Surgery Exam 2

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Where does the vein for the left ovary come from?

Comes off of the left kidney's vein

How is doing a Buccal Mucosal Bleeding Time test related to the kidney?

Uremia may impair platelet adhesions/aggregation

What is included in a diagnostic plan for the kidneys?

CVC, biochemistry panel, coag panel, BMBT, UA, urine culture, blood pressure, thoracic rads

Which lateral, R or L, is best to do a abdominal radiograph for the kidneys?

Right lateral

What does an excretory urograph tell you?

The quality of urination rates

What should you note about the contrast given when doing an excretory urograph?

Iodinated contrast is renal toxic

What is the time course of the different shots during an excretory urograph?

Taken at 0 min (base), 5 min (angiograph), 20 min (renal), and 40 min (excretory)

What is pyelography?

Injection of contrast directly into the renal pelvis

What is ultrasound good for when assessing the kidneys?

Good for architectural changes, dilated renal pelvices, US guided biopsy

How can you evaluate the vasculature of the kidneys?

CT angiography is supior to an EU

What is scintigraphy used for when assessing the kidneys?

Glomerular filtration rate

If you are removing a kidney, what is a good test to perform and why?

Scintigraphy; Test the GFR of each individual kidney to assess the impact of removing a kidney

What are the basic preoperative considerations you should make before performing kidney surgery?

Correct pre-existing problems if possible or be aware of them if you cannot, oncotic support, monitor urine output, avoid nephrotoxic drugs, avoid drugs that cause hypotension, may need drugs to of set hypotension, epidurals can reduce anesthetic requirements

How much of CO do the kidneys get and why is this important to note?

25% of CO; they can hemorrhage a lot, and proper blood volume is necessary to keep them properly perfused

What are some post-operative considerations for renal surgery?

Intravenous fluids, analgesia, monitor urine output and weight of the animal, monitor blood pressure, monitor for systemic issues like uremia (biochem, CBC and platelets, etc . . .)

What are the congenital kidney defects discussed in class?

Agenesis or dysgenesis, renal ectopia, fusion, polycystic kidney disease

What is the difference between agenesis and dysgenesis of the kidneys?

Agenesis - ureter absent; dysgenesis - ureter present

Where are the kidneys located when you have renal ectopia?

Originate near the aortic bifurcation and "ascend"

Are the kidneys still functional in cases of renal ectopia?

Position doesn't affect function

Describe kidney fusion:

"Horseshoe" shaped; normal function

What is the main problem with congenital defects of the kidneys?

They are often accompanied with other congenital defects

What breed is polycystic kidney disease common in?

Persian cats; reported in other purebred cats; rare in dogs

Describe the pathogenesis of polycystic kidney disease:

Originate from renal tubular cells, compress surrounding parenchyma and lead to renal failure; treatment unsuccessful

What is the only way of treating polycystic kidney disease?

Kidney transplant

What are the acquired renal disorders talked about in class?

Renal neoplasia, acquired renal cyst, perirenal pseudocyst, renal abscess, renal trauma

How common are primary renal tumors?

Primary renal tumors are rare

Are renal tumors benign or malignant?

Majority are malignant

What is the most common renal tumor in cats?

Lymphoma

What is the most common renal tumor in dogs?

Renal cell carcinoma

What is the treatment of choice for renal neoplasia?

Nephrectomy; partial nephrectomy is the opposite kidney is diseased

Are acquired renal cysts real cysts?

They are epithelial lined

How do you treat acquired renal cyst?

US guided draining and ethanol infusion described

What are perirenal pseudocysts?

Fluid between capsule and parenchyma

What is associated with perirenal pseudocysts?

Linked with chronic renal disease

What species is perirenal pseudocysts more common?

More in cats

What are renal abscesses associated with?

Pyelonephritis, nepholiths, renal biopsy, hyperadrenocorticism, DM

How do you treat renal abscesses?

Supportive care and nephrectomy

What is the best way to treat renal trauma?

Manage them conservatively, better than going to surgery

When should you use renal biopsies?

Only if results will change the course of action

What are the possible techniques at getting a renal biopsy?

Percutaneous (blind), US guided, Key-hole (flank), laparoscopic, laparotomy

If doing a laparotomy to gain a renal biopsy, what should you remember?

