ureteral obstruction in small animals
TRANSCRIPT
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URETERAL OBSTRUCTION IN SMALL ANIMALS
Courtney Ikuta, DVM
Department of Surgery
VCA West Coast Specialty and Emergency Animal Hospital
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URETERAL OBSTRUCTION
Vague history and clinical signs
Difficult diagnosis
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URETERAL OBSTRUCTION
New therapeutic options
Improved outcomes
Less costly than traditional approach
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PATHOPHYSIOLOGY
Ureteroliths: most common
Calcium oxalate: 98% feline, 50-75% canine
Neoplasia: trigone
Stricture: congenital or acquired
Blood stones
Obstructive pyonephritis
Trauma
Polyp
Local abscess
Locally invasive neoplasia
Radiation therapy
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PHYSIOLOGIC RESPONSE TO URETERAL OBSTRUCTION
Immediate ureteral pressure increase (peaks 5 hours)
Renal blood flow decreases to 40% of normal within 24 hours
20% of normal by 2 weeks
Decrease in GFR
Contralateral increase
7 days post obstruction: 35% permanent loss
14 days post obstruction: 54% permanent loss
Normal dogs
Over 4 months to reach maximal return to function
Partial obstruction: full return after 4 weeks of obstruction
Early intervention to relieve obstruction is recommended
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HISTORY AND CLINICAL SIGNS
FELINE
• Vomiting
• Lethargy
• Decreased appetite
• Acute or chronic weight loss
• +/- signs of uremia
• Uncommon: dysuria, pain
CANINE
• Vomiting
• Lethargy
• Decreased appetite
• Dysuria
• Renal pain
• +/- signs of uremia
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Physical Examination
Feline
• +/- Big kidney-Little kidney
• Pale mucous membranes
• Anemia
• Heart murmur
Canine
• Renal pain
• Fever
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Laboratory Findings
Feline
• Anemia: 48%
• Azotemia: 83%
• Hyperphosphatemia: 54%
• Hyperkalemia: 35%
• Hypercalcemia: 14%
• Hypocalcemia: 22%
Canine
• Neutrophilia: 63%
• Thrombocytopenia: 44%
• Azotemia: 50%
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Urinalysis
Feline
• UTI: 34%
Canine
• UTI: 77% – 25% of these had negative culture
on pre-op urine
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IMAGING
Radiographs
Ultrasound
Percutaneous antegrade pyelography
Computed tomography
GFR studies/scintigraphy
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RADIOGRAPHS
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ULTRASOUND
>10mm: likely complete/near complete obstruction
5-10mm: gray zone, dependent on other clinical signs, patient, etc
<5mm: possible early obstruction or partial
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PERCUTANEOUS ANTEGRADE PYELOGRAPHY
Visualize the renal pelvis and ureter
Localize obstruction
Obtain sample for bacterial culture
Fluoroscopy
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CT
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GFR STUDIES
Tc99 diethylenetriamine pentacetic acid scintigraphy
Obstructed kidney: typically reduced GFR
Not predictive of return to function
Consider for nephroureterectomy
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MEDICAL MANAGEMENT
Stabilization prior to definitive treatment
IV fluid therapy
Monitor CVP, weight, electrolytes, hydration status
Caution: fluid overload
Antimicrobial therapy: 77% of dogs have concurrent infections, 34% cats
17% will have movement of ureteral stones
7.7% will pass stone
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MEDICAL MANAGEMENT
Mannitol: 1mg/kg/min x 24 hours if no cardiac disease
Discontinue if no improvement after 24 hours
Spasmolytics: Amitriptyline, α-adrenergic blockade (prazosin, tamsulosin), β-adrenergic agonists, glucagon
Anecdotal evidence at best
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OUTCOME: MEDICAL MANAGEMENT FELINE
Mortality rate: 33% died or euthanized before discharge
87% fail to see improvement in renal function
If survived to discharge only 30% had improvement in azotemia
13% had improvement with medical management with 7.7% documented stone passage
Unsuccessful for stricture
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TIMING TO INTERVENTION
Relieve nephroureteral obstruction as soon as the patient is stable
Save the nephrons!
