TOA
PAYOH VETS
toapayohvets.com
Blk 1002, Toa Payoh Lor 8, 01-1477, Singapore 319074 Tel: 6254-3326, 9668-6469, 9668-6468.
judy@toapayohvets.com
21 May, 2015
Focus: Small animals - dogs, cats, guinea pigs, hamsters, turtles &
rabbits
Recurrent urolithiasis - 5
surgeries for a recurring bladder stone problem
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Case written:
January 7, 2013
Update:
21 May, 2015
Taking images of cases with the
camera phone to document your cases and to do retrospective studies of
your performance will make you a better veterinary surgeon.
There may be some parts of the anatomy changes which you might have missed
during the examination but images taken will be there for you to review.
This is time-consuming and that is why most doctors and vets don't bother
as images must be taken and filed properly.
For example, in the complicated case of the Shih Tzu with 5 bladder
surgeries.
He had 2 surgeries to remove the bladder stones several weeks ago. Two
vets (Vet 1 and 2) removed the bladder stones in two separate surgeries.
However, the Shih Tzu had bladder stones and Vet 3 operated on him.
with perineal urine leakage after a bladder surgery by Vet 3 to remove
urinary stones, an image of the swollen perineum (presumed with leaked
urine from the traumatised perineal urethra) was taken by me. See image on
the left.
This
is one supporting evidence and there must be others to substantiate this
urine leakage (ultrasound of scrotum filled with fluid), swelling of left
inguinal area near where Vet 3 made a skin incision to access the bladder
for urinary stone removal daily with blood-tinged fluid while the dog was
catherised with a smaller sized urinary catheter
Note that the scrotal sac is also swollen and Vet 3 had said that
ultrasound revealed fluid. According to the owner, the whole of the lower
part of the inguinal area was much swollen and that was why the dog had to
be hospitalised for 8 days by Vet 3 who then recommended a 2nd
urethrostomy and scrotal ablation to resolve the problem of urine leakage.
This image was taken when the dog was seen at Toa Payoh Vets on Day 9
after Vet 3's bladder surgery which had removed all bladder stones
(post-op X-rays showed no stones). The owner came to Toa Payoh Vets as his
daughter was a classmate of my son. So, Vet 4 (Dr Daniel) was tasked with
the resolution of the dog's urinary problem.
How to resolve this problem with the least cost to the owner? That is the
tough part. Will a 2nd urethrostomy and closure of the first urethral
stoma and scrotal ablation as suggested by Vet 3 resolve the problem for
once and for all?
Dr Daniel (Vet 4) at Toa Payoh Vets was asked by the owner to neuter the
dog and remove the large left inguinal swelling of the size of an egg.
He stitched up the urethral stoma (first urethrostomy done by Vet 1) so
that the dog could pee as a normal dog, from the tip of the penis. Would
this resolve the problem?
Well, it did not appear to do so as the left inguinal swelling filled with
blood-tinged fluid (I presumed it was urine leakage + blood) of around 30
ml per day for the next 4 days. Vet 3 had likely ruptured
the urethra leading to leakage of urine and blood in the left inguinal
area.
Large left inguinal swelling due to urine + blood
accumulation
Problem and surgical solution explained by
illustration for the owner
Inguinal fluid and urine for lab analysis
Surgical plan from Dr Sing Kong Yuen
"Closing the urethral stoma so that
the dog could pee normally from the tip of the penis is good for the dog,"
I said to Dr Daniel. "But there is the daily need to aspirate the 30 ml of
blood-tinged fluid from the left inguinal area. It cost the owner around
$7,000 to do the past 3 surgeries to remove the bladder stone and given
time, your surgical approach may work. But time means money expenditure
for the owner. "
As Dr Daniel had to go overseas, I became the Vet 5 as I took over the
case and reviewed the complicated urine leakage problem. This involved
talking to Vet 3 as to what had been done.
Vet 3 said: "We did an ultrasound and saw fluid inside the scrotum. This
was not recorded in the case report as the owner was not charged."
Ultrasound can reveal fluid in an organ but will not be able to tell
whether it i urine or blood or both.
This is where the perineal swelling in this image substantiated a
possible urine leakage. I proposed a dye test but it is
extremely expensive to do dye test to reveal the location of the perineal
urethral leakage. The surgery at Vet 3 had cost $2,000 according to the
owner.
So, what's the best economical solution now? What is in the best interest
of the dog? If expenses keep mounting, the dog may be put to sleep by the
owner. A solution must resolve the problem to the owner's satisfaction and
to the dog being able to live a normal life without difficulty in
urination.
What should I do? This is a complicated urinary tract problem due to urine
leakage presumed to be from a tear in the perineal urethra (see image of
perineal swelling above) and subcutaneous fluid presented daily along the
left side of the penile length.
I thought hard. The dog had gone through 4 anaesthesias and surgery.
Veterinary expenses were considerable.
My surgical approach was to extend the urethra stoma made by Vet 1. This
had been closed by Dr Daniel as he wanted the dog to pee normally from the
tip of the penis. Then I did a scrotal ablation (cut off the scrotal sac),
close up the inguinal sheaths and stitch the urinary catheter to the
prepuce to retain it in for around 4 days to let the perineal catheter to
heal. This is the theory.
The dog still had difficulty
in urination after Vet 3's surgery. My surgical approach to post-op
complications from Vet 3's surgery
which had removed the bladder stones
Open up the wound
Scrotal ablation
Enlarged Vet 1's
urethrotomy incision
Ensure urethra is patent
Healing of the surrounding areas
Goes home with prescription diet
S/D
Dog is able to pee via the
original enlarged urethrostomy for the past 3 months and as at Jan
7, 2013. Dog eats prescription diet C/D. Urinary analysis and X-rays
on a regular basis are recommended. Will the owner comply?
In
practice, this worked as the dog is now
peeing normally with no blood in the urine
when it came back for stitch removal on
Sep 28, 2012, around 14 days after my
surgery.
UPDATE as at Jan 7, 2013
The dog pees through the first
urethrostomy without any difficulty. The
owner came to buy the C/D canned food. It
is good news. Post-op urine
and blood tests
and X-rays are advised but
owner compliance with regular monitoring will
be difficult due to various reasons.
P.S. Urethrostomy = a hole is cut
into the urethra (passage for urine from bladder to the tip of the penis).
TOA
PAYOH VETS
