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How to manage
feline ureteric
obstruction
Aetiology
Calculi are the most common cause of
ureteric obstruction in cats. Other causes
reported include neoplasia, strictures,
trauma and iatrogenic ligation following
ovariohysterectomy.
The majority (>98%) of ureteral
stones are formed from calcium oxalate.
Calcium oxalate stones that do not pass
spontaneously need to be removed
surgically as they cannot be dissolved
medically. Some cats are persistent
stone formers and approximately 35%
of cats with calcium oxalate stones are
hypercalcaemic.
Acute complete obstruction or severe
partial obstruction results in potentially fatal
post-renal azotaemia. Hydronephrosis
develops following ureteric obstruction
and, if the obstruction is not relieved,
fibrosis and irreversible damage results.
The sooner the obstruction is relieved, the
less nephron damage occurs. Partial
obstructions result in less severe damage
compared with complete obstructions.
Often cats have bilateral ureteric
obstruction at the time of presentation.
When the initial ureter becomes
obstructed, the glomerular filtration rate
increases in the contralateral kidney and
the cat may not show any clinical signs
and may not be azotaemic. There is initial
hydronephrosis on the affected side, but
the kidney eventually shrinks and has
significantly reduced function. If the
contralateral kidney becomes similarly
obstructed, severe post-renal azotaemia
may develop and the cat may show
clinical signs.
Presenting signs
Clinical signs associated with ureteric
calculi can be vague and of variable
severity. Signs of unilateral ureteric
obstruction in the absence of chronic
kidney disease may go unnoticed by the
owners. Many cats present with a
non-specific history of lethargy,
inappetence and recent or chronic weight
loss. If the cat has concurrent significant
kidney disease then signs may be more
severe and can include polyuria,
polydipsia, vomiting and generalized
weakness. Cats can also be pyrexic if
pyelonephritis is present. In addition,
ureteric obstruction is painful and some
cats react to palpation of the overlying
spine or abdominal wall.
Diagnosis
Abdominal palpation may reveal signs of
pain over or around the kidneys. One
kidney may appear to be enlarged (the
obstructed side) while the other may
appear small (atrophied following a
previous episode of ureteric obstruction),
giving rise to the big kidney, little kidney
presentation. Such a finding warrants
immediate investigation and/or renal
imaging.
Serum biochemistry in affected cats
can vary from being normal (e.g. in cats
with a unilateral obstruction and without
chronic kidney disease (CKD) to revealing
signs of severe azotaemia, including raised
urea, creatinine, phosphate and potassium.
Urine specific gravity is often <1.035.
Anaemia (e.g. due to CKD) is commonly
seen in affected cats. Urine should be
collected by cystocentesis for sediment
examination and bacterial culture/
sensitivity testing.
It is not possible to differentiate a cat
with combined CKD and ureteric
obstruction from a cat with acute on
chronic renal failure (uraemic crisis) using
blood and urine analyses alone. Abdominal
imaging techniques are required to confirm
the diagnosis.
Ultrasonography is useful as it is widely
available, non-invasive and can detect
hydroureter, hydronephrosis (Figure 1) and
often the site of obstruction . Examination
of the remainder of the urinary tract should
always be carried out as multiple
ureteroliths, nephroliths and cystoliths are
Nicola Kulendra of
The Royal Veterinary
College and Tim
Charlesworth of
Eastcott Referrals take
us through the
approach to this tricky
feline problem
U
reteric obstruction is an
increasingly diagnosed condition
in cats. Calcium oxalate
urolithiasis is the most common
cause. Cats often present with vague
clinical signs, so diagnosis can be
challenging. One ureter can often be
obstructed without causing any significant
clinical signs, and cats are presented in an
advanced stage of disease when the other
ureter becomes obstructed. The condition
is often misdiagnosed as acute on chronic
renal failure as cats may have a sudden
worsening of their azotaemia and without
abdominal ultrasonography it is impossible
to differentiate the two conditions.
Traditional therapeutic options have been
associated with high complication rates,
but recent improvements in surgical
implants have been associated with better
long-term success rates.
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common. Abdominal radiography is also
useful, as the majority of feline ureteroliths
are calcium oxalate and thus radiopaque
(Figure 2). The sensitivity of
ultrasonography for the detection of feline
ureteroliths is 77%, that of abdominal
radiography is 81%, and when the two
modalities are used together they have a
sensitivity of 90%.
If abdominal ultrasonography is
equivocal and there is a high clinical
suspicion of ureteric obstruction, other
techniques, such as positive contrast
antegrade pyelography, can be used.
A long 22 G needle is directed into the
renal pelvis under ultrasound or
fluoroscopic guidance and the attached
syringe and three-way tap can be used
to obtain a urine sample for bacterial
culture and sensitivity testing and then to
inject iodinated contrast agents to
highlight the affected ureter. More
advanced imaging modalities, including
computed tomography (CT), magnetic
resonance imaging (MRI) and nuclear
scintigraphy, have been described but
are not usually required.
