scald postoperatively.
Prior to surgery a urethral catheter is passed, if possible. After a routine castration, an elliptical incision is made around the scrotum and penis. Then the subcutaneous tissues are dissected to expose penile urethra. The penile urethra is dissected free from surrounding connective tissue. The ventral attachment of the
The suture is tied and cut leaving the ends 3-4 cm long to act as a stay suture. A mosquito hemostat is placed
on this suture to provide traction and countertraction
to enhance visualization of the urethral mucosa. The second suture is placed opposite the first suture and tied as described for the first. A stay suture is also placed here. A third urethrostomy suture is placed directly on the dorsal midline to hold the dorsal margin of urethral mucosa to the dorsal margin of the skin incision. Alternating sutures from dorsal to ventral are placed until approximately one half of the penile urethra has been sutured to skin. The remainder of the penis is amputated and the subcutaneous tissue and skin are closed routinely. Fine ophthalmic instruments make tissue handling and suturing easier. Use of a 2X magnifying loupe and headlamp light source enhances visualization of the urethral mucosa and facilitates accurate suturing. It is critical for the surgeon to recognize the glistening urethral mucosa and carefully suture it to skin. This will decrease (or eliminate) the chance of urethral stricture.
Perineal urethrostomy; dorsal approach: Perineal urethrostomy can be performed with the patient
placed in dorsal recumbancy. This positioning is more ergonomic for the surgeon and allows easy access of the urinary bladder for concurrent cystotomy. When positioning the cat tie the hind limbs cranially until the pelvis is slightly elevated off the surgery table. Place
a folded towel under the pelvis to support this slightly elevated position. The surgical technique is as described above for the perineal urethrostomy performed using a perineal approach.
POSTOPERATIVE CARE AND ASSESSMENT:
Perineal Urethrostomy: An Elizabethan collar should be considered, especially in patients that may be prone to self-mutilation. Patients should be kept quiet and away from other animals. An indwelling urinary catheter placed routinely postoperatively is NOT necessary following an uncomplicated urethrostomy.
PROGNOSIS
The prognosis for surgical management of urethral
and cystic calculi is dependant upon preoperative management of azotemic patients prior to anesthesia, success of retropulsion of urethral stones into the urinary bladder, care in removing all stones via cystotomy, and care of ensuring urethral mucosa to skin apposition during urethrostomy.
Patients that have successful retropulsion of urethral calculi and do not require urethrostomy have an excellent prognosis. If careful attention is paid during cystotomy to ensure that no calculi are left behind (see discussion on cystotomy technique), the prognosis for cure is excellent. Long term prognosis is dependant on evaluaiton of calculus composition, dietary management, management of urinary tract infection, and attention to
pelvic urethral to the pubis (i.e., ishiocavernosus m.) is identified and transected. The penile urethra is freed from its connective tissue attachments to the pelvic
floor using blunt digital dissection. The retractor penis muscle is identified on the dorsal aspect of the penis and is dissected from its attachment on the penis. The dissected retractor penis muscle is then used to develop the dorsal plane of dissection to separate the pelvic urethra from its dorsal connective tissue attachments. Once the urethra is dissected enough to visualize the dorsolaterally located bulbourethral glands penile dissection can stop. The penis is catheterized and
the urethral orifice identified. An incision is made from the penile urethra to the pelvic urethral to the level of the bulbourethral glands using a Stevens tenotomy scissor or Iris scissor. The urethral orifice at the level of the bulbourethral glands is generally of large enough diameter to accept the flange of a tomcat catheter.
After incision of the urethra, the glistening urethral mucosa is identified. 5-0 nonabsorbable monofilament suture with a swaged on cutting or taper-cut needle
is recommended by the author. The first urethrostomy suture is placed at the dorsal aspect of the urethrotomy incision on the right or left side at a 45o angle to include urethral mucosa and skin (suture split thickness of skin).
Your Singapore, the Tropical Garden City
        551
            





































































   551   552   553   554   555