7 days post obstruction: 35% permanent loss
14 days post obstruction: 54% permanent loss
40 days post obstruction: minimal recovery
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SURGICAL MANAGEMENT
Traditional
Ureterotomy
Ureteral reimplantation
Ureteronephrectomy
Ureteral resection and anastomosis
Renal transplantation
Interventional
Ureteral stent
Ureteral bypass
Lithotripsy
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Anatomy
Feline
• Ureteral diameter: 0.4mm
Canine
• Ureteral diameter 21-30kg dog: 2.0 to 2.5mm
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URETEROTOMY
Magnification is essential
Operating microscope vs. loupes
Microsurgical instruments and suture (7-0 to 10-0)
Caution with suction: ureteral edema
Caution with electrocautery: lateral thermal spread
Stent placement more common
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URETERAL REIMPLANTATION
End-to-Side Neoureterocystostomy
Distal ureteral masses, extramural ectopic ureters, distal ureteroliths
Magnification
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URETERAL RESECTION AND ANASTOMOSIS
Uncommon procedure
Requires operating microscope and two experienced surgeons
Luminal disparity: dilated proximal ureter and normal distal ureter
3-4 weeks before coordinated peristalsis returns to the ureter
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OUTCOME: TRADITIONAL SURGERY FELINE
8% confirmed uroabdomen, but 34% had abdominal effusion
7% persistent ureteral obstruction
17% failure to improve renal function
13% revision surgery
3% fluid overload
25% did not survive to discharge
40% reobstruction within 1 year
50% mortality at 1 year
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OUTCOME: TRADITIONAL URETERAL SURGERY CANINE
21% failure renal function improvement
15% worsening of renal function
13% second surgery: recurrence, stricture
43% persistent renal dysfunction
43% recurrent or persistent UTI
25% with positive stone culture had negative pre-op urine culture
25% died or euthanized due to renal disease
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SAVE THE NEPHRONS
>30% of cats will develop chronic kidney disease
Indication for nephroureterectomy:
Renal neoplasia
Degree of pyelectasia and obstructed GFR do not correlate to post-operative prognosis
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URETERAL STENT
Save the nephrons!
62% of cats with ureteral obstruction had nephroliths
40% of cats re-obstruct after ureterotomy
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URETERAL STENT
Proximal and distal pigtail for retention
Inner diameter - .018”, .025”, .035”
Outer diameter - 2 Fr, 3.7 Fr, 4.7 Fr
Hydrophilic multi fenestrated radiopaque shaft
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URETERAL STENT
Double pigtail
Renal pelvis
Urinary bladder
Multi fenestrated radiopaque
Fluoroscopic guidance
Multiple approaches
Open antegrade or retrograde
Cystoscopic retrograde
Percutaneous antegrade
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URETERAL STENT EQUIPMENT
Ureteral stent, guidewire, dilator
Size dependent on patient
Fluoroscopy
Contrast
Remainder depends on approach
Ultrasound
Laparotomy
Cystoscopy
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CYSTOSCOPIC RETROGRADE
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Ureteral Obstruction 32 Image courtesy of Dr. Tracy Hill
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URETERAL STENT
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Ureteral Obstruction 33 Image courtesy of Dr. Chick Weisse
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SAVED NEPHRONS
Obstructed 2 weeks post stent placement
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OUTCOME: URETERAL STENT FELINE Cause: 75% stones, 24% stricture, 1% obstructive pyonephrosis 17% Ureteral penetration with guidewire intraop but no uroabdomen postop 6.7% leakage when concurrent ureterotomy 17% fluid overload postop 6% pancreatitis 5% failure of creatinine to improve 7.5% died prior to discharge: CHF, pancreatitis 38% dysuria: 98.4% responsive to prednisolone 13% postop UTI vs 34% preop UTI 23% reobstruction 18% chronic hematuria 6% stent migration 27% require stent exchange
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OUTCOME: URETERAL STENT CANINE
Cause: 55% ureteroliths, 40% neoplasia, 5% strictures
<1% ureteral perforation, leakage, tear
1 patient did not survive to discharge
7% persistent hematuria
9% reobstruction
13% UTI postop vs 59% UTI preop
6% migration
2% encrustation
1 stent fracture
1 dysuria
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URETERAL BYPASS
Subcutaneous Ureteral Bypass (SUB)
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URETERAL BYPASS
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OUTCOME: SUB FELINE
Cause: 20% stricture, 76% ureteroliths, 4% obstructive ureteritis
3.5% kinking
5% leakage: required replacement device
10% device occlusion: managed conservatively
3% failure of creatinine to improve
5.8% failed to survive to discharge
Not related to surgical complications
15% postop UTI vs 35% preop
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TO SUB OR TO STENT
2 retrospective studies
No difference in survival to discharge or hospitalization time
Complications
10% stent: vesiculoureteral reflux, dysuria
0% SUB
Ureteral stricture
UTI: resistance?
Follow up: more rechecks with SUB
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EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY
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EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY
32 dogs
90% success
30% require repeat treatments
Ureteral stenting improves outcomes
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POSTOPERATIVE CARE
Esophageal feeding tube
Almost all cats, severely ill dogs
Allows for nutritional support, water w/o Na load
Central line
CVP monitoring
Fluid diuresis + CKD = difficult fluid balance
Urinary catheter
In more critical patients
More accurately monitor ins/outs
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POSTOPERATIVE CARE
Maintain fluid balance
Post-obstructive diuresis: 3-5X maintenance or more
Better slightly behind than overloaded
Body weight 3-4x per day
Nutritional support
Pain management
Antibiotics if appropriate
Monitor electrolytes, BUN, Cr q24h
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PROGNOSIS
Variable depending on multiple factors:
Chronicity of obstruction
Degree of obstruction
Species
Cause for obstruction
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OUTCOMES: SYNOPSIS
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Medical Management
Surgery Interventional Radiology
Mortality 33% 25% 6%
No improvement creatinine
87% 19% 3%
Reobstruction 92% 38% 14%