Treatment
Medical management
Most cases of ureteric obstruction benefit
from a period of medical management,
although this is only successful at fully
resolving the ureteric obstruction in a
Figure 1: Ultrasonogram of a kidney with
hydronephrosis secondary to ureteric
obstruction
Figure 2: (A) Lateral and
(B) ventrodorsal radiographs of a cat
with multiple irregularly shaped and
sized mineral opacities within the
renal pelvis and left ureter
A
B
minority of cases (17% of cats). Cats that
present with significant hyperkalaemia are
usually best treated surgically after an
initial 2448 hours of stabilization; those
cats unresponsive to medical management
may undergo surgery sooner.
Medical management includes
analgesia (usually opioids), appropriate
intravenous fluid therapy and
pharmacological intervention. Multiple
drugs (e.g. amlodipine, amitriptyline,
glucagon and diuretics such as mannitol)
have been used with the aim of relieving
ureteric spasm, encouraging ureteric
dilation or increasing urine production.
However, it must be stressed that evidence
to support the use of these drugs is lacking
and potential adverse effects in severely
sick cats must be considered. Cats need
to be closely monitored during this initial
stabilization period and have their weight,
hydration status, blood pressure,
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How to manage feline ureteric obstruction
respiratory rate, electrolytes, creatinine and
PCV checked regularly (at least daily).
Renal imaging should be repeated at
4872 hours a decrease in renal pelvis
dimensions together with resolution of the
azotaemia would suggest resolution of the
ureteric obstruction.
Other non-surgical techniques that
can be used include extracorporeal shock
wave lithotripsy, although this has met
with mixed success in feline cases and is
not widely used or available. Nephrostomy
tubes can be placed and will rapidly
resolve the azotaemia and decrease
intra-ureteric/pelvic pressure but can be
associated with complications, including
urine leakage, dislodgement and
infection. They are also very challenging
to place percutaneously in cats and
provide only short-term palliation,
requiring the ureteric obstruction to be
removed using other techniques.
Surgical management
Traditional techniques
Surgical removal of an obstructing
ureterolith is achieved via a midline
coeliotomy. Full exploration of the urinary
tract is mandatory as multiple ureteroliths
may be present. Once the obstruction has
been localized a decision as to how to
remove it must be made.
Proximal calculi can be flushed back to
the renal pelvis by performing a cystotomy
and catheterizing the affected ureter. The
calculi can then be removed via pyelotomy,
which is technically easier and may be less
likely to result in significant ureteral
stenosis. Distal ureteric obstructions can
be managed by transection of the affected
portion (ureterectomy) and re-implantation
of the remaining ureter into the apex of the
bladder (neoureterocystostomy; Figure 3).
This can be accomplished using either
intra-vesicular (the bladder is incised and
the ureteral mucosa is directly sutured to
the bladder mucosa) or extra-vesicular
(the ureter is dropped in to the bladder
via a stab incision and sutured without
performing a cystotomy) techniques.
Both techniques require magnification
and are technically challenging. Loss of
ureteric length can create tension, but
this can often be offset by caudal
mobilization of the kidney (renal
descensus) or cranial anchoring of the
bladder apex (e.g. psoas cystopexy).
Other surgical options for mid-ureteric
obstructions include ureterotomy (Figures 4
and 5) or resection and anastomosis.
Ureteronephrectomy is rarely a viable
option as >80% of cats are azotaemic at
the time of presentation, implying
dysfunction of the other kidney, thus as
much renal function as possible needs to
be preserved in these patients.
Complications may be seen in
approximately 30% of cases and include
oedema/inflammation at the
Figure 3: Close-up view of
neoureterocystostomy
being performed in a
dog. Ureterectomy has
been performed and the
remaining dilated ureter
has been pulled through
an apical stab incision
visualized via a separate
cystotomy incision. The
ureter has been
catheterized
Figure 5: Ureterolith
removed via
ureterotomy
Figure 4: Intraoperative photograph of
a feline ureterotomy being closed.
A length of 2M polypropylene has been
placed into the ureteric lumen to help
preserve orientation during closure
ureterovesical junction, stenosis, urine
leakage (uroabdomen) and persistent
obstruction. Urine leakage is the most
common complication and is seen in
<16% of cases. Recurrence of ureteric
obstruction has been reported in <40%
of cats that undergo surgical
management, 85% of which had
identifiable nephroliths at the time the
original procedure was performed.
Mortality rates of approximately 20%
have been reported for cats undergoing
surgical management for ureteric
obstruction. However, survival rates for
surgical management are better than those
for medical management, with 91% cats
who survived the first month following
diagnosis alive after 12 months compared
with 66% of cats who received medical
management alone.