Occlude the renal artery to control bleeding;

What are laparotomy renal biopsies used for?

Wedge or incisional biopsies

What size of needle should be used for renal biopsies?

14-18 gauge

When is partial nephrectomy indicated for?

In animals with renal insufficiency or previous nephrectomy, isolated lesion or trauma

Describe the technique of a partial nephrectomy:

Occlude renal artery and vein, excise tissue, close pelvis, cover defect (renal capsule, omentum, or hemostatic sealants (fibrin, aldehyde, cyanoacrylate glue))

What should you always remember about the kidney when doing surgery?

Major bleeding is possible, the kidney has a capsule

What are the indications for nephrectomy?

Trauma, persistent infection, renomegaly, obstructive calculi with persisten hydronephrosis, neoplasia, kidney donation

What are two things to remember about when considering a nephrectomy?

Make sure contralateral side is normal, pay attentions to vascular anatomy (bleeding)

What are the most common type of uroliths?

Calcium oxalate most common

If an animal has azotemia, what does this mean?

Means both kidneys are affected

What is part of a complete workup for uroliths?

Symptoms and lab work changes may be absent, culture the urine, image the entire urinary tract

How successful is medical management alone of uroliths?

66% successful

What is involved in medical management of uroliths?

Diuresis, drugs to induce ureteral relaxation (Calcium channel blockers, glucagon, amitriptyline

In cases of uroliths, what are the indications for renal surgery?

Comprimised renal function, hematuria, pain, UTI, obstruction

What are the surgical options for dealing with uroliths?

Lithotripsy (dogs only), nephrectomy, pyelolithotomy, ureterotomy, ureteral resection and anastomosis, ureteral reimplantation, nephrotomy

Describe the nephrotomy procedure?

Unilateral only (stage if bilateral), release kidney from retoperitoneum, occlude vessels, incise capsule, intersegmental vs bisectional nephrotomy

T or F - There are effects on GFR when performing a nephrotomy:

Inconsistent finding; Basically do this only if there is a strong need to do it

What happens when closing a nephrotomy site?

Digital compression is required for 5-10 minutes while blood flow is restored; then the capsule is closed with a simple continuous pattern but the suturues are not placed through the parenchyma

What is pyelolithotomy?

Removing a stone from the renal pelvis

What is ureteral anastomosis indicated for?

Indicated for ureteroliths or trauma

When dealing with the ureters, what should you remember?

The ureters don't like being handled; react a lot

What are the risks of ureteral anastomosis?

Leakage, obstruction/stricture

How can you combat strictures in ureters?

Spatulate the ureter ends before anastomosis

What is the complication rate of ureteral re-implantation?

Lower complication rate than ureteral R and A

What is the procedure of a Ureteral Re-implantation?

Abnormal portion of ureter removed, distal end spatulated, sutured to the bladder mucosa/submucosa

What are the risks associated with ureteral catheters?

Stranguria, imperfect location, ureteral trauma, UTI

What do ectopic ureters produce?

Urinary incontinence

Who are predisposed to ectopic ureters?

Dogs, females, skye terriers, Golden retrievers, labrodor retrievers, huskies

What other anomalies are ectopic ureters associated with?

Hydroureter, renal dysgenesis, vestibulovaginal abnormalities

What can you do to diagnose ectopic ureters?

Must rule out other disease (Survery rads, UA, and culture), US, contrast-enhanced rads, contrast CT (most sensitive), cystoscopy

What is the difference between intramural and extramural ectopic ureters?

Intramural means the ureter travels in the wall of the bladder and urethra for awhile before opening into the urethra farther down; Extramural is not in the wall

What are the possible options for surgically treating ectopic ureters?

Cystoscopy-guided laser ablation, cystotomy (intramural - incise and suture ureter to bladder mucosa; extra-mural - reimplant ureter into bladder)

Describe the procedure of treating an ectopic ureter?

Identify the ureteral orifice, incise across the bladder wall into the lumen of the ureter, opening of the ureter is sutured to the bladder mucosa, distal ureter is ligated, sutured closed or removed

Why might an animal have postoperative incontinence after ectopic ureter surgery?

Abnormal function of urethral sphincter mechanism

What is a neouretercystotomy?

