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The upper urinary tract

image of The upper urinary tract
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Abstract

Surgical procedure involving the upper urinary tract of small animal patients are indicated for a variety of diagnostic, prognostic or therapeutic reasons. Patients with diseases of the upper urinary tract frequently present with clinical signs of renal disease or renal failure. This chapter considers techniques in the kidneys, the ureters, the bladder as well as including practical tips and warnings. Renal biopsy; Bisectional nephrotomy; Intracorporeal endoscopic laser lithotripsy; Ureteronephrectomy; Cystotomy/cystectomy.

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Figures

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14.3 A normal intravenous urogram showing both kidneys and contrast medium filling the proximal ureters.
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14.4 Lateral abdominal radiograph of a 4-year-old Pug bitch diagnosed with bilateral nephroliths.
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14.5 Pyelolithotomy: surgical removal of a small nephrolith through a pyelotomy incision.
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14.6 Cystoscopic image showing variably sized cystoliths within the bladder lumen.
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14.7 Laser energy is transmitted via small optical quartz fibres that pass through the biopsy channel of rigid and flexible endoscopes. Insertion of a 365 µm laser fibre into the open end of a catheter sheath, which protects the laser fibre as it passes through the endoscope.
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14.8 The open-ended catheter sheath is passed through the biopsy channel located on the bridge of the rigid endoscope.
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14.9 Excised kidney from a 6-year-old mixed-breed dog diagnosed with idiopathic renal haematuria. Note the large blood clot filling the renal pelvis.
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14.10 Calculation of total and individual glomerular filtration rate (GFR) with nuclear scintigraphy. ROI = region of interest.
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14.11 Ventrodorsal abdominal radiograph of a 7-month-old mixed-breed bitch presented for urinary incontinence. Intravenous urogram demonstrates severe right hydronephrosis, pyelectasia and dilatation of the ureter associated with an ectopically displaced ureter. The left kidney is non-functional and cannot be visualized.
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14.14 Lateral abdominal radiograph of a 1-year-old male Great Dane presented for abdominal pain and lethargy. Intravenous urogram demonstrates a rupture of the caudal pole of the left kidney and extravasation of contrast medium into the retroperitoneal space.
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14.15 Spiral contrast-enhanced CT scan of a 4-year-old neutered Gordon Setter bitch presenting with acute abdominal pain. Note loss of integrity of the convex surface of the left kidney and contrast medium leakage into the area of soft tissue.
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14.16 Lateral abdominal radiograph of a 4-year-old neutered Gordon Setter bitch with acute abdominal pain. Widening and streaking of the retroperitoneal space is suggestive of fluid accumulation in this region.
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14.17 Alternative surgical procedure for partial nephrectomy. (a) Following temporary vascular occlusion of the renal pedicle, the renal capsule is peeled away from the parenchyma to be resected. (b) Long, straight needles are used to pass an absorbable suture through the parenchyma at the proposed resection site. (c) The suture is cut and then tied in three separate ligatures, taking care not to damage the ureters or renal vessels. (d) The parenchyma distal to the ligatures is excised and the capsule is sewn back over the end of the kidney. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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14.18 Lateral abdominal radiograph of a 7-month-old female neutered Domestic Shorthaired cat presented for polyuria and polydipsia. Multiple bilateral calcium oxalate ureteroliths are present.
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14.19 Ureterotomy. The surgical incision can be made directly over the ureterolith. The incision can be closed longitudinally or transversely.
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14.20 Lateral abdominal radiograph of an 11-year-old Domestic Shorthaired cat after bilateral ureterotomies to remove multiple ureteroliths. A nephrostomy drainage catheter was placed for urinary diversion. Contrast medium injection through the nephrostomy catheter demonstrates that the ureter is patent. The proximal ureter and renal pelvis are significantly dilated.
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14.21 Hybrid operating room/interventional medicine laboratory where both percutaneous and hybrid interventional procedures are performed. The room functions as a sterile theatre, with fluoroscopic imaging, an array of catheters, wires, devices and stents immediately accessible, and multiple monitors to display real-time imaging and patient monitoring data to the veterinary surgeons, nursing staff and observers.
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14.22 Varying sizes (2–6 Fr) of double-pigtail ureteral stents are commercially available for minimally invasive or surgically assisted placement in dogs and cats.
