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Surgical Management of Obstructive Urolithiasis by Perineal Urethrostomy in

a Tom Cat

Article in International Journal of Science and Research (IJSR) · February 2020

DOI: 10.21275/SR20203213826

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 International Journal of Science and Research (IJSR)
ISSN: 2319-7064
ResearchGate Impact Factor (2018): 0.28 | SJIF (2018): 7.426

Surgical Management of Obstructive Urolithiasis by

Perineal Urethrostomy in a Tom Cat
M. Gokulakrishnan1, K. Jothi Meena2
Madras Veterinary College, Tamil Nadu Veterinary and Animal Sciences University, Chennai-600 007, India
1
Assistant Professor, Department of Clinics, Madras Veterinary College, Chennai, India
2
B.V.Sc. Scholar, Madras Veterinary College, Chennai, India

Abstract: A 2 year old intact domestic tom cat weighing 4.75 kg was referred to Small Animal Surgery Out Patient unit of Madras
Veterinary College Teaching Hospital with the history of intermittent licking of its genitalia, hematuria and stranguria with progressive
reduction in appetite for the past two weeks.Clinical examination revealed a distended, tensed abdomen, which on palpation, depicted
bladder involvement that was painful and unresponsive to manual decompression. A distended obstructive bladder was noticed along
with dorsal and cranial displacement of adjacent organs on a lateral and ventrodorsal abdominal radiograph, in addition
ultrasonography was performed to rule out bladder epithelial health. On ultrasound thickened bladder wall with non shadowing
sediments along with a dilated pelvic urethra was noticed in addition to an hyperechoic mass obstructing the distal penile urethra.
Based upon the radiograph and ultrasonographic findings the case was tentatively diagnosed as obstructive urolithiasis

Keywords: obstructive urolithiasis-perineal urethrostomy- cat

1. Case presentation and Diagnosis distended on following day.The presence of a urethral plug
occluding the urethral lumen was considered to be the most
A 2-year-old intact domestic tom cat weighing 4.75 kg was likely cause of obstruction based on the information
referred to Small Animal Surgery Out Patient unit of Madras collected from the history, radiograph and urinalysis,
Veterinary College Teaching Hospital with the history of although it was not possible to quantify the degree of
intermittent licking of its genitalia, hematuria and stranguria contribution of urethral spasm and oedema to this problem.
with progressive reduction in appetite for the past two
weeks.The cat discussed in the case report was mainly kept 2. Treatment
indoors and its owners described it asa “lazy” and “nervy”
pet. Additionally, it exhibited a high body condition score, The cat was premedicated with diazepam @ 0.5 mg/kg body
which may have contributed to the primary episode of weight and Butorphanol @ 0.2mg/kg body weight
urethral obstruction. Clinical examination revealed a intravenously. Anaesthesia was induced with propofol @
distended, tensed abdomen, which on palpation, depicted 4mg/kg body weight intravenously. The perineal urethra is
bladder involvement that was painful and unresponsive to the location of choice for urethrostomy in cats. It is a
manual decompression. A distended obstructive bladder convenient location for surgical manipulation, the urethral
was noticed along with dorsal and cranial displacement of diameter will accommodate passage of most urethral calculi
adjacent organs on a lateral and ventrodorsal abdominal and there is less urine scald postoperatively. Prior to surgery
radiograph, in addition ultrasonography was performed to a urethral catheter is passed, if possible. After a routine
rule out bladder epithelial health. On ultrasound thickened castration, an elliptical incision is made around the scrotum
bladder wall with non-shadowing sediments along with a and penis. Then the subcutaneous tissues are dissected to
dilated pelvic urethra was noticed in addition to an expose penile urethra. The penile urethra is dissected free
hyperechoic mass obstructing the distal penile urethra. from surrounding connective tissue. The ventral attachment
Based upon the radiograph and ultrasonographic findings the of the pelvic urethral to the pubis (i.e., ishiocavernosus m.)
case was tentatively diagnosed as obstructive urolithiasis. is identified and transected. The penile urethra is freed from
The pet was sedated with butorphanol and diazepam @ 0.2 its connective tissue attachments to the pelvic floor using
mg/kg and 0.25 mg/kg intravenous respectively following blunt digital dissection. The retractor penis muscle is
which, conservative management was performed through identified on the dorsal aspect of the penis and is dissected
tom cat catherization to relieve the obstruction, to provide from its attachment on the penis. The dissected retractor
patency and to carry out urinalysis. Urinalysis revealed a penis muscle is then used to develop the dorsal plane of
less acidic pH (7.3), increased specific gravity and presence dissection to separate the pelvic urethra from its dorsal
of struvite crystals with epithelial cells and RBCS. A routine connective tissue attachments. Once the urethra is dissected
hematobiochemical profile was taken to rule out organ enough to visualize the dorsolateral located bulbourethral
health which revealed marginal anaemia., glands penile dissection was stopped. The penis is
thrombocytopaenia, azotaemia and hyperkalemia. Patient catheterized and the urethral orifice identified.
was stabilised with intravenous fluid therapy to restore
hydration and urine output was quantitated during the first An incision is made from the penile urethra to the pelvic
24 hours.Despite catheterization, pet evinced unsuccessful urethral to the level of the bulbourethral glands using an Iris
micturition, subsequently the bladder was periodically scissor. The urethral orifice at the level of the bulbourethral