Basically creating a new hole in the bladder for the ureter to go through

Define a ureterocele:

Prolapse of a ureter into the bladder, may cause an obstruction of urine

What are the advantages of performing a cystoscopically guided laser ablation over open surgery for ectopic ureters?

Reduced postoperative pain and hospitalization

What is the indication for feline renal transplant?

End stage renal disease unresponsive to medical therapy

What is the survival rate of patients receiving a feline renal transplant?

77.5% survive to discharge

What may be required in acute renal failure or ethylene glycocl toxicity situations?

Hemodialysis

Describe what is included in feline renal transplant preoperative screening:

CBC, Chem panel, Blood type (and match to donor), thyroid hormone, UA/culture/prot:creat, Abdominal rads and US, Cardiac workup, infectious disease screening: FeLV, FIV, Toxoplasmosis

What things are contraindicated for Feline Renal Transplant?

Neoplasia, CHF, FeLV or FIV, Recurrent/existing UTI, Uncontrolled hyperthyroidism, fractious temperament

What are the three things that make feline renal transplant a long term commitment?

Financial, Emotional, Long-term care

How do you immunosuppress the cats that receive renal transplants?

Cyclosporine and prednisolone; ketoconazole

Why is ketoconazole given along with the immunosuppression drugs for renal transplants?

Inhibits cytochrome P450 so less cyclosporine has to be given (not degraded as fast)

Which kidney is typically transplanted and why?

Left kidney; longer vein

Where is the transplanted kidney typically anastomosed to?

To the caudal aorta and vena cava

What solution aids in preserving organs between transplants?

Phosphate-buffered sucrose organ preservation solution

Why must cyclosporine levels be monitored in a transplant case?

There is a 12 hour trough you have to assess so that the cat doesn't start rejecting the kidney

How are the vein and artery anastomosed to the aorta and vena cave in renal transplants?

End-to-side anastomosis

How small of suture is being used for the anastomosises of the vessels in transplants?

8-0, 7-0

When they remove the ureter of the kidney to be transplanted, what is taken with it?

Part of the wall of the bladder, lessens any risk of stricture when placed in the recipients bladder

Name complications that can occur with renal transplants:

Hemorrhage, graft thrombosis, ureteral obstruction, delayed graft function, acute rejection (13-26%), chronic rejection, hemolytic uremic syndrome, urolithiasis, retroperitoneal fibrosis, immunosuppression complications (infection, Diabetes mellitus, neoplasia)

How more likely is an drug immunosuppressed cat from renal transplant to get Diabetes mellitus? Lymphoma?

5x more likely; 6x more likely

What is a possible complication of laser ablation of ectopic ureters?

You go too far and create a hole in the bladder

Why are dogs not good candidates for renal transplant?

They don't stop rejecting kidneys

What is a main thing to consider when assessing for renal transplants in cats?

If there are signs of problems in both kidneys that point to a systemic issue, a new kidney is not going to help

Where do the transplant donor cats come from?

Cats raised in a pathogen free environment

In order to reduce risk of damage to the donor kidney, how long can the surgery be?

One hour or less

What is one of the main reasons cats only leave the hospital after renal transplants 77% of the time?

Acute rejection

What is one of the most common long term complications of feline renal transplant?

Neoplasia

What are possible diagnostics for assessing the urinary bladder?

Cystocentesis (cytology and culture), Rads, contrast rads, US, contrast enhanced CT, cystoscopy, catheter biopsy

What conditions can cystoscopy be used therapeutically for?

ectopic ureters, cystic calculi, collagen injection

How can you avoid tissue trauma when operating on the urinary bladder?

Stay sutures (not forceps), cold saline for hemostasis (not electrocautery), saline and suction to increase visibility (not gauze sponges)

When doing any body cavity surgery, what should you do when exteriorizing an organ that can leak?

Pack off the cavity

What are indications for a cystotomy?

Calculi, repair trauma, biopsy/resect masses, ectopic ureters

Why is doing a cystotomy good for getting tissue samples and culture?

Can get a full thickness biopsy, culturing the wall of the bladder can identify bacteria that are being harbored there

Why must we engage the submucosa when closing a cystotomy site?

The submucosa is the holding layer

When closing the bladder cystotomy, what is one important thing to note?