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14.23 Close-up view of one of the looped ends of a double-pigtail ureteral stent catheter with multiple fenestrations.
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14.24 Images obtained during retrograde ureteral stent placement in a 6-year-old female cat with bilateral obstructing ureteroliths. This procedure is performed as a hybrid approach with surgical exposure and fluoroscopic imaging. (a) The right ureteral stent has already been placed. A dilator is advanced into the left ureteral orifice following ventral cystotomy. Iodinated contrast medium is infused to highlight the left ureter and renal pelvis. The left renal pelvis is dilated and multiple filling defects (arrowed) represent the ureteroliths. (b) A hydrophilic guidewire is advanced up the ureter and directed into the left renal pelvis. Optimally, the wire is curled into the renal pelvis with one or two loops, to afford a stable position prior to stent advancement. (c) The stent is advanced over the wire and into the renal pelvis. (d) As the wire is withdrawn, the proximal portion of the stent forms a loop (pigtail) constraining the stent within the renal pelvis and ureter. The guidewire is then fully withdrawn, the distal loop of the stent placed within the bladder, and the cystotomy site and abdomen closed routinely.
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14.25 Cystoscopic view of the ureteral orifices (flat C-shaped openings) normally positioned within the trigone region of the bladder.
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14.26 Lateral and ventrodorsal radiographs taken of the cat in Figure 14.24 after the procedure. The double-pigtail appearance of the ureteral stents can be seen, spanning from the renal pelvis to the bladder lumen. Multiple nephroliths remain in the left kidney; however, passive ureteral dilation around the stent may help to facilitate their passage if they enter the ureter.
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14.27 Percutaneous anterograde ureteral stent placement in a 10-year-old male dog with TCC of the bladder and proximal urethra. (a) Percutaneous renal access has been obtained and iodinated contrast medium highlights the left renal pelvis and ureter. An end-hole catheter is advanced down the ureter over a hydrophilic guidewire, and contrast medium highlights the complete obstruction to ureteral flow at the ureterovesicular junction. (b) The guidewire is manipulated across the ureterovesicular junction and curled in the bladder. (c) After the guidewire has been manipulated out of the urethra, a long vascular sheath (arrowed) is advanced from the urethra and retrograde up the ureter over the guidewire. (d) A second guidewire is advanced up the sheath and curled in the renal pelvis (arrowed). The first guidewire serves as a safety wire in case ureteral access is lost during stent deployment. (e) The ureteral stent is then advanced within the sheath, over the guidewire, and as the guidewire is withdrawn the proximal loop of the stent forms in the renal pelvis. The sheath and wire are then carefully withdrawn to deploy the distal loop in the bladder. (f) Lateral postoperative radiograph of the final stent position spanning the tumour and decompressing the ureteral obstruction.
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14.28 SUB device placement in a cat with obstructive ureterolithiasis. (a) The locking loop nephrostomy tube and cystostomy tube both have Dacron cuffs that are advanced to the renal capsule and bladder, respectively. The bladder cuff is both sutured and glued, while the renal cuff is glued and held in place by a plastic retainer around the tube. (b) Both tubes are bluntly directed through the abdominal wall and attached to the shunting port, leaving sufficient space on either side for a gentle angulation of the tube into the abdomen to avoid kinking. (c) Radiographic image of the SUB device in place. Note that the nephrostomy tube is fully advanced until the radiographic marker is within the renal pelvis and the pigtail is locked via a string that is held taut by the shunting port. Typically, the nephrostomy tube is connected to the caudal end and the cystostomy tube to the cranial end of the shunting port to maintain gentle curvature of the tubing. (d) The SUB device is flushed and assessed for any evidence of leakage by inserting a 22 G Huber needle into the shunting port and injecting saline or aqueous contrast medium. The port may also be used for urine sampling as needed.
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14.30 Surgical removal of cystic calculi through a ventral midline cystotomy. A bladder spoon is used for retrieval of calculi.
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14.31 Percutaneous cystolithotomy: transabdominal view of multiple cystoliths within the bladder lumen. Small cystoliths (<3 mm) can be removed by transurethral flushing or urohydropulsion. Larger cystoliths (>5 mm) require laser fragmentation or basket retrieval using the endoscope.