Volume 9 Issue 2, February 2020

www.ijsr.net
Licensed Under Creative Commons Attribution CC BY
Paper ID: SR20203213826 DOI: 10.21275/SR20203213826 424
 International Journal of Science and Research (IJSR)
ISSN: 2319-7064
ResearchGate Impact Factor (2018): 0.28 | SJIF (2018): 7.426
glands is generally large enough diameter to accept the treated medically. Furtherstudies may focus on identifying
flange of a tomcat catheter. After incision of the urethra, the an ideal duration of catheterisation to better clarify the role
glistening urethral mucosa is identified. this variable has on the outcome. The present case observed
no improvement when increasing the hospitalisation and
5-0 nonabsorbable monofilament suture with a swaged on urethral catheterisation periods from 24 to 60 hours. Neither
cutting or taper-cut needle is recommended by the author. the volume of IV fluids delivered nor the continuation of
The first urethrostomy suture is placed at the dorsal aspect of IVFT after removal of the urinary catheterwas associated
the urethrotomy incision on the right or left side at a 45 o with the risk of recurrent UO.Griffinand Gregory(1992)
angle to include urethral mucosa and skin (suture split Other variables, such as administration of the α1-adrenergic
thickness of skin). The suture is tied and cut leaving the ends receptor antagonist Prasozininstead of Phenoxybenzamine
3-4 cm long to act as a stay suture. A mosquito hemostat is have been recognised to reduce the risk of reoccurrence.
placed on this suture to provide traction and countertraction
to enhance visualization of the urethral mucosa. The second The cat in this report was advised oral prazosin however the
suture is placed opposite the first suture and tied as pet did not produce favourable outcome.The implementation
described for the first. A stay suture is also placed here. A of environmental modifications reduced the risk of recurrent
third urethrostomy suture is placed directly on the dorsal UO, but increasing water consumption was the
midline to hold the dorsal margin of urethral mucosa to the onlyindependent factor associated with a lower reoccurrence
dorsal margin of the skin incision. Alternating sutures from rate.(Little.,2007)In the case it seemed likely for the
dorsal to ventral are placed until approximately one half of reoccurrence of the obstructive episode to be associated with
the penile urethra has been sutured to skin. The remainder of a urethral stricturecaused by repeated urinary catheterisation.
the penis is amputated and the subcutaneous tissue and skin In the absence of reoccurrence, it would have been adequate
are closed routinely. Fine ophthalmic instruments make to maintain the cat on acalculolytic diet to prevent
tissue handling and suturing easier. Use of a 2X magnifying reobstruction by struvite-containing urethral precipitates as
loupe and headlamp light source enhances visualization of demonstrated by (Osborne., et al.1991) BacterialUTI is
the urethral mucosa and facilitates accurate suturing. It is rarely the initial cause of FLUTD, therefore obtaining a
critical for the surgeon to recognize the glistening urethral urine culture only at the time of catheter removal and
mucosa and carefully suture it to skin. This will decrease (or dispensingantimicrobials accordingly seems to be
eliminate) the chance of urethral stricture. appropriate. (MacLoughlin.,2000)