Don't go over kill

Name complications associated with cystotomy:

Hematuria, uroabdomen, UTI, stones

How long is hematuria post-cystotomy acceptable?

1-2 days post surgery

When excising a portion of the bladder, what should you remember to do?

Preserve the trigone

What are indications for cystectomy?

Excision of patient urachus/urachal diverticulum, discrete bladder neoplasia or polyp, bladder trauma/necrosis

What is a common side effect or complication of a cystectomy?

Pollakiuria common (>75%); the bladder will regain size with time though

What do you do with ureters if performing a cystectomy?

Can reimplant the ureters

How can you decompress a bladder before a cystectomy?

Use a Foley catheter

What is the basic way of dealing with bladder trauma?

If necrotic, debride the edges and close it like a cystotomy but again, preserve the trigone

What are indications for a cystostomy?

Stabalize (Lower urinary obstruction), bladder or urethral trauma, obstructive disease (neoplasia), neurogenic bladder atony

What are your short term options for a cystostomy?

Foley or mushroom tip catheter

What are your options for a long term cystostomy?

Low-profile silicone gastrostomy tube

Describe the basic technique of placing a cystostomy catheters:

Paramedian position, purse-string suture in bladder wall, catheter passes through purse-string into bladder, Dr. Colopy says never to pexy the bladder because what happens if you want to further surgery

What are some complications of cystostomy catheter placements?

UTI, Cystic calculi

What is the main consideration of dealing with UTIs after a cystostomy catheterization surgery?

Don't want to promote resistant bacteria; culture and treat intermittently, avoid continuous antibiotics

What are the indications for a cystopexy?

Perineal hernia, incontinence (mixed results), cystostomy tube (she says never do it)

What are the three options for performing a cystopexy?

Incisional, tube cystopexy, laparoscopic assisted

Name the congenital conditions of the bladder discussed in class:

Patent urachus, vesicourachal diverticulae (most common), bladder hypoplasia

What is a patent urachus?

Communication between the bladder and the allantoic sac

How do you diagnose the congenital bladder issues mentioned in class?

Contrast cystography

What are ways the bladder can sustain trauma?

neoplasia, trauma, iatrogenic, obstruction

Name symptoms of bladder trauma:

Hematuria, anuria, dysuria, abdominal bruising, abdominal pain, systemically ill

Name the metabolic changes associated with bladder trauma:

Azotemia, dehydration, metabolic acidosis, hyperkalemia

If you do an abdominocentesis and find that the urea and creatinine are higher than serum creatinine, what has happened?

Ruptured bladder (remember though that there is really nothing that points to uroabdomen alone)

How can you determine the source of a uroabdomen?

Cystourethrogram or Excretory Urogram

How do you treat bladder trauma?

If it's a small tear, can catheterize and let it heal on its own; Supportive care, cystostomy tube; possibly surgery; Must be stabilized before surgery; Resect unviable tissue and close; consider wrapping with omentum

What is another name for calcium oxalate?

Struvite

How can you retrieve and remove a cystic calculi?

Routine cystostomy, catheter assisted, cystoscopic, laparoscopic assisted, lithotripsy

What is lithotripsy?

Breaking up of urinary system stones via sound waves

What are the things important to do before and after removing stones form the bladder?

Need pre-op radiographs immediately before surgery; pass a catheter anterograde and retrograde to ensure all removed, post-op radiographs, submit stones for analysis, bladder wall for culture

How polypoid cystitis situations Neoplastic?

No (but must biopsy)

What is polypoid cystitis associated with?

UTI, calculi, etc . . (basically irritation)

What are symptoms of polypoid cystitis?

Hematuria, stranguira, UTI

What is the key with dealing with polypoid cystitis?

Need to treat the underlying disease

How common is polypoid cystitis?

Rare

How common are bladder neoplasias?

Rare

What is the most common bladder neoplasia?

Transitional cell carcinoma

Where do bladder tumors most commonly reside?

Trigone predilection

What diagnostics can you do to look for tumors of the bladder?

Image bladder, biopsy, thoracic rads, pelvic rads, CT, abdominal US

What is included in treatment of bladder tumors?

Possibly surgery, chemotherapy, NSAIDs, radiation

Describe the differences in the urethra between male and female:

Male - long and thin, Female - short and wide

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