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where is best approach for removing urolith? What are other options?
- PRESCROTAL
- scrotal (and castrate)
- perineal (salvage in cats)
- prepubic (salvage)
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what procedure creates a permanent opening of urethra to exterior? indications?
- urethrostomy
- -nondisplacable stones
- -chronic stone formation
- -urethral stenosis
- -penile trauma
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for urethrostomy, is prepuce included in the draped field?
yes! so need to flush when scrubbing pt
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for urethrostomy, which muscle is displaced to see urethra? then what is done?
- retractor penis m.
- palpate os penis edge, put in vertical position before cutting down to urethra --> remove stones/flush w catheter in place
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How do you close urethra? what are post op treatments for urethrostomy?
- can heal by 2nd intention, or close w/5-0 absorbable, taper needle
- fluids + NSAIDS + Abs +catheter for 1-2d
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When suturing urethra to skin, what order are layers sutured? What size should opening be for urethrostomy?
- inside-out (mucosa to skin) --> bridge cavernosous to control oozing
- stoma of 2.5-3cm
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What is wilson and harrison technique?
- perineal urethrostomy for CATS only
- requires partial amputation of penis
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What are some etiology of urethral laceration and rupture?
- pelvic or os penis fracture
- penile trauma
- iatrogenic from catheter
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How are urethral laceration/ruptures diagnosed? treatement?
- + contrast urethrography or US
- minor can heal spontaneously
- soft catheter or urethral splint
- simple apposition w/3 to 5-0 (end to end anastm)
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What is involved in the salvage procedure prepubic anastomosis?
anastamose remnants of penis to bladder and hope innervation still works
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what salvage procedure creates a urethrostomy on the ventral body wall, cranial to pubis? what are indications for this procedure?
- antepubic urethrostomy
- -salvage for stricture, neoplasia, trauma to urethra
- -recurrent stricture of perineal urethrostomy
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What are some disadvantages associated with antepubic urethrostomy?
- urine scald (can tx w/baby oil or vasoline)
- ascending UTI
- potential for urinary incontinence
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If amputation of urethral prolapse is indicated, how is hemostasis maintained for the sx? what type of suture to close? Post op concerns?
- rummel turniquit around penis ->catheter to maintain patency during sx and after to monitor output
- close w/simple interrupted (short tags) and REST/isolate
- C/S for antibiotic choice; NSAIDS + ecollar
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What are some anatomical considerations that make the cat more prone to FLUTD?
- no prescrotal area
- conical/tapered urethra
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what age cat is most susceptible to FLUTD? breed?
- 2-6 yr (both genders, esp males)
- increased risk for Persian and Burmese
- (decr. risk for Siamese)
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FLUTD is a SYNDROME. what are some of the clinical signs?
- dysuria, hematuria, crystalluria
- licking genitals; "crying"
- reduced emission, urethral obstruction
- sandy material
- can appear to o' like straining to defecate (r/o constipation via palpation)
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Patients w/ FLUTD often present in shock. What would chemistry reveal? What can you do to initially relieve the pt?
- elevated BUN/Creatinine (from backflow of urine)
- cystocentesis to decompress bladder
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What % of patients develop a UTI from being catheterized to treat obstruction? What % had UTI before being catheterized?
- 20% (make sure to use aseptic tools and clean technique)
- (only 3% before cath.)
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what is medical option for treated FLUTD patients? when is sx indicated?
- prescription diets (like C/D); in early stage can try urohydropropulsion = massage abdomen to allow urine to pass
- sx when medical tx fails or recurrent urethral obstruction
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Does bacteria play a primary role in development of FLUTD?
no, but not completely sure of etiology; diagnosis of rule outs
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What is difference between urethral plug and urolith?
- plug: matrix of gelatinous, friable, doughy, amorphous
- urolith: organized internally, non-deformatble, solid (struvite or Ca oxalate)
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What procedure is salvage for male cat w/recurrent urethral blockage or one with irreversible mural lesions causing obstruction?
perineal urethrostomy (wilson and harrison technique)
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for wilson & harrison technique, which part of urethra is opened to be sutured to skin?
pelvic urethra (penis partially amputated)
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with cat in perineal position, what suture do you place before starting the sx? After that, what do you do if cat is intact?
- purse sting around anus
- castrate and scrotal ablation--> then make elliptical incision around scrotum and prepuce
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for PU, how far do you dissect ventral to the penis?
to ischial arch (see ischiocavernosus mm. that connects to arch --> scrape to detach)
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After you sever the retractor penis m., you pull the penis to disengage from any connective tissue. How do you know you have disengaged adequately?
visualize bulbourethral glands --> stays in incision site even if not pulling on penis (then incise urethra up to this point)
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After incising the urethra up to bulbourethral gland, how do you check that you've established a good opening?
Halsteds inserted up to instrument's joint w/no resistance
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When closing PU, where are first sutures placed?
- suture 11, 12 and 1 oclock from inside - out
- then stagger sutures rest of the way down, leaving 2-3cm open --> then clamp and amputate rest of penis using circumferential ligature
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what suture is used for PU?
- monofilament
- (monocryl, PDS, monofilament nylon, vicryl)
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What change to the mucosa do you expect to see at first after PU?
redder and metaplasia
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What are post op consideration for PU? should catheter be left in place?
- indwelling catheter only if urethral tear is present
- remove sutures in 7-10d
- E collar
- use paper litter, popcorn, etc
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what are common post op comlications following PU?
- recurrent FLUTD and bacterial cystitis (10-19%)
- urethral stricture due to sx technique (11.5%)
- urolithiasis (6%)
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what is number 1 post op complications of PU due to?
- surgeon's technique!
- -fail to fully separet from pelvic attachment
- -wrongly incise urethra
- -nerve damage from rough handling
- -suture technique/dehiscence
- -excessive catheterization
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What post op complication of PU is possibly secondary to severe vascular damage at sx?
necrotic perineum
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What post op complication of PU is due to excessive dorsal dissection that penetrated rectum?
urethrorectal fistula (place catheter to maintain patency)
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What should you do if post op PU leads to stricture/stenosis?
redo the surgery (this is an emergency!)
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