tpvets_logo.jpg (2726 bytes)TOA PAYOH VETS
toapayohvets.com

Date:   16 July, 2009  
Focus: Small animals - dogs, cats, hamsters, guinea pig & rabbits.

 


tpvets_logo.jpg (2726 bytes)An intern learns how to bathe a puppy with diarrhoea. She needs to pony-tail her long hairs to do work.

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Toa Payoh Vets Clinical Research
Making veterinary surgery alive
to a veterinary student studying in Australia
using real case studies and pictures
 

The Silkie Had Difficulty In Urination
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Case written: 13 June 2007
Updated:
16 July, 2009

Be Kind To Pets educational story is to share my veterinary experiences with vets in other parts of the world. All veterinary surgical reference books seldom discuss the overall management of the case of urethral and bladder stones surgery in the dog from the clinician's point of view. 

Silkie 8 years old.  Dysuria. Leg up for a long time. Little urine passed. Toa Payoh Vets
For a veterinarian, it is a happy scene to see a male dog peeing normally within one second of leg lifting on day 6 of the surgery.

At 4 p.m on June 12, 2007 (day 6) after surgery , the Silkie Terrier was taken out from his crate.  "He prefers the grass patch to pee,"  James said. The 8-year-old male dog with urethral and bladder stone removal surgery on June 7, 2007 lifted up his left hind leg and easily peed light yellow urine.  Before surgery, he put up his hind leg for over an eternity of several seconds with little or no dark brown urine coming out.

Back to the beginning of the story. On Jun 7, 2007 (day 1), 8% halothane gas to quickly anaesthesize the dog.  Then lower to 2% halothane gas for maintenance.  The dog was intubated with a breathing tube into the lung.  Groin area shaved. The following procedures are briefly described. 

Urohydropropulsion - Put dog on sternum. Finger inside rectum to press on urethra. Inject via catheter 20 ml of sterile saline. Release digital pressure. The theory is that the saline will flush the stones into the bladder. Therefore, no need urethral surgery to remove stones behind the os penis.  With large stones (seen in X-ray), this procedure was a waste of time. However, I tried it. It was ineffective and I had to perform urethrotomy.

Incise urethra behind os penis. Remove urethral stones. Stitch up. Remove bladder stones. Toa Payoh VetsUrethrotomy --- Insert F/8 sterile catheter into urethra. It could not get into the bladder as the stones behind os penis blocks it. At least 4 urethral stones were removed.  2 big stones around 3 mm in diameter  blocked urethra behind the os penis (penile bone).
Urethra stitched up with 5/0 interrupted absorbable suture. Skin then stitched up with 3/0 interrupted absorbable suture.

Cystotomy --- 40 ml saline flushed into bladder via catheter to dilute and drain out the dark brown urine. Then more saline to inflate the bladder. I incise 1 cm into the thick bladder wall at its apex, ventral surface. Took the bladder out of the body as much as possible. Thick walled. Big wide red veins on its surface indicating that infection (cystitis) had been present for some months. As I cut the bladder, urine and saline shot out. I made sure that the urine shooting out did not get inside the peritoneal cavity of the dog otherwise there will be peritonitis.

8-year-old male Silkie. Bladder & urethral stones. Toa Payoh VetsFlushing the bladder of all debri and stones --- I clamped the 1-cm muscle wall of the bladder. My assistant inject another 40 ml of saline via the catheter into the bladder twice. I removed the clamp and let the urine and saline shoot outside the body. The liquid spurted onto the floor and would have splattered onto me if the position of the surgical site was directed at me. All bladder stones and debri should have been flushed out from the 1 cm incision. From the X-ray, the stones could be around 0.6 cm in diameter.    

Catherisation --- Not more than 5 days are recommended. On day 1, the catheter was pulled out by the dog from the inside out.  The 2 nylon stitches anchoring the outer end of the catheter to the groin skin were intact. "The catheter came out from inside," my veterinary assistant said. The Elizabeth collar had been taken out too and the dog licked the operation areas. Blood plus urine leaked out from the behind the os penis surgical site.

