Monday, August 5, 2013

1056. Update on Westie with bladder stones: KPI for removal of 4 bladder stones from a male dog - The invisible 4th stone

The male dog's anatomy is more complicated than a female as there is the penis obstructing the incision. A skin incision is cut beside the penis between mammary gland 5 and 4. Other than that the surgery is the same.


Westie, M, 9 years, bladder stones x 4. The case is introduced at:
http://2010vets.blogspot.sg/2013/08/1054-westie-passes-blood-in-urine-since.html

I did the surgery today Aug 5, 2013 to record my KPI for a male dog. The previous report was the KPI for a female dog. The case is at:
http://www.sinpets.com/F5/20130615stones_urinary_poodle.htm



A: Injection of Induction Drugs  1.12 pm
B: Isoflurane gas first given: 1.16 pm
C: Isoflurane gas stopped:      2.15 pm
D: First skin incision:             1.30 pm
E:  Completion of skin stitching  2.16 pm

E-A = 1 hour & 4 minutes
E-D = 46 minutes
C-B = 59 minutes

The surgery took 46 minutes. The 4 stones were spiked and it took some time to grasp them out from the neck of the bladder.  The bladder was severely inflamed and the wall was thick at 5 mm wide. Two layers of 3/0 absorbable sutures closed the 1-cm cut at the apex of the bladder. The overall operation including induction took around 1 hour as done by me. I had done several bladder stone cases over the 30 years of practice and so I can perform shorter surgery and risk doing a KPI for Toa Payoh Vets. To set a benchmark to measure performance of speed, accuracy and correctness.

As this is an old dog, the speedier the surgery, the lower the risk of anaesthetic death.  The dog was barking furiously within 4 hours after recovery from anaesthesia, ready to charge out. I noted he has passed urine, at first yellowish and later bloody. This is to be expected and means no leakage from the bladder after stitching.  A video is being produced.


This case is rather tricky. According to the X-ray taken by Vet 2, there are 3 bladder stones. I was most glad to grasp 3 stones out and was satisfied. However, I inserted the forceps into the bladder to make three 360-degree sweep of the mucosa from the neck to the apex and sideways. I felt a gritty stone and was most surprised to find a 4th stone of similar size! Always perform this procedure. I did flush normal saline into the bladder via the catheter and also inserted a cathether via the inside of the bladder to flush any stones out of the urethra. Never in my imagination would I imagine a 4th invisible stone as the X-rays showed 3.




This illustrated that the vet must be meticulous to thoroughly sweep the inside of the bladder. The 4th stone was also spiked at the neck of the bladder. And I had thought I had completed my task after getting out 3 big stones.
As I can't take another bladder X-ray after surgery owing to financial constraints as some vets do. Failure to remove any big stones would result in haematuria again and unhappiness from the owner. Therefore, do the forceps sweep of the interior of the bladder as palpation did not reveal any since the bladder wall was 5 mm thick. The stones were around 5 mm across and hard to feel though I did palpate the bladder directly.

These are not the usual rounded ones. They were stuck at the neck of the bladder as they were spiked. Calcium oxalate crystals were found in the urine and presently I will presume they are calcium oxalate. The stones are sent for lab analysis.

Not all old dogs survive the anaesthesia. Therefore, the vet must be speedy as well as be accurate in his surgical performance. As to the factor of "correctness", this case illustrated that 4 bladder stones were the correct number. If I had closed the bladder after removal of 3 bladder stones as shown in the X-ray, my surgery would be deemed "incorrectly" done.

I did a retrospective review of the X-ray and cropped it. There appeared to be 4 stones as shown below:




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Extract of KPI from female poodle with bladder stone removal

KPI FOR SURGERY
How long it takes to remove one bladder stone from a poodle?

Poodle, 10 years, 4.1 kg 38.8 C. Dog was panting but owner said this was normal behaviour of excitement. Urinated blood yesterday, incontinent and now had abdominal distension the size of a small mango, indicating a much swollen bladder with difficulty in peeing.

Had antibiotics for past 7 days. Blood in urine. Dark red cloudