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TUGAS MATA KULIAH

ILMU BEDAH KHUSUS VETERINER

TEKNIK OPERASI CYSTOTOMY

NAMA/NIM
I Made Agus Suryanatha 1309005030
I Komang Alit Budiartawan 1309005042
Agnes Indah Widyanti 1309005052
Wanda Della Oktarin Hutagaol 1309005077
Satria Anugrah Dewantara 1309005083
Gusti Ayu Made Sri Antari 1309005125
Wahid Danang Pranantha 1309005141

LABORATORIUM BEDAH VETERINER


FAKULTAS KEDOKTERAN HEWAN
UNIVERSITAS UDAYANA
TAHUN 2016
RINGKASAN

Cystotomy adalah prosedur operasi untuk membuka vesica urinaria. Cystotomy


dilakukan terutama untuk mengeluarkan kalkuli yang ada pada vesica urinaria dan
uretra, tumor vesica urinaria, trauma akibat kecelakaan atau tertusuk oleh benda
runcing, untuk tujuan biopsy, memperbaiki ureter ektopik dan vesica urinaria pecah,
dan membantu dalam diagnosis untuk mengobati infeksi saluran kencing.
Penyebab dari kalkuli yang terdapat pada vesica urinaria adalah akumulasi dari
mineral yaitu kalsium. Cystotomy diindikasikan untuk pengobatan masalah kandung
kemih termasuk pengangkatan batu kandung kemih, kandung kemih tumor, dan
pembekuan darah. Prosedur ini juga dapat dilakukan untuk mendapatkan sampel biopsi
kandung kemih.Cystotomy dilakukan untuk memperbaiki pecah atau trauma parah
pada kandung kemih.
Pada praoperasi Cystotomy yang dilakukan diantaranya : persiapan alat dan
bahan, mempersiapan ruang operasi, mempersiapan operator dan pasien serta
melakukan premedikasi dan anestesi. Setelah semua persiapan telah disiapkan maka
operasi dilakukan.

Kata Kunci: Cystotomy, Operasi, Vesica Urinaria

SUMMARY

Cystotomy is a surgical procedure to open the bladder. Cystotomy done mainly


to remove existing calculi in the bladder and urethra, bladder tumors, trauma from
accidents or punctured by a sharp object, for biopsy purposes, improve ectopic ureter
and bladder rupture, and aid in the diagnosis to treat urinary tract infections.
The cause of calculi were found on urinary vesica is the accumulation of
minerals, namely calcium. Cystotomy indicated for the treatment of bladder problems
including removal of bladder stones, bladder tumors, and blood clots. This procedure
can also be performed to obtain biopsy samples of bladder kemih.Cystotomy done to
repair broken or severe trauma to the bladder.
On Preoperative Cystotomy performed include: preparation of tools and
materials, preparing the operating room, preparing the operator and patient and do
premedication and anesthesia. After all the preparations have been prepared so that the
operation is performed.

Keywords: Cystotomy, Operation, Bladder

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KATA PENGANTAR

Puji syukur kami haturkan kehadirat Tuhan Yang Maha Esa atas segala
limpahan rahmat dan hidayah-Nya sehingga Paper “Teknik Operasi Cystotomy” ini
dapat diselesaikan tepat waktu.
Makalah ini dibuat dalam rangka menyelesaikan tugas yang akan dijadikan
landasan dalam penilaian softskill pada proses pembelajaran Mata Kuliah Ilmu Bedah
Khusus Veteriner Fakultas Kedokteran Hewan Universitas Udayana.
Ucapan terima kasih dan penghargaan yang setinggi-tingginya kami sampaikan
kepada dosen pengajar yang telah memberikan banyak bimbingan dan arahan kepada
kami dalam penyusunan makalah ini. Tidak lupa penulis juga mengucapkan terima
kasih kepada semua pihak yang telah membantu dan memberikan dukungan pada kami.
Kami menyadari bahwa tulisan ini masih banyak kekurangan baik dari segi
materi, ilustrasi, contoh, maupun sistematika penulisan. Oleh karena itu, saran dan
kritik dari para pembaca yang bersifat membangun sangat kami harapkan. Besar
harapan kami karya tulis ini dapat bermanfaat baik bagi pembaca pada umumnya
terutama bagi dunia kedokteran hewan di Indonesia.

Denpasar, 2 Oktober 2016

Penulis

iii
DAFTAR ISI

COVER ..........................................................................................................................
RINGKASAN/SUMMARY ........................................................................................ ii
KATA PENGANTAR ................................................................................................ iii
DAFTAR ISI .............................................................................................................. iv
DAFTAR GAMBAR .................................................................................................. v
DAFTAR LAMPIRAN ............................................................................................... vi
BAB I PENDAHULUAN ............................................................................................ 1
1.1 Latar Belakang .............................................................................................. 1
1.2 Rumusan Masalah ........................................................................................ 1
BAB II TUJUAN DAN MANFAAT PENULISAN ................................................... 2
2.1 Tujuan Penulisan ......................................................................................... 2
2.2 Manfaat Penulisan ........................................................................................ 2
BAB III TINJAUAN PUSTAKA ............................................................................... 3
3.1 Pengertian Cystotomy................................................................................... 3
3.2 Penyebab Cystotomy .................................................................................... 3
3.3 Tujuan Dan Manfaat Pembedahan Cystotomy ............................................. 4
BAB IV PEMBAHASAN ........................................................................................... 5
4.1 Tindakan Praoperasi Cystotomy ................................................................... 5
4.2 Teknik Operasi Cystotomy ........................................................................... 6
4.3 Perawatan Pascaoperasi Cystotomy ........................................................... 10
BAB V SIMPULAN DAN SARAN ......................................................................... 12
5.1 Simpulan ..................................................................................................... 12
5.2 Saran .......................................................................................................... 12
DAFTAR PUSTAKA ................................................................................................ 13

iv
DAFTAR GAMBAR

Gambar 1. Radiography pada vesica urinaria anjing ................................................... 6


Gambar 2. Daerah insisi pada abdomen ...................................................................... 7
Gambar 3. Insisi pada abdomen anjing ........................................................................ 7
Gambar 4. Alat Balfour Abdominal Retractor ............................................................. 8
Gambar 5. Insisi pada Vesica Urinaria ........................................................................ 8
Gambar 6. Insisi pada vesica urinaria berindikasi tumor ............................................. 8
Gambar 7. Pengangkatan kalkuli pada vesica urinaria ................................................ 9
Gambar 8. Pembedahan pada vesica urinaria karena tumor ........................................ 9
Gambar 9.Penjahitan pada daerah insisi cystotomy.................................................. 10
Gambar 10. Penjahitan pada daerah abdomen penutupan insisi daerah cystotomy ... 10

v
DAFTAR LAMPIRAN

Lampiran 1 Laparoscopic cystotomy for urolith removal in dogs: three case reports ...
Lampiran 2 Bladder/Urethral Stone(s) Surgical Philosophy .........................................
Lampiran 3 Procedures Pro Cystotomy .........................................................................

vi
BAB I
PENDAHULUAN
1.1 Latar Belakang
Ilmu bedah merupakan cabang ilmu pengobatan atau terapi yang
mengusahakan pulihnya ke kondisi normal dari akibat suatu gangguan dalam
tubuh dengan menggunakan alat, tangan dan mekanis. Pembedahan pada sisitem
urinaria (perkencingan) yang sering dilakukan adalah nephrotomy, nephrectomy,
urethromy, urethrostomy, dan cystotomy. Ilmu bedah yang sering dilakukan
terkait dengan adanya gangguan pada vesica urinaria ini adalah cystotomy.
Cystotomy merupakan suatu tindak pembedahan atau operasi yang
membuka kantung kencing (vesica urinaria) dan kemudian menutupnya lagi
seperti semula. Cystotomy penting dipelajari karena merupakan terapi akhir pada
penanganan gangguan yang ada di vesica urinaria. Sebelum dilakukan
pembedahan pada sistem perkencingan, perlu dilakukan evaluasi status pasien
seperti keadaan cairan tubuh pasien. Evaluasi yang bisa dilakukan adalah dengan
urinalisis, evaluasi fungsi ginjal, dan hemogram (gambaran darah).
Cystotomy tidak hanya dilakukan pada saat pasien mengalami batu
kencing. Cystotomy juga akan dilakukan pada saat keadaan pasien terdapat
tumor pada vesica urinaria, trauma pada kecelakaan atau tertusuk benda runcing,
pada keadaan ureter ektopik, dan pada pemeriksaan secara biopsi.

1.2 Rumusan Masalah


1. Apa yang dimaksud dengan Cystotomy?
2. Apakah penyebab dari Cystotomy ?
3. Apakah tujuan dan manfaat operasi Cystotomy?
4. Bagaimana tindakan praoperasi Cystotomy ?
5. Bagaimana teknik operasi Cystotomy ?
6. Bagaimana perawatan pasca operasi cystotomy?

1
BAB II
TUJUAN DAN MANFAAT PENULISAN

2.1 Tujuan Penulisan


1. Agar mengetahui yang dimaksud dengan Cystotomy
2. Agar mengetahui penyebab dari dilakukannya Cystotomy
3. Agar mengetahui tujuan dan manfaat operasi Cystotomy
4. Agar mengetahui tindakan praoperasi Cystotomy
5. Agar mengetahui teknik operasi Cystotomy
6. Agar mengetahui perawatan pasca operasi cystotomy

2.2 Manfaat Penulisan


Penulis berharap paper ini dapat bermanfaat bagi pembaca khususnya
mahasiswa Fakultas Kedokteran Hewan yang menggambil mata kuliah Bedah
Khusus Veteriner, agar memahami mengenai Cystotomy dan teknik
pembedahnnya. Selain itu juga diharapkan paper ini mampu menjadi referensi
pembuatan paper lainnya dengan topik serupa.

2
BAB III
TINJAUAN PUSTAKA

3.1 Pengertian Cystotomy


Cystotomy adalah prosedur operasi untuk membuka vesica urinaria.
Cystotomy dilakukan terutama untuk mengeluarkan kalkuli yang ada pada vesica
urinaria dan uretra, tumor vesica urinaria, trauma akibat kecelakaan atau tertusuk
oleh benda runcing, untuk tujuan biopsy, memperbaiki ureter ektopik dan vesica
urinaria pecah, dan membantu dalam diagnosis untuk mengobati infeksi saluran
kencing.Sebelum dilakukan cystotomy perlu dilakukan pemeriksaan kondisi
umum pasien dan adanya tanda-tanda uremia, oleh karena itu terapi cairan sangat
perlu diberikan untuk menunjang status pasien.
Cystotomy adalah salah satu prosedur bedah yang paling umum dilakukan
pada anjing. Kadang-kadang, pada anjing terbentuk kristal abnormal dalam urin
yang menyebabkan infeksi sekunder untuk penyakit sistemik, infeksi vesica
urinaria, atau ketidakseimbangan gizi. Kristal-kristal dapat tumbuh menjadi batu
padat yang dapat menyebabkan iritasi vesica urinaria atau infeksi.
Selain itu, batu bisa masuk dalam uretra dan mengganggu proses
perkencingan pada hewan. Keberadaan batu dapat menyebabkan hewan
melakukan buang air kecil dalam volume kecil namun sering, menyebabkan
kencing darah kebiruan, atau tidak mampu buang air kecil. ureter ektopik juga
diobati melalui suatu cystotomy.

3.2 Penyebab dilakukannya Cystotomy


Penyebab dari kalkuli yang terdapat pada vesica urinaria adalah akumulasi
dari mineral yaitu kalsium. Indikasi melakukan Cystotomy adalah untuk
mengambil kalkuli yang ada pada vesica urinaria dan uretra, tumor vesica
urinaria, trauma akibat kecelakaan atau tertusuk oleh benda runcing, untuk tujuan
biopsy, memperbaiki ureter ektopik, dan untuk mengesplorasi ruptur vesika
urinaria yang merupakan abnormalitas yang paling sering terjadi pada hewan

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kecil. Hasil akhir dari ruptur vesika urinaria juga mengakibatkan terjadinya
kebocoran urine ke dalam rongga abdomen (Fossum, 2002).

3.3 Tujuan dan Manfaat Operasi Cystotom


Cystotomy diindikasikan untuk pengobatan masalah kandung kemih
termasuk pengangkatan batu kandung kemih, kandung kemih tumor, dan
pembekuan darah. Prosedur ini juga dapat dilakukan untuk mendapatkan sampel
biopsi kandung kemih.Cystotomy dilakukan untuk memperbaiki pecah atau
trauma parah pada kandung kemih.

4
BAB IV
PEMBAHASAN

4.1 Tindakan Praoperasi Cystotomy


1. Persiapan alat dan bahan
Persiapan alat
Alat-alat yang digunakan dalam pelaksanaan operasi adalah meja bedah,
meja sorong, pisau cukur, scaple, arteri klem, gunting ujung tumpul dan
runcing, gunting bengkok, spuit, forcep, needle, needle holder pinset
anatomis, pinset sirurgis, drapping, Balfour Abdominal Retractor dan
stetoskop.
Persiapan bahan
Bahan yang digunakan adalah cat-gut, sarung tangan, benang nilon,
tampon, alkohol 70%, iodium tintur, aquades, NaCl fisiologis, Penisilin
kristal, penisilin oil, vitamin B kompleks, xylazin dan atropin sulfat.
2. Persiapan Ruang Operasi
Ruang operasi dan meja operasi didesinfeksi menggunakan desinfektan.
Selain itu, perlengkapan alat juga didesinfeksi. Kemudian dilakukan fumigasi
dengan menggunakan formalin 10% dan KMnO4 (1:2) dan dibiarkan selama
15 menit. Adapun alat yang harus dipersiapan seperti :
- Seperangkat alat bedah minor
- Sterilisasi alat bedah minor dengan alkohol 70%
- Pengeringan alat bedah minor menggunakan kain/handuk steril.
3. Persiapan operator dan pasien
Persiapan Operator yaitu seorang operator harus mmemiliki beberapa
kesiapan seperti menggunakan seperangkat alat pelindung diri (APD) yang
memiliki tujuan untuk sterilitas prosedur pelaksanaan operasi selain itu
seorang operator juga harus memiliki kesiapan diri dalam melaksanakan
tindakan operasi.

5
Persiapan pasien yaitu sebelum tindakan operasi dilaksanakan, hewan
terlebih dahulu dianamnesa, pemeriksaan fisik secara umum. Selain itu
radiograph (x-ray) atau abdominal ultrasound dapat dilakukan untuk
mengetahui penyebab penyakit. Kemudian sebelum dilakukan tindakan
operasi hewan harus dipuasakan.

Gambar 1. Radiography Pada Vesica Urinaria Anjing


4. Premedikasi dan anestesi
Premedikasi merupakan suatu tindakan pembeian obat sebelum
pemberian anestesi yang dapat menginduksi jalannya anestesi. Premedikasi
dilakukan beberapa saat sebelum anestesi dilakukan. Tujuan premedikasi
adalah untuk mengurangi kecemasan, memperlancar induksi, mengurang
keadaan gawat anestesi, mengurangi timbulnya hipersalivasi, bradikardia dan
muntah selama anestesi. Premedikasi yang digunakan adalah atropine sulfat
yang diberikan secara subcutan. Kemudian untuk anestesi digunakan
ketamine yang dikombinasikan dengan xylazine yang disuntikkan 10 menit
setelah pemberian atropine sulfat yang diberikan secara intra muscular.

4.2 Teknik Operasi Cytotomy


- Tahap pertama, posisikan hewan baring dorsal, kemudian cukur semua rambut
yang menghalangi sampai benar-benar bersih. Untuk hewan jantan,

6
pencukuran rambut yang ada pada daerah praeputium harus dilakukan dengan
sangat hati-hati.
- Tahap kedua, lakukan incise pada region abdomen secara bertahap sampai
mencapai bagian praeputium. Aplikasikan Balfour Abdominal Retractor
untuk mempertahankan posisi abdomen agar terbuka selalu selama
pembedahan. Sebelum mengeluarkan komponen abdomen, lapisi bagian luar
dengan kasa laparotomi steril guna mencegah terjadinya kontaminasi. Cari
vesica urinaria, dan arahkan ke posisi menghadap operator. Pastikan hewan
sebelumnya berada dalam posisi sudah dipuasakan dengan waktu tertentu
guna mencegah terjadinya pengisian vesica urinaria selama pembedahan
berlansung.

Gambar 2. Daerah Insisi Pada Abdomen

Gambar 3. Insisi Pada Abdomen Anjing

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Gambar 4. Alat Balfour Abdominal Retractor
- Tahap ketiga, incisi perlahan vesica urinaria dan lanjutkan dengan gunting
Metzenbaum dengan rapi (pada bagian ventral vesica urinaria). Untuk luas
incisi tergantung dari besarnya kalkuli atau tumor.

Gambar 5. Insisi Pada Vesica Urinaria

Gambar 6. Insisi Pada Vesica Urinaria Berindikasi Tumor

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- Tahap keempat, angkat semua benda asing (kalkuli) yang ada sampai benar-
benar tuntas.

Gambar 7. Pengangkatan Kalkuli Pada Vesica Urinaria

Gambar 8. Pembedahan Pada Vesica Urinaria Karena Tumor


- Tahap kelima, lakukan penutupan/penjahitan pasca incisi dengan
menggunakan jenis jahitan simple continous pattern menggunakan benang
absorbable (cat gut).

9
Gambar 9. Penjahitan Pada Daerah Insisi Cystotomy
- Tahap keenam, pastikan tidak ada lagi pendarahan, bersihkan darah yang
masuk keruang abdomen dengan kasa steril, lalu kemudian reposisi kembali
semua komponen abdomen. Selanjutnya dilakukan penutupan/ penjahitan
peritonemum, sisi dalam integument, dan terakhir integument itu sendiri.

Gambar 10. Penjahitan Pada Daerah Abdomen Penutupan Insisi Daerah Cystotomy

4.3 Perawatan Pasca Operasi Cystotomy


Pada prinsipnya hampir sama dengan nephrotomy, dimana produksi urin
terus dimonitor dengan disertai pemberian cairan infus Ringer Laktat. Analisis
kalkuli perlu dilakukan untuk mencegah terjadinya kalkuli ulangan. Untuk
memberikan kenyamanan pada hewan, biasanya diberikan obat anti-inflamasi
atau anti nyeri (analgesik) selama beberapa hari setelah operasi dan disertai
pemberian antibiotik. Seringkali dilakukan pemasangan kateter selama 1-3 hari.
Luka tempat insisi harus dijaga kebersihannya dengan memberikan antiseptika
setiap hari.

10
Terapi penunjang bisa diberikan untuk mempercepat proses kesembuhan
seperti membatasi gerak yang berlebihan untuk menjaga jahitan tidak lepas.
Amati bekas sayatan dua kali sehari untuk menjaga agar tidak terjadinya
peradangan pada bekas insisi. Perhatikan apakah terjadi perubahan warna pada
urin serta pada saat hewan buang air kecil tampaknya mudah atau sulit. Jika
terjadi komplikasi, harus segera lakukan tindakan. Jahitan pada kulit biasanya
sudah bisa dibuka 7-14 hari setelah operasi.
Walaupun vesica urinaria strukturnya lemah, insisi pada vesica urinaria
akan cepat sembuh, dan kesembuhannya dapat mencapai 100% dalam 14-21 hari.
vesica urinaria akan membesar setelah prosedur cystotomy, hal ini terjadi karena
adanya kombinasi regenerasi ephitelial, sintesis dan remodeling jaringan luka,
hipertropi dan proliferasi otot polos, dan vesica urinaria yang meregang.

11
BAB V
SIMPULAN DAN SARAN

5.1 Simpulan
Cystotomy adalah prosedur operasi untuk membuka vesica urinaria.
Cystotomy dilakukan terutama untuk mengeluarkan kalkuli yang ada pada vesica
urinaria dan uretra, tumor vesica urinaria, trauma akibat kecelakaan atau tertusuk
oleh benda runcing, untuk tujuan biopsy, memperbaiki ureter ektopik dan vesica
urinaria pecah, dan membantu dalam diagnosis untuk mengobati infeksi saluran
kencing
Penyebab dari kalkuli yang terdapat pada vesica urinaria adalah akumulasi
dari mineral yaitu kalsium. Cystotomy diindikasikan untuk pengobatan masalah
kandung kemih termasuk pengangkatan batu kandung kemih, kandung kemih
tumor, dan pembekuan darah. Prosedur ini juga dapat dilakukan untuk
mendapatkan sampel biopsi kandung kemih.Cystotomy dilakukan untuk
memperbaiki pecah atau trauma parah pada kandung kemih.
Pada praoperasi Cystotomy yang dilakukan diantaranya : persiapan alat dan
bahan, mempersiapan ruang operasi, mempersiapan operator dan pasien serta
melakukan premedikasi dan anestesi. Setelah semua persiapan telah disiapkan
maka operasi pembedahan dilakukan.
Terapi penunjang bisa diberikan untuk mempercepat proses kesembuhan
seperti membatasi gerak yang berlebihan untuk menjaga jahitan tidak lepas.
Amati bekas sayatan dua kali sehari untuk menjaga agar tidak terjadinya
peradangan pada bekas insisi. Perhatikan apakah terjadi perubahan warna pada
urin serta pada saat hewan buang air kecil tampaknya mudah atau sulit. Jika
terjadi komplikasi, harus segera lakukan tindakan. Jahitan pada kulit biasanya
sudah bisa dibuka 7-14 hari setelah operasi.
5.2 Saran
Kesembuhan dari Cystotomy yang dilakukan tergantung dari individu
hewan yang dioperasi serta perawatan pascaoperasi yang dilakukan.

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DAFTAR PUSTAKA

Brun, M.V., Oliveira,S.T., Messina,S.A., Stedile,R., Oliveira R.P.. 2008.


Laparoscopic Cystotomy For Urolith Removal In Dogs: Three Case
Reports.Arq. Bras. Med. Vet. Zootec., v.60, n.1, p.103-108, 2008
Fossum, T.W. (2002) Small Animal Surgery, ed 2nd Mosby, St. Lois London.
Philandelphia sydney. Toronto.
Merkley F, David. Bladder/Urethral Stone(s) Surgical Philosophy. Diplomate
American College of Veterinary Surgeons. Veterinary Surgical Specialists of
Nebraska.
Pope, Eric R. 2016. Procedures Pro Cystotomy. Ross University. Page: 30-34
Sudisma, I.G.N., Putra Pemayun, I.G.A.G, Jaya Warditha, A.A.G., dan Gorda, I.W.
2006. Ilmu Bedah Veteriner dan Teknik Operasi. Denpasar: Pelawa Sari
Denpasar.]

13
LAMPIRAN

14
Arq. Bras. Med. Vet. Zootec., v.60, n.1, p.103-108, 2008

Laparoscopic cystotomy for urolith removal in dogs: three case reports

[Cistotomia laparoscópica na remoção de urólitos em cães: relato de três casos]

M.V. Brun1, S.T. Oliveira2, S.A. Messina1, R. Stedile2, R.P. Oliveira1

1
Universidade de Passo Fundo
Bairro São José - BR 285 - Km 171
Caixa Postal 611/631
99001-970 – Passo Fundo, RS
2
Universidade Federal do Rio Grande do Sul – Porto Alegre, RS

ABSTRACT

The use of laparoscopic surgery for the removal of cystic calculi in three dogs was reported. Three trocars
were used, one in the ventral midline (10mm) and the others in the right (10mm) and left (5mm) flanks.
The calculi were removed and the bladder was sutured with intracorporeal technique in two layers, a
simple continuous pattern and interrupted or continuous Lembert pattern. No postoperative complications
were observed. One patient had a recurrence of urolithiasis, attributed to inadequate conservative
treatment and to the lack of an appropriate diet. It was submitted to another similar videolaparoscopic
cystotomy without complication. The proposed technique is appropriate and an alternative to
conventional cystotomy for treatment of canine vesical urolithiasis.

Keywords: dog, laparoscopy, endosurgery, minimally invasive surgery, bladder

RESUMO

Descreve-se a remoção de cálculos vesicais por cirurgia laparoscópica em três cães utilizando-se três
portais (dois de 10mm e um de 5mm) dispostos na linha média ventral e nas paredes abdominais direita e
esquerda. Após a remoção das litíases, realizou-se sutura intracorpórea da parede vesical, em padrão
contínuo simples, abrangendo as quatro camadas do órgão e em Lembert contínuo ou interrompido,
incorporando a serosa e a muscular. Não houve complicações pós-operatórias. Um dos pacientes
apresentou recidiva da doença, condição atribuída ao manejo dietético deficiente no pós-operatório.
Esse paciente foi novamente submetido à cistotomia laparoscópica similar sem a ocorrência de
complicações. A técnica proposta foi adequada e pode ser utilizada como alternativa para cistotomia por
celiotomia no tratamento de litíases vesicais em cães.

Palavras-chave: cão, laparoscopia, endocirurgia, cirurgia minimamente invasiva, bexiga

INTRODUCTION Endoscopic surgery was initially used in urinary


 tract of dogs for diagnostics purposes (Grauer et
Cystotomy is the most common procedure to al., 1983). Latter, laparoscopic surgery was used
remove vesical calculi in small animals for treatments of different diseases such as
(Waldron, 1993; Dória et al., 2007). This dioctophimosis (Brun et al., 2002),
surgical removal is indicated for obstructive hydronephrosis (Beck et al., 2000), retroflexion
lithiasis, except for those constituted of of the bladder (Rawlings et al., 2002), and
magnesium ammonium phosphate (Waldron, colopexy (Brun et al., 2007). Despite the
1993), permitting uroliths analysis (Fossum, existence of different endoscopic cystotomy
2002). techniques (Rawlings et al., 2003; Rudd and

Recebido em 23 de junho de 2006


Aceito em 23 de novembro de 2007
E-mail: mbrun@upf.br
Brun et al.

Hendrickson, 1998), the treatment of vesical and confirmed hematuria, proteinuria, pyuria,
lithiasis by laparoscopic or laparoscopic-assisted bacteriuria, and bilirubinuria were confirmed.
surgery is not usual; therefore, only few The urine pH and specific gravity were 7.5 and
scientific publications are available. 1,015.0, respectively. The presence of cylinders
(4/hpf) and epithelial cells (480/hpf) was
Rawlings et al. (2003) described the video- detected by microscopy. Considering the size of
assisted surgery, which consists of the insertion the calculi, approximately 3.0cm, surgical
of a cystoscope directly into the bladder by way removal was selected. Subsequent chemical
of miniceliotomy, allowing for an in-depth analysis showed that they were constituted of
inspection of the organ lumen. In that study, the carbonate, oxalate, calcium phosphate, and of
dogs were positioned in Trendelenburg position magnesium ammonium phosphate. The animal
and one 10-mm trocar was introduced in the did not demonstrate signs of further urolithiasis
ventral midline. Similar trocar was introduced in six months after surgery. But, eighteen months
the peritoneal cavity, in the ventral midline or later, the patient returned with hematuria. The
paramedially, depending on the sex of the owner said that the animal had not been fed the
patients. The bladder was grasped by Babcock special diet. Radiography showed two vesical
forceps and externalized from the cavity, calculi. At the request of the owner, repeat
allowing the introduction of the cystoscope videolaparoscopic cystotomy was performed,
through the organ wall with removal of the using the same technique (that will be explained
lithiasis. Although this technique has proven further), except for an interrupted Lembert
effective, it does not allow the removal of large pattern in the second bladder layer. In this
calculi, for which laparoscopic cystotomy surgery, the adhered omentum was seen in the
followed by intracorporeal suturing is ventral bladder wall and in the transverse
recommended (Rudd and Hendrickson, 1998) or abdominal muscle, where the 10mm lateral
the open cystotomy (Waldron, 1993; Dória et al., trocar was positioned. The surgery lasted 60
2007). The suitability of laparoscopic surgery in minutes and there were no complications. In the
the management of cystic calculi in a cat was post-operative period, the patient showed a
also reported (Brun et al., 2004). primary cicatrisation and no signs of urolithiasis
for 12 months.
Given that laparoscopic surgery has been more
advantageous to humans than conventional The second patient was an adult mongrel bitch,
surgery in terms of recovery and postoperative weighing 8kg, with a small ventral abdominal
pain, esthetics and early return to normal hernia and no absorbable sutures in the ventral
activities (Monson et al., 1995; Solomon and medium line. Hematuria and pollakiuria were
Eyers, 1996), the aim of this study was to detected in this dog. Ultrasonographically,
describe the laparoscopic technique to remove similar images as in the first animal were
large vesical calculi in dogs. obtained; but, the bitch had a single round-
shaped calculus (3.2 x 2.7cm). The values of
CASUISTIC hematology were unremarkable. Leukocytosis
(16,300.0/Pl) was evident with neutrophilia
Three female dogs diagnosed with bladder (12,980.0/Pl), eosinopenia (1,151.0/Pl), and
uroliths were submitted to laparoscopic lymphopenia (1,315.0/Pl). The alanine amino-
cystotomy, with the consent of their owners. The transferase (20.0UI/l), creatinine (0.76mg/dl),
first patient was a four-year-old Poodle Standard, and serum urea values (40.0mg/dl) were in the
not spayed, weighting 12kg. This dog had physiological limits. Calculi analysis revealed
presented dysuria and hematuria for four months carbonate, oxalate, calcium, magnesium, and
and abdominal pain during the physical exam, ammonia. Sixteen months after surgery, the
but it was afebrile. In the radiographic exam, animal did not demonstrate signs or new
three triangular calculi were visualized within the urolithiasis.
bladder. Ultrasonography confirmed the presence
of the calculi. Values of hematocrit (45%), serum The third patient was an 8kg adult mongrel bitch,
proteins (6.2g/dl), urea (60.0mg/dl), and with incontinence and hematuria of unknown
creatinine (0.85mg/dl) were in the normal range. duration. Physical exam revealed a solid mass in
Urine was collected by cystocentesis technique the urinary bladder. In the radiographic exam,

104 Arq. Bras. Med. Vet. Zootec., v.60, n.1, p.103-108, 2008
Laparoscopic cystotomy...

two rounded-shaped calculi were observed (3 x A longitudinal incision in the ventral surface of
2cm). Bladder wall thickening was also evident. the organ was made after grasping the bladder
Values of hematocrit (39.1%), serum protein with Babcock forceps, in the first patient using a
(6.0g/dl), creatinine (0.56mg/dl), and alanine harmonic scalpel, and in the others by
amino-transferase (34.0UI/l) were in the Metzenbaum scissors. The calculi were removed
physiological limits. Hematology demonstrated with Kelly or grasping forceps and placed in a
macrocytic anemia (4,670,000.0/Pl; specimen retrieval bag. After inspection of the
VGM=83.9fl) and thrombocythemia interior of the bladder, the bladder wall was in
(141,000.0/Pl). Leukocytosis was observed closed two layers of buried sutures with 3-0
(24,360.0/Pl) with neutrophilia (21,437.0/Pl) and polyglycolic acid avoiding the mucous layer. In
lymphopenia (975.0/Pl). Urine was collected by the first layer, the simple continuous pattern was
catheter. Urinary pH and specific gravity were used; and in the second layer, the suture was
7.0 and 1,024.0, respectively. Severe hematuria, made with interrupted Lembert in the first dog
proteinuria, pyuria, bacteriuria, and bilirubinuria (Fig. 2). In the other two animals, a continuous
were observed. The chemical analysis of the Lembert was employed.
calculi demonstrated that they were constituted
of carbonate, oxalate, calcium, magnesium, and The efficacy of the first suture layer was checked
ammonia. Ten months after surgery the dog had by filling the bladder with saline solution by a
no recurrence. Foley catheter. An omental flap was placed over
the vesical wound in the first patient; but in the
The surgical procedure was performed under others, omentum was sutured in the bladder with
general anesthesia with isofluorane1 vaporized in simple interrupted sutures.
O2 to 100%, after anesthetic induction with
propofol2, 10mg/kg, IV, and fentanyl3, 5Pg/kg, The specimen retrieval bag was grasped with
IV. In all surgeries, the animals were positioned Kelly forceps and exteriorized from the
in horizontal recumbency. Ringer lactate4, abdominal cavity through the right trocar. An
20ml/kg/h, IV, and fentanyl (2Pg/kg, IV) were one-centimeter lengthening of the wound was
administered during surgical procedure. Thirty necessary to break the calculus inside the tissue
minutes before surgery, cephalothin5, 30mg/kg, bag and then they were removed. After the
IV, was given and the bladder was irrigated with drainage of CO2 from the cavity and trocar
0.1% polyvinylpyrrolidone iodine solution6 using removal, the suture of the larger operative
a Foley catheter. wounds (10mm trocars) was made in two layers,
one in the parietal musculature and the other in
An incision was made in the ventral medium line the skin. The smaller wound (5mm trocar) was
2cm distal to the umbilical scar. In the first closed in a simple pattern. A Sultan pattern was
patient, pneumoperitoneum with CO2 was used in the musculature; and in the skin an
created through a Veress needle inserted in the interrupted simple suture using 2-0 nylon was
operative wound. In the other two animals, a performed.
10mm trocar was employed. One bitch had been
previously undergone a celiotomy and presented Postoperative care comprised antibiotics:
small ventral abdominal hernia. The intracavitary cephalothin, (q8h, 7d), in the first two patients;
pressure was stabilized at 12mmHg through the and enrofloxacin7 (5mg/kg, SC, q24h, 7d) in the
trocar positioned in the ventral medium line. third patient. In all animals, ketoprofen8
Two more trocars were introduced via the flanks, (2mg/kg, SC, q24h, 3d) was used. Cleaning of
one in the right lateral (10mm) and the other in the operative wounds with saline solution was
the left lateral (5mm), creating a triangular undertaken every 8 hours. To avoid the
disposition (Fig. 1). recurrence of urolithiasis, a special diet was
indicated.

1
Isoflurane, Cristália - Itapira – Brazil.
2
Diprivan, Cristália - Itapira – Brazil.
3
Fentanil 0,05mg/ml, Cristália - Itapira – Brazil. .
4
Ringer lactato; Cristália - Itapira – Brazil.
5 7
keflin 1g, Eli Lilli do Brasil Ltda, São Paulo – Brazil. Flotril 10%, Schering-Plough, Rio de Janeiro – Brazil.
6 8
Riodeine; Rioquimica, São José do Rio Preto – Brazil. Ketofen 1%, Rhodis-Mérieux, Paulínia – Brazil.

Arq. Bras. Med. Vet. Zootec., v.60, n.1, p.103-108, 2008 105
Brun et al.

Figure 1. Triangular placement of trocars in laparoscopic cystotomy for the removal of bladder stones in dogs. CR=
cranial; CD= caudal; R= right; L=left.

Figure 2. Laparoscopic technique for the removal of bladder stones in dogs. The sequence of surgical maneuvers is
shown in the first patient. A) Surgical wound involving the four layers of the bladder, showing three calculi (CA);
FL= Foley cateter. The extremities of grasps touching the thickness wall of the bladder. B) Removal of the calculi
before their placement into the retrieval bag. C) Application of the first suture layer in simple, continuous pattern. D)
Application of the second suture layer for the occlusion of the bladder; BL= bladder. In this patient, it was used an
interrupted Lembert suture with 3-0 polyglycolic acid and continuous Lembert with the same thread.

106 Arq. Bras. Med. Vet. Zootec., v.60, n.1, p.103-108, 2008
Laparoscopic cystotomy...

No complication during the operative and post- The animals of this study were maintained in
operative periods was observed. The number and ventral recumbency without inclination though
position of the trocars and the instrumentation the Trendelenberg positioning could have
were effective for the procedures. The time facilitated laparoscopy. Respiratory and
necessary to remove all the uroliths in each circulatory dysfunctions were not associated with
patient was, respectively: 120, 147, and 130min. the adopted position; but be could with the
inclination of the patient (Allen, 1996).
All the patients were discharged three days after
surgery. A special commercial diet9 was The omentopexy followed what Rawlings et al.
prescribed after surgery. The Foley catheters (2003) performed and it is based in the
were removed on the first or second possibility of helping the local cicatrisation and
postoperative day. All the patients ate solid food decreasing the risk of peritonitis, because the
from the first postoperative day. After seven omentum hinders the suture line, promoting
days, the skin sutures were removed and the neovascularization, granulation tissue,
wounds healed uneventfully. controlling infection, and helping lymphatic
drainage (Ellison, 1989; Thornoton and Barbul,
DISCUSSION 1997).

In this work, the use of laparoscopic surgery to According to Rudd and Hendrickson (1998), the
remove the lithiasis was preferred considering position of the intravesical endoscope during
the better results in relation to the conventional surgery facilitated the visualization of the vesical
surgery, mainly the ones related to the post- mucosa and the proximal urethra in all patients,
operative period (Monson et al., 1995; Flowers et aiding disposal of remaining calculus particles, a
al., 1997; Liem et al., 1997). common mistake associated with the surgical
treatment of urolithiasis (Fossum, 2002).
The technique of Rawlings et al. (2003) was
chosen to remove the calculi because of their CONCLUSIONS
large size, differently from what was indicated
by Rudd and Hendrickson (1998), in relation to As the only alteration in the patients of this study
the employment of just a simple continuous was the recurrence in the first patient, without
suture for the closure of the bladder after correlation with the procedure, the proposed
laparoscopic cystotomy, in all three cases. A technique can be used as alternative to the
simple continuous with Lembert suture patterns cystotomy for celiotomy in treatment of bladder
were selected, as suggested by Waldron (1993) calculi in dogs.
and Fossum (2002).
ACKNOWLEDGEMENTS
The continuous horizontal mattress could be
used, as mentioned by Rudd and Hendrickson To the collaborators: Daniela Scandolara
(1998); but, in this study the authors opted for Gonçalves, Eduardo Santiago Ventura de Aguiar,
the continuous simple suture, because it Carlos Afonso de Castro Beck, and Ricardo
promotes a better occlusion for the water and the Zanella.
air (Toombs and Bauer, 1993). Differently from
Edwards III et al. (1995), that used linear stapler REFERENCES
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operative costs and considering the suggestion (Eds). Principles of endosurgery. Cambridge:
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BECK, C.A.C.; PIPPI, N.L.; BRUN, M.V. et al.
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OLIVEIRA, R.P. et al. Tratamento de cistolitíase C.J.V. et al. Comparison of conventional anterior
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BARCELOS, H.H.A. et al. Colopexia MAHAFFEY, M.B. Laparoscopic-assisted
laparoscópica com retalho de tela de cystopexy in dogs. Am. J. Vet. Res., v.9, p.1226-
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et al. Técnicas cirúrgicas para urolitíase assisted cystoscopy for removal of urinary
obstrutiva em pequenos ruminantes: relato de calculi in dogs. J. Am. Vet. Med. Assoc., v.222,
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RUDD, R.G.; HENDRICKSON, D.A. Minimally
EDWARDS III, R.B.; DUCHARME, N.G.; invasive surgery of the urinary system. In:
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108 Arq. Bras. Med. Vet. Zootec., v.60, n.1, p.103-108, 2008
VETERINARY SURGICAL
SPECIALISTS
OF NEBRASKA, P C

David F. Merkley DVM MS


DIPLOMATE AMERICAN COLLEGE OF
VETERINARY SURGEONS
SOFT TISSUE AND ORTHOPEDIC SURGERY

Business: 402-206-1877
dfmerk@VeterinarySurgicalSpecialists.com
__________________________________________________________________________

Bladder/Urethral Stone(s)
Surgical Philosophy
One of the most frustrating aspects of surgery of the lower urinary tract for bladder and or
urethral stones is the unexpected complication of leaving a stone behind. This will not be a
discussion of the stone types seen in dogs or cats but a discussion of how to be sure that you retrieve
all of the stones and debris present during your surgery. As a urinary tract surgeon we have a pledge
to “leave no stone behind.”
There are significant differences in how we approach a female that has many small bladder
and/or urethral stones and the male that has similar issues. There are significant anatomical
differences that dictate the surgical approach to stone removal.
There are also differences that have developed in the last 10 years in where we make our
incisions in the urinary bladder wall. The ventral bladder incision has replaced the dorsal bladder
incision for many reasons.
Finally, we have altered the technique that we used to close the bladder wall incisions. Single
layer appositional patterns have replaced double layer closures (inversion or appositional with
seromuscular inversion).
All of this information has developed in the last 10-15 years and many veterinarians are not
yet aware of the changes that are being suggested.
Urethrotomy is rarely needed in the male dog that has urethral stones. Almost all urethral
stones can be repelled into the bladder and removed through the cystotomy incision. Occasionally, a
permanent urethrostomy will be needed in the male dog if significant urethral damage has occurred
(rare) or if the animal has had repeated episodes of urethral obstruction and a semi permanent relief
is sought. A permanent urethrostomy should be performed in the scrotal position (scrotal
urethrostomy). Perineal urethrostomy in the male dog is very undesirable (urine scalding of rear
legs). It is only used in rare situations. This technique is almost entirely confined to the feline.

Situation:
Bladder stones in the male dog with several small urethral calculi located behind the os penis
(most common) or at the ishial arch:
This animal presents straining and possibly dripping a few drops of red tinged urine.
Radiographs reveal a very large bladder that is severely distended. The presence of many small
stones in the bladder may be seen (struvites, oxalates or silicates). If no stones are visualized and
you believe they must be present then contrast and double contrast studies may be indicated (urates
or cystine stones). The penile urethra that narrows as it enters the os penis is the clue to the over
distended bladder. Is it packed with stones? Bladder decompression is the most important issue
that is immediate. Stone removal and/or hydro propulsion from the urethra can wait. Placement of a
bladder decompressing catheter is of utmost urgency. Depending on the size of the dog a 3 ½, 5, 8
or 10 Fr. polypropylene catheter can be passed. Rubber catheters and feeding tubes do not have the
strength to get past packed stones. In most cases the smaller catheter can be teased by the obstructing
stones into the bladder for decompression. You must be very cautious about flushing as you try to
pass the catheter. You do not want to over distend the bladder or rupture it. If passing a catheter
cannot be done a cystocentesis may relieve enough of the back pressure against the stones to allow
the small polypropylene catheter to pass. I do not take this technique lightly and only do it if I
cannot get the catheter to pass the urethral stones. If the bladder is tense enough it is possible to
rupture it or at least to make a larger hole than desired and begin losing urine into the abdominal
cavity. If you have decided that you are going to have to hydro propulse the stones into the bladder
than you must be sure that the majority of urine has been removed from the bladder by cystocentesis.
You do not want to worsen an already stretched bladder wall or rupture it with aggressive urethral
flushing to hydro propulse stones. Once the catheter is in place attention must be given to the kidney
and bladder. What is the kidney function? Do we have an elevated BUN and creatinine? Stone
removal can wait. Keep the bladder small with catheter decompression. You do not want this
damaged bladder wall to be overstretched again. Intramural hemorrhage at this point is already
going to lead to bladder wall fibrosis and a decrease in contractility. Once stability is achieved
(kidneys and bladder) stone removal can be contemplated.
The animal is anesthetized and clipped for posterior abdominal surgery. You should
surgically prepare the abdomen as you routinely do. The preputial cavity should be repeatedly
flushed with a DILUTE (1:40) povidone iodine or chlorhexidine solution. The preputial cavity and
the tip of the penis will remain in the surgical field during the cystotomy procedure for extensive
penile flushing so that we can insure that no urethral stones are inadvertently left behind.
The posterior abdomen is approached by reflecting the penis and prepuce to one side. The
cranial preputial muscle and the cranial preputial artery and vein may or may not be transected. The
abdominal incision is made on midline through the linea alba and it extends all the way to the pubic
symphasis. You will take the incision as far cranial as you need to get good exposure to the bladder.
The bladder is located and the ligament that attaches the bladder to the ventral midline is transected.
Find the apex of the bladder and place a 3-0 stay suture through the wall (silk or nylon). Be sure the
bite in the bladder wall is substantial, since it will be used to manipulate the bladder. Note: Many
veterinarians retroflex the bladder out of the abdomen so that the incision can be made of the dorsal
surface of the bladder. There is no sound reason to do this. Today we recommend that you make
your bladder incision on the VENTRAL SURFACE of the bladder. The ureters enter the bladder on
the dorsal surface and you can feel very comfortable that you will not involve them in your approach
with a central bladder wall incision. I also believe it is much easier to palpate the urethral exit point
in the trigone and it is much easier to gain access to the urethra with a catheter if that is needed
(more common in females) if a ventral cystotomy incision is used. There are many positives for a
ventral bladder wall incision and no negatives. The incision should run along the attachment of the
ventral medial ligament (old ventral mesentery).
The stay suture is pulled cranial to stretch the bladder forward and it is stabilized to the
drape. The bladder is packed off from the rest of the abdomen to “limit operative field
contamination” and to “limit urine spillage into the abdomen.” As the ventral incision is made into
the lumen the excess urine is suctioned or sponged away. Two lateral stay sutures can be placed to
open the incision so that the lumen can be examined and any obvious stones removed. Note: Rarely
can you visualize the trigone area and the urethral exit. This is usually true with a ventral incision
and is always true with a dorsal incision. We put our finger into the lumen to feel for unseen stones
and may inadvertently easily push small milliary stones and/or crystal debris into the proximal
urethra and not even realize what has happened. We conclude that the bladder is empty and close,
not realizing that several small stones and/or crystal are still present in the proximal urethra outside
of our feel.
In this situation that we are discussing our patient has urethral stones (os penis or ischial
arch) that we have seen on our work up films. We now must work on cleaning the urethra of
milliary stones, crystals and other debris that might be present. The key to success and the best
chance of limiting the possibility of recurrence is to leave nothing behind.
Retract the prepuce and expose the tip of the penis. Grab the mucus membrane along the
penis with a hemostat to keep it exposed and outside the prepuce. Take a 10 Fr. polypropylene
urinary catheter and a 35 cc syringe. You will also need 500 mls. of saline. Pass the large
polypropylene catheter into the tip of the penis as far as necessary to cover the side holes. This
usually will be short of the os penis. Grip the tip of the penis around the catheter so that saline will
not back flush as you flush saline into the urethra. Fill the syringe with saline and begin the flush
VERY SLOWLY. Begin the flush very slowly so that you can be sure that the saline is moving
through any stones that may be lodged behind the os penis or along the ischial arch. Once you see
saline flowing into the bladder and coming out the bladder incision you can increase the pressure of
the flush from the syringe. By the time you have reached the end of the 35 ml flush you should be
almost blasting saline into the urethra. Any stones that were in the neck of the urethra will be the
first to enter the bladder. Repeat the HIGH PRESSURE flush as many times as needed to be sure
you have cleared the urethra. If you are counting stones from a radiograph image, be sure that you
do not lose any into the suction apparatus being used for removal of saline. At some point you are
going to want to test the urethra for clearance of stones. If the animal is large enough and you feel
the 10 Fr. polypropylene catheter will pass through the os penis, advance it to the level of the
proximal end of the penis. Carefully feel for stones catching the side holes of the catheter. If you
feel anything you will need to flush more. You can now do the flush injection right in the area of the
stone lodgment. The turbulence created in the area from the saline coming out of the side holes of
the catheter and hitting the wall of the urethra will dislodge most all stones and crystal debris and
flush them into the bladder. Rarely do I have to do a urethrotomy. Note: I have never ruptured a
urethra with this very aggressive flushing technique. Flush until all stones are removed. The
catheter can be advanced with intermittent flushing until it comes out the bladder incision.
Withdraw the catheter to the original position and flush twice more. You can now feel confident you
have removed all urethral debris. You will have used most of the 500 mls of saline. Please note that
if the 10 Fr. catheter is too large to pass through the os penis to check for stone presence in the
urethra you will have to try a 8 Fr., 5 Fr. or 3 ½ Fr. Use the largest catheter that you can get through
the os penis since you want to maximize flow and turbulence with your flush.
Note: In the male dog most flushing will come from the tip of the penis into the bladder.
Rarely will you have to flush from the bladder out. The key to success when you think you have
flushed enough is to flush some more. Flush with pressure. This is the only way that you can move
stones and/or crystal debris from the male urethra.

Situation:
Female dog/cat that has milliary bladder stones.
The surgical approach to the bladder in the female is exactly the same. Do a ventral midline
abdominal approach and a ventral cystotomy. Stay away from those ureters on the dorsal side. Stay
suture placement in the apex is the same. The only real difference is the flushing technique. The
urethral exit in the female is in the vaginal vault and is very difficult to catheterize from the vaginal
side. Approach the female urethra for flushing from the urinary bladder. This technique is more
complicated and precise. After all visable stones have been removed from the bladder you must
flush the whole urethra as aggressively as we just described for the male. You may have pushed
small stones and/or crystal debris into the proximal urethral neck through the trigone. Advance the
tip of the 10 Fr. polypropylene catheter into the proximal urethra a short distance. Flush with a 20
ml saline volume. The flush solution will back flow into the bladder and may bring back a small
stone or two or crystal debris that was in the proximal urethra. Advance the catheter another cm or
so. Repeat the flush. Again the flush will come back into the bladder. Another stone? Advance the
catheter again another cm or two. Repeat the flush again. The saline may come back into the
bladder or it may go the other direction out of the urethra and the vagina. Your technician can verify
that the table is wet under the drape. If the saline comes back into the bladder with this flush repeat
this advancement process until the saline goes out the urethra and vagina. Find the spot where if you
draw the catheter back a cm the flush will come back into the bladder and if you advance it a cm it
will go out the vaginal urethra. Sometimes if you are lucky you will find the spot and saline will go
both ways with the flush. Now repeat the flush-back, then forward. Repeat the flush-back, then
forward. Keep repeating until you feel comfortable that all debris has been flushed from the female
urethra. Then flush some more.
Occasionally a fairly large stone will enter the female urethra and lodge next to the urethralis
muscle just inside the urethral opening into the vagina. These are very difficult if not impossible to
dislodge with flushing. It is rarely possible to catheterize the vaginal urethral opening and back-
flush the stone. The most effective method in removing a stone in this position is to advance a 6
inch alligator forceps from the bladder incision into the urethra until you feel the stone. Open the
forceps and grab it and draw it back into the bladder. If you cannot move it you begin crushing it so
that it can be flushed from the urethra. This is done blindly and by feel. Be calm and do not get
excessively aggressive. Work patiently and you will have success.

Key to success: FLUSH, FLUSH, AND FLUSH SOMEMORE

Bladder Closure:
Inverting suture patterns on the bladder should not be used anymore. They are technically
very difficult to do well, especially on a bladder with a thick wall or on a very small bladder.
Appositional patterns have been shown to provide just as much strength and are not prone to
leakage. Serosal contact is not needed for a fluid tight seal as was previously thought. Good tissue
apposition with mild tissue pressure is important and can be easily achieved with an appositional
pattern. Some veterinarians do double layer appositional closure. We have found the single layer
appositional with a simple interrupted pattern to be very effective. A non-absorbable suture material
such as 3-0, 2-0, and even 0 PDS is very appropriate (match suture size to bladder size). Remember
that inflamed bladders can easily allow smaller materials to tear through. Large bites help alleviate
this issue. Large simple interrupted sutures that do not enter the lumen give good bladder wall
security. With larger bites more tissue pressure occurs between sutures so that a fluid tight seal is
achieved. THIS IS TECHNICALLY SO MUCH EASIER TO DO AND THE RESULTS ARE
EXCELLENT. Some veterinarians do a similar closure but with a continuous pattern.

Stone culture and identification:


The role of bacteria in stone biology cannot be overemphasized. Crushing and culturing the
center of a stone will always give you the organism if antibiotic therapy has compromised your
ability to get the organism identified from urine or bladder wall. We culture urine, bladder wall and
stone to maximize our ability to get an organism identified.
With the development of diet alteration to help prevent stone recurrence it is important that
correct stone identification be carried out. Two laboratories are available to us:
1. Urolithiasis Laboratory, Inc.
P.O. Box 25375
Houston, TX 77265-9950
800-235-4868

2. University of Minnesota

3. Animal Reference Pathology (ARUP)


500 Chipeta Way
Salt Lake City, UT 84108
800-426-2099
PROCEDURES PRO

CYSTOTOMY
Eric R. Pope, DVM, MS, DACVS
Ross University
DEPARTMENT  h  CATEGORY  h  PEER REVIEWED

I
ndications for cystotomy
include exploration of the
lower urinary tract, removal
of cystic and urethral calculi
(Figure 1, next page), correction
of ectopic ureters, removal of
masses (eg, polyps), and biopsy.

ASK YOURSELF
h What is your differential

diagnosis for this


dermatitis and otitis
presentation?
h Which diagnostic would

you perform next?


h Which topical otic

ingredients are considered


safer to use if a tympanic
membrane is ruptured?
h How would you treat the

otic stenosis?

29    cliniciansbrief.com    February 2016 February 2016    cliniciansbrief.com    29


PROCEDURES PRO  h  SURGERY  h  PEER REVIEWED

Cystotomy can be completed via traditional open approach, and


1) an open approach via midline specialized equipment is required.1
celiotomy or 2) a limited caudal Cystotomy via ventral midline
midline approach in conjunction celiotomy may be the most com-
with cystoscopy or urethroscopy. mon approach in general practice.
Although the limited approach may
be less invasive, total costs are Positioning & Location
often higher than with the more Cystotomy is conducted with the
patient in dorsal recumbency. Male
dogs can be positioned with the
pelvic limbs extended caudally
because the prepuce can be
included in the prepared field
should urethral catheterization be
necessary. Placing the pelvic limbs
of female dogs and cats in so-called
“frog-leg” position with the tail
hanging over the surgery table can
provide good access for normo- or
retrograde urethral catheteriza-
tion intraoperatively; this position-
ing also works well in male cats
when cystotomy is combined with
either urethral catheterization or
perineal urethrostomy.

1 The ventral abdomen should be


clipped and aseptically prepared
d Cystotomy for multiple cystoliths.
from the xiphoid to the caudal
aspect of the pubis. The perineum
can also be included in the prepa-
IMPORTANT CONSIDERATIONS IN CYSTOTOMY CLOSURE ration. The prepuce and vulva
should be flushed with antiseptic
Many suture patterns and techniques have been used successfully to close the urinary
solution (eg, 0.05% chlorhexidine
bladder. Essential key points to minimize complications are:
solution) surgically prepared and
h The urinary bladder heals quickly, typically achieving 100% of normal strength in
included in the field to facilitate
3 weeks.2-4 intraoperative catheterization.
h Sutures should engage the submucosa, which is the layer of strength.2,4,5

In cats and female dogs, a ventral


h Apposition of like layers results in a rapid gain in wound strength and does not
midline celiotomy is performed
reduce lumen size4
from just caudal to the umbilicus
h Minimal to no suture material should penetrate the lumen2-5, especially in patients
to the cranial brim of the pelvis. In
with chronic or recurrent urinary tract infections that could be predisposed to male dogs, a parapreputial skin
calculogenesis3 (Figure 2).
incision is used. Ligation or elec-
h The closure must be watertight and strong enough to withstand pressures trocoagulation of the preputial
generated during micturition.3 branches of the caudal superficial

30    cliniciansbrief.com    March 2016


epigastric vein and subcutaneous ous, simple continuous oversewn
vessels minimizes bleeding. Tran- with an inverting pattern (eg,
sect the preputial muscle, retract Cushing), single layer Cushing pat-
the prepuce to the opposite side, tern, and Cushing pattern oversewn
and perform a midline celiotomy. with the Lembert pattern have all
The preputial muscle can be tagged been used.2-5 Inverting patterns
with suture to identify it during should be avoided when the bladder
closure. wall is thickened or friable.

Although a cystotomy can be per- The simple continuous pattern can


formed on the dorsal or ventral be used in normal or thickened
surface of the bladder2, a ventral bladders. A simple continuous pat-
midline cystotomy is recom- tern engaging the seromuscular
mended. Ventral cystotomy pro- layers and submucosa, while avoid- 2
vides excellent visualization of the ing the mucosa, should be placed.
bladder lumen—especially the Suture bites should be 3 mm to d Suture removed from lumen of the

trigone area—and can be extended 4 mm apart with similar distance bladder of a dog with history of
into the proximal urethra if addi- between sutures. In normal blad- multiple cystotomies for cystolith
tional exposure is necessary. ders, the simple continuous pattern removal associated with urinary tract
can be oversewn with a Cushing infections.
Catheterization pattern at the discretion of the sur-
The bladder becomes thickened and geon, but there is no demonstrated
edematous with prolonged exteri- benefit over a single layer closure.4
orization and repeated manipula- If an inverting pattern is used, take
tions. Stay sutures can reduce care to avoid excessive inversion of
repeated grasping of the bladder. tissue, which could result in
The urethra can be catheterized obstruction.
normograde (from bladder to ure-
thral orifice), retrograde (from ure-
thral orifice to bladder), or in both
A monofilament intermediate last-
ing absorbable suture material
3
directions to verify patency and to such as poliglecaprone 25 (ie, d Exploration of a dog with
flush calculi, when present, from Monocryl, ethicon.com) or gly- uroperitoneum after closure of
the urethra. Placement of an comer 631 (ie, Biosyn, covidien. ruptured urinary bladder with a
indwelling urethral catheter in com) in size 3/0–5/0 on a taper simple continuous pattern.
small female dogs and female point needle works well. Resistance
cats can be facilitated by passing a should be felt when the submucosa
catheter normograde from the is engaged.
bladder, attaching it to the tip of a the transected preputial muscle
second catheter, and withdrawing Follow-Up should be sutured. When cystotomy
the normograde catheter to pull The bladder can be filled with saline has been performed for cystolith
the indwelling catheter through to check for leaks. Simple inter- removal, postoperative radiographs
the urethra and into the bladder if rupted or cruciate suture(s) to seal or other imaging appropriate for
retrograde placement is difficult. leaks should be placed. The surgery the stone type should be performed
site should be lavaged with warm to confirm complete removal of the
On Sutures sterile saline before routine closure stones from the bladder and ure-
Simple interrupted, simple continu- of the abdominal wall. In male dogs, thra. There is a relatively high

March 2016    cliniciansbrief.com    31


PROCEDURES PRO  h  SURGERY  h  PEER REVIEWED

frequency of stones being left buprenorphine typically works well. be monitored for evidence of dehis-
behind even when the bladder and In dogs, continue NSAIDs for 3 to cence (Figure 3, previous page),
urethra are extensively flushed 5 days for their anti-inflammatory infection, persistent hematuria,
during surgery.7 and analgesic effects as long as the excessive stranguria, and obstruc-
patient is well-hydrated and renal tion (see Important Consider-
Monitor urine output and appear- function is normal. A single post- ations in Cystotomy Closure,
ance (eg, hematuria) postopera- operative dose of an NSAID can be page 30). Dehiscence or suture line
tively. Continue fluid administration considered with the previously men- leakage is the result of infection,
as long as blood clots continue to tioned precautions.  inadequately placed sutures, or
pass to reduce the risk of obstruc- increased intravesicular pressure
tion. Control pain with opioids Complications secondary to impaired urine out-
perioperatively. In cats, transmuco- Complications after cystotomy are flow.
sal (placed in buccal pouch) uncommon, but the patient should

STEP-BY-STEP
WHAT YOU WILL NEED
h General surgery pack (ie,

scalpel handle, DeBakey thumb


forceps, needle holders, STEP 1
Metzenbaum scissors,
Position the patient in dorsal
hemostats)
recumbency. Pictured is a cat with
h Balfour or similar abdominal recurrent urethral obstruction and
retractors calcium oxalate uroliths (A). A per-
h Surgical and laparotomy ineal urethrostomy and cystotomy
sponges were performed without having to
reposition the patient. Parapreup-
A
h Red rubber or similar soft
tial incision in a male dog (B).
catheters for urethral or
ureteral catheterization
h 3/0 or 4/0 nylon for stay sutures
Author Insight
h 3/0 – 5/0 monofilament
Perform cystotomy on ventral
absorbable suture material on aspect of bladder for better
a taper point needle for exposure of the trigone area.
cystotomy closure
h Poole or similar suction tip

h Formalin containers for biopsy

specimens
h Sterile cup or culture swab and

medium for transporting


mucosal biopsies and/or small
stones for culture
h Warm sterile saline for lavage
B

32    cliniciansbrief.com    March 2016


STEP 2
Exteriorize the urinary bladder and pack it off
with moistened laparotomy sponges. Place stay
sutures to stabilize the bladder and minimize
repeated manipulations of the bladder. Aspirate
urine if the bladder is full.

Author Insight
Use stay sutures to stabilize
the bladder during surgery.

STEP 3
Make a stab incision into the bladder lumen on
the ventral midline. Suction any remaining
urine from the bladder. Extend the incision with
Metzenbaum scissors. Stay on the midline as the
incision is extended caudally to avoid encroach-
ment on the ureters as they enter the dorsolateral
aspect of the bladder at the trigone.

STEP 4
In the absence of a scrubbed-in assistant, the stay
sutures may be attached to the surrounding
drapes to maintain exposure of the bladder lumen.

March 2016    cliniciansbrief.com    33


PROCEDURES PRO  h  SURGERY  h  PEER REVIEWED

STEP 5 Author Insight


Suture the bladder in a simple continuous pattern (A and B). The photograph Use a monofilament
with detail (C) shows passing the suture through the serosa, muscularis, and absorbable suture and avoid
submucosa while avoiding penetration of the mucosa. exposure of the suture
material in the bladder lumen.

A B C

STEP 6
Alternatively, suture the bladder
with a simple continuous pattern
oversewn with a Cushing
pattern. n

Author Insight
Continuous patterns have a tendency to loosen as the sutures
are placed—a common, easily avoided cause of leakage. Be sure
to check for loosening with a hemostat before ending the
pattern.

References
1. Arulpragasam SP, Case JB, Ellison GW. Evaluation of costs and time required 5. Stone EA, Kyles AE. Cystotomy and partial cystectomy. In: Bojrab MJ,
for laparoscopic-assisted versus open cystotomy for urinary cystolith Waldron DR, Toombs JP, eds. Current Techniques in Small Animal Surgery.
removal in dogs: 43 cases (2009 -2012). JAVMA. 2013;243(5):703-708. 5th ed. Jackson, WY: Teton NewMedia; 2014:481-482.
2. Cornell KK. Cystotomy, partial cystectomy, and tube cystostomy. Clin Tech 6. Appel SL, Lefebvre SL, Houston DM, et al. Evaluation of risk factors
Small Anim Pract. 2000;15(1):11-16. associated with suture-nidus cystoliths in dogs and cats: 176 cases (1999-
3. Radasch RM, Merkley DF, Wilson JW, Barstad RD. Cystotomy closure: A 2006). JAVMA. 2008;233(12):1889-1895.
comparison of the strength of appositional and inverting suture patterns. 7. Grant DC, Harper TAM, Werre SR. Frequency of incomplete urolith removal,
Vet Surg. 1990;19(4):283-288. complications, and diagnostic imaging following cystotomy for removal of
4. Thieman-Mankin KM, Ellison GW, Jeyapaul CJ, Glotfelty-Ortiz CS. uroliths from the lower urinary tract in dogs: 128 cases (1994 -2006). JAVMA.
Comparison of short-term complication rates between dogs and cats 2010;236(7):763-766.
undergoing appositional single-layer or inverting double-layer cystotomy
closure: 144 cases (1993-2010). JAVMA. 2012;240(1):65-68.

34    cliniciansbrief.com    March 2016

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