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14.32 Percutaneous cystolithotomy stone basket.
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14.33 Self-expanding metallic urethral stent. (a) Nitinol urethral stent partially deployed from the stent delivery system. (b) Close-up view of the stent.
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14.34 Images from a dog with obstructive TCC of the bladder trigone. (a) A contrast urethrogram is performed to localize the site of obstruction (arrowed) and to obtain measurements of urethral diameter and the length of the obstruction. The calibrated marker catheter in the colon serves as a reference measure of the degree of radiographic magnification in the image to normalize measurements. Maximal distension of the non-affected portion of the urethra is achieved and a stent chosen that is the same diameter as the urethra, or slightly larger, and of a length sufficient to span the obstruction fully. (b) A hydrophilic guidewire is advanced across the obstruction and curled within the urinary bladder. (c) The stent delivery system is then advanced over the guidewire. The stent can be seen between the platinum marker bands (arrowheads). (d) The stent is gradually expanded under fluoroscopic visualization and opened to span from the bladder trigone to beyond the filling defect of the tumour/obstruction. (e) Once the stent has been deployed, a repeat urethrogram shows improved patency through the site of obstruction. (f) Ventrodorsal fluoroscopic image of the final stent position shows external compression by the tumour. The stent will continue to exert a radial force on the tumour and will probably open further with time.
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14.35 Endoscopic view of a self-expanding metallic urethral stent placed within the urethra.
Image of Core (needle) biopsy instrument.
Core (needle) biopsy instrument. Core (needle) biopsy instrument.
Image of Biopsy rod extended, demonstrating site for core biopsy specimen.
Biopsy rod extended, demonstrating site for core biopsy specimen. Biopsy rod extended, demonstrating site for core biopsy specimen.
Image of Untitled
Image of Untitled
Image of Untitled
Image of Excision of a 1.5 cm wedge of tissue from the convex surface of the kidney.
Excision of a 1.5 cm wedge of tissue from the convex surface of the kidney. Excision of a 1.5 cm wedge of tissue from the convex surface of the kidney.
Image of Closure of the biopsy site in the renal capsule using 1.5 metric (4/0 USP) absorbable suture material in an interrupted or continuous pattern.
Closure of the biopsy site in the renal capsule using 1.5 metric (4/0 USP) absorbable suture material in an interrupted or continuous pattern. Closure of the biopsy site in the renal capsule using 1.5 metric (4/0 USP) absorbable suture material in an interrupted or continuous pattern.
Image of Following mobilization of the kidney, an incision of about two-thirds of the length of the kidney is made along its convex surface.
Following mobilization of the kidney, an incision of about two-thirds of the length of the kidney is made along its convex surface. Following mobilization of the kidney, an incision of about two-thirds of the length of the kidney is made along its convex surface.
Image of The renal parenchyma can be bluntly separated with a scalpel handle and arcuate or interlobar vessels can be ligated and severed.
The renal parenchyma can be bluntly separated with a scalpel handle and arcuate or interlobar vessels can be ligated and severed. The renal parenchyma can be bluntly separated with a scalpel handle and arcuate or interlobar vessels can be ligated and severed.
Image of Surgical removal of a nephrolith through a nephrotomy incision. Temporary vascular occlusion is performed with a Rummel tourniquet.
Surgical removal of a nephrolith through a nephrotomy incision. Temporary vascular occlusion is performed with a Rummel tourniquet. Surgical removal of a nephrolith through a nephrotomy incision. Temporary vascular occlusion is performed with a Rummel tourniquet.
Image of After removal of the nephrolith(s) the renal pelvis is flushed with warm saline to remove any debris.
After removal of the nephrolith(s) the renal pelvis is flushed with warm saline to remove any debris. After removal of the nephrolith(s) the renal pelvis is flushed with warm saline to remove any debris.
Image of Surgeons performing laser lithotripsy. The patient is aseptically prepared and surgically draped. The surgeons are gowned and gloved and wear laser eye protection during the procedure.
Surgeons performing laser lithotripsy. The patient is aseptically prepared and surgically draped. The surgeons are gowned and gloved and wear laser eye protection during the procedure. Surgeons performing laser lithotripsy. The patient is aseptically prepared and surgically draped. The surgeons are gowned and gloved and wear laser eye protection during the procedure.