3. Discussion The choice of surgical technique will be determined by the

cause of the obstruction and its location in the urinary tract.
The term FLUTD describes clinical syndrome produced by The PUtechnique used and is reserved to relieve distal
many conditions that affects the feline lower urinary tract urethral obstruction. Modifications to the PUtechnique have
Acar,et al (2010). Some risk factors associated with FLUTD been developed although they have not been widely adopted
have been identified such as excessive body weightIstanbul. to date. Their common goal is to take advantage of thewider
Bass et al (2005), inactivity and stress. UO can occur in up pelvic urethra to produce a widened tube for urine
to 58% of male cats with FLUTD. The cat discussed in the flow.Nelson, R.W. and Couto, C.G. (2003) If a cystotomy is
case report was mainly kept indoors and its owners required, PU is performed in dorsal recumbencyallowing
described it asa “lazy” and “nervy” pet. Additionally, it simultaneous access to the urinary bladder. In the case the
exhibited a high body condition score, which may have radiograph eliminated the suspicion of urolithiasis
contributed to the primary episode of urethral thereforesurgical opening of the bladder was unnecessary. It
obstruction.Bernard, A. and Viguier, E. (2003) was the author’s preference to perform the procedure
positioning the patient inventral recumbency.Short-term
Clinical signs of UO at presentation can be categorised to complications of the PU include haemorrhage, stricture
local lower urinary tract signs, resulting from the formation, wound dehiscence, urine extravasation, perineal
obstruction, and systemicsigns associated with the herniaand urinary incontinence. These can be reduced by
accumulation of uraemictoxins and with the acid-base and using good surgical technique, including appropriate intra-
electrolyte imbalances. Hyperkalemia and uraemia are major pelvic dissection andcareful apposition of the urethral
causes of death in male cats with urethral obstruction; mucosa to the skin. Saroglu, et al (2003)
however, some cats with recurrent FLUTD as observed in
the present case. In the long term, the commonest complication of PU is
recurrent UTI as a consequence of urethral shortening and
Surgical management of the cat with UO has changed over direct exposureof the urethral orifice (Smeak, 2010).
the years from being a first line of treatment to generally
being reservedfor cases where medical management Reoccurrence of UO is uncommon when PU is performed
techniques are no longer achieving their aim. Corgozinho et properly and 88% of the owners assessed their cat’s quality
al.(2007) Irrespective of the cause of obstruction, of life as good following PU.
medicaltreatment must focus on the restoration of urethral
patency and urine flow , reversing life-threatening
electrolyte disturbances,maintaining adequate tissue
perfusion and minimising visceral pain.Gregory and
Vasseur(1983) A longer duration of urinary catheterisation
may decrease the risk of short-term recurrent UO in cats
Volume 9 Issue 2, February 2020
www.ijsr.net
Licensed Under Creative Commons Attribution CC BY
Paper ID: SR20203213826 DOI: 10.21275/SR20203213826 425
 International Journal of Science and Research (IJSR)
ISSN: 2319-7064
ResearchGate Impact Factor (2018): 0.28 | SJIF (2018): 7.426
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Catheter In Situ
Volume 9 Issue 2, February 2020
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Paper ID: SR20203213826
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