Stents
The relatively high incidence of
uroabdomen and stricture formation
following ureterotomy and ureterectomy
has prompted the development of new
surgical techniques. Stents are
polyurethane tubes that contain multiple
fenestrations (Figure 6). There is a pigtail
at either end; one end sits in the renal
pelvis and the other end sits in the
ureteric opening at the bladder trigone.
These stents provide passive ureteric
dilation and urine can flow either through
or around them.
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Figure 6: Double pigtail polyurethane stent
Initially, a catheter is placed through
the kidney parenchyma into the renal pelvis
and a hydrophilic guidewire is passed
though the catheter, down the ureter and
into the bladder. The catheter is then
removed and a dilator is passed over the
guidewire. The dilator is subsequently
removed and a stent is placed over the
guidewire with one pigtail in the renal
pelvis and the other in the bladder trigone
(Figure 7). However, it is not always
possible to place the stents passed the
obstruction and in these cases ureterotomy
or ureterectomy is often necessary; these
cats are still at risk of uroabdomen
postoperatively, so it is advisable to place
a Jackson-Pratt abdominal drain. The drain
allows for urine drainage during the period
of postoperative diuresis where urine
production can be >20 ml/kg/hr.
Stents can be challenging to place and
surgery times can be prolonged. In
addition, there is a high rate of dysuria
because of the position of the pigtail in the
trigone. Other complications include stent
fracture, migration and encrustation
leading to blockage.
Subcutaneous ureteric bypass (SUB)
system
This is an extra-anatomical device
consisting of a pigtail nephrostomy tube
and a cystostomy tube, which are
connected via a subcutaneous access
port (Figure 8).
Intraoperative fluoroscopy is needed
at multiple stages during the procedure.
The nephrostomy tube is placed first.
A guidewire is placed in the renal pelvis via
a catheter, which is then removed. The
nephrostomy tube is placed over the
guidewire and, once the correct position
has been confirmed using fluoroscopy, the
pigtail is locked, securing its position.
Figure 7: Postoperative lateral radiograph of a cat with bilateral ureteric stents
A
B
Figure 8: (A) Lateral and (B) ventrodorsal radiographs of a cat
with bilateral SUB systems 1 year following placement. Note
the two nephrostomy tubes that enter the subcutaneous
port caudally and the single cystostomy tube that exits the
port cranially
A Dacron cuff is glued to the renal capsule
using sterile cyanoacrylate glue.
The cystostomy tube is placed in the
bladder via a small stab incision and
through a purse string suture and secured
via sutures placed through the Dacron cuff
to the bladder wall at the apex (Figure 9).
These two tubes are then passed
through the body wall and connected to
the subcutaneous port using sterile
cyanoacrylate glue (Figure 10). The
system is checked for leakage via a
contrast study; the contrast medium is
injected using a Huber needle placed in
the subcutaneous port. The Huber
needle is the only needle compatible with
the SUB system as it is non-coring and
thus will prevent leakage when removed.
The SUB system is technically simpler
to place than stents, with shorter surgery
times and less severe dysuria noted.
However, potential complications include
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Figure 9: Intraoperative photograph showing a
nephrostomy tube placed in the right kidney
and a cystostomy tube
Figure 10: Intraoperative photograph of the
subcutaneous port
Picture courtesy of Zoe Halfacree
Figure 11: Lateral radiograph of the cat in
Figure 8 undergoing a contrast study to ensure
patency of the SUB system. Contrast medium is
visible in both renal pelves and the bladder.
Following relief of the obstruction, the right
ureter has become unobstructed
urine leakage, tube kinking leading to
obstruction, infection and encrustation.
The SUB system should be checked every
36 months to ensure patency (Figure 11).
Prognosis
The main factor affecting outcome in these
cats is the severity of the kidney disease as
a result of the obstruction. One study found
that cats with an International Renal
Interest Society (IRIS) CKD stage of 1 or 2
had a good long term outcome and those
with a score of 3 or 4 had a median life
expectancy of 272 days. To date, no
factors associated with survival have been
identified and so it is impossible to
ascertain the outcome of these cats prior
to treatment.
Conclusion
Ureteric obstruction is a potentially
life-threatening condition with a relatively
poor prognosis in cats with variable renal
function. There is no one ideal surgical
option; however, currently, the SUB system
may be the best solution in these cats,
where appropriate facilities for its
placement are available.
Higher resoluton images and references are
available online and in e-companion
MORE ONLINE
34 October 2014
AVSTS/SAMSoc AUTUMN MEETING
The Association of Veterinary Soft Tissue Surgeons is a
satellite group of BSAVA. Members include specialist
surgeons and general practitioners. In October AVSTS is
running a joint scientific meeting with the Small Animal
Medicine Society. The topic will be Organ Failure and the
meeting will be held in the Queens Hotel in Chester. As
always, this promises to be a thought-provoking and
entertaining meeting with world-class speakers.
Visit www.avsts.org.uk for full details and to book online.
Email avstsadmin@fsmail.net for more details.
Organ failure
A medical and
surgical approach
How to manage feline ureteric obstruction
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