Post-op care very important --- At least 5 days hospitalisation --- Post-operation nursing is very important as the owner seldom knows what to do if the dog is sent home after surgery. In this case, the catheter was pulled out by the dog. A new one was inserted. But it was hard to get it into the bladder as the dog was laid on his side on the operation table. What to do? Anaesthesize the dog with gas. The urethral muscles relaxed and the catheter was inserted. This time, sticky bandaged the catheter tip to the prepuce and wrap the elastoplast bandage around the body.

On day 3, the elastoplast was removed. Some blood plus urine leaked out from the prepuce. The area was cleaned up. A bigger Elizabeth collar was used. The dog was spoon fed with home-cooked food and given water. No dry food.

On day 5, the catheter "dropped off" as the self-adhesive bandage wrapped round the body of the dog was not sufficient to prevent him getting the catheter out. He was observed to pass urine normally. Large red purple areas around his surgery site indicated attempts to lick the whole area. I gave the dog an inflammatory injection. He felt so much better and the redness receded by at least 50% on day 6.

For a veterinarian, it is a happy scene to see a male dog peeing normally within one second of leg lifting on day 6 of the surgery.

At the time of this report, it was 4 p.m on day 6 after surgery , the Silkie Terrier was taken out from his crate.  "He prefers the grass patch to pee,"  James said. The 8-year-old male dog with urethral and bladder stone removal surgery on June 7, 2007 lifted up his left hind leg and easily peed light yellow urine.  Before surgery, he put up his hind leg for over an eternity of several seconds with little or no dark brown urine coming out. 

Economics  --- The total cost of consultation, anaesthesia and 2 surgeries (urethral and bladder) was S$600. X-rays were taken by another veterinary surgery. Blood tests ought to be done but that would add up to the cost. Prescription diet and follow up urine analysis 3 monthly were recommended.

Owner's permission to talk to the other vet. It is always ethical to get the permission from the owner to talk to the other veterinarian who first saw the case. Sometimes this was ot possible due to the personality traits of the other veterinarian. However, in this case, the veterinarian was very helpful in giving me the history of the case. Our paths crossed. She used to be my intern as a 20-year-old who was doing "A" levels at night. A girl who wanted to be a veterinarian. She saw practice for a few months before she went for her foundation studies in Kuala Lumpur and later studied veterinary medicine in Australia. That was at least 15 - 20 years ago. I have no doubt about her competence to do the surgery, but it was the cost of surgery that made the owner seek me.  I don't know how much she charged but the market rate would be around $1,000 as the surgery would take as long as one hour.

She was kind enough to share her surgical experiences about urohydropropulsion using lubricant and saline and the surgical procedures.   

Summary: Surgery takes more than one hour.  Post-operation nursing is very important as the dog tries to pull off the catheter and will not eat or drink much.  Sticky elastoplast taping of the catheter to his prepuce was the only way to make sure that the catheter stayed for 2 days. Needs to change after 2 days as the bandaged area is wet with urine flow.  When self-adhesive bandage was used, the dog managed to get the catheter out.  Anti-inflammatory injection given to bring down intense itch at operation site for this dog. 

Electrolytes and antibiotics given orally for first 2 days at least.  Make sure that the Elizabeth collar is much bigger. Also check every 2 hourly.  Home-cooked food needed. Make sure that he does not take dry dog food.  He was as strong dog, looking much younger than his peers. 

If you send this dog home immediately after surgery, most likely there will be lots of problems as the urethral area stitches break down, resulting in a hole in the urethra. Dog then leaks urine via the urethral opening --- very unsatisfying situation for many owners.  It is preferred that the dog stays at least 14 days but costs would be higher. 

UPDATE IN 2009:
The veterinary costs can be over $2,000 and therefore many Singapore dog owners don't bother to follow-up after treatment. In this case, the owner did not come back for review since the surgery.

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 Clinical Research

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All rights reserved. Revised: July 16, 2009

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