Image of The open-ended ureteral catheter sheath is passed through the biopsy channel of the cystoscope to facilitate and protect the laser fibre as it is passed.
The open-ended ureteral catheter sheath is passed through the biopsy channel of the cystoscope to facilitate and protect the laser fibre as it is passed. The open-ended ureteral catheter sheath is passed through the biopsy channel of the cystoscope to facilitate and protect the laser fibre as it is passed.
Image of Endoscopic image of the tip of the laser fibre. Only a small collar of the insulated covering is visible.
Endoscopic image of the tip of the laser fibre. Only a small collar of the insulated covering is visible. Endoscopic image of the tip of the laser fibre. Only a small collar of the insulated covering is visible.
Image of Endoscopic image of the laser fibre orientated perpendicular to and touching the cystolith to be fragmented.
Endoscopic image of the laser fibre orientated perpendicular to and touching the cystolith to be fragmented. Endoscopic image of the laser fibre orientated perpendicular to and touching the cystolith to be fragmented.
Image of Endoscopic view of the four-wire stone retrieval basket device being positioned for cystolith retrieval.
Endoscopic view of the four-wire stone retrieval basket device being positioned for cystolith retrieval. Endoscopic view of the four-wire stone retrieval basket device being positioned for cystolith retrieval.
Image of Urohydropulsion is performed after laser lithotripsy to removed stone fragments that are ≤5–7 mm. The bladder is distended with sterile fluid through the cystoscope. The cystoscope is removed and the patient is raised to a vertical position. Manual palpation and gentle agitation of the bladder is performed to dislodge small fragments. Manual expression of the bladder is performed by applying constant pressure to the abdominal wall in the region of the bladder. All urine should be collected and filtered to remove the stone material.
Urohydropulsion is performed after laser lithotripsy to removed stone fragments that are ≤5–7 mm. The bladder is distended with sterile fluid through the cystoscope. The cystoscope is removed and the patient is raised to a vertical position. Manual palpation and gentle agitation of the bladder is performed to dislodge small fragments. Manual expression of the bladder is performed by applying constant pressure to the abdominal wall in the region of the bladder. All urine should be collected and filtered to remove the stone material. Urohydropulsion is performed after laser lithotripsy to removed stone fragments that are ≤5–7 mm. The bladder is distended with sterile fluid through the cystoscope. The cystoscope is removed and the patient is raised to a vertical position. Manual palpation and gentle agitation of the bladder is performed to dislodge small fragments. Manual expression of the bladder is performed by applying constant pressure to the abdominal wall in the region of the bladder. All urine should be collected and filtered to remove the stone material.
Image of Kidney being rotated medially to locate the renal artery and vein.
Kidney being rotated medially to locate the renal artery and vein. Kidney being rotated medially to locate the renal artery and vein.
Image of A 6-year-old male Bulldog undergoing ureteronephrectomy. The dog presented with gross haematuria due to a proximal ureteral tumour.
A 6-year-old male Bulldog undergoing ureteronephrectomy. The dog presented with gross haematuria due to a proximal ureteral tumour. A 6-year-old male Bulldog undergoing ureteronephrectomy. The dog presented with gross haematuria due to a proximal ureteral tumour.
Image of Stay sutures are placed in the apex of the bladder and sides of the cystotomy incision to facilitate examination of the lumen.
Stay sutures are placed in the apex of the bladder and sides of the cystotomy incision to facilitate examination of the lumen. Stay sutures are placed in the apex of the bladder and sides of the cystotomy incision to facilitate examination of the lumen.
Image of TCC involving approximately 50% of the mucosal surface of the bladder. Note extension of the tumour into the trigone (arrowed).
TCC involving approximately 50% of the mucosal surface of the bladder. Note extension of the tumour into the trigone (arrowed). TCC involving approximately 50% of the mucosal surface of the bladder. Note extension of the tumour into the trigone (arrowed).
Image of Closure of a cystotomy incision using a one-layer, continuous appositional suture pattern.
Closure of a cystotomy incision using a one-layer, continuous appositional suture pattern. Closure of a cystotomy incision using a one-layer, continuous appositional suture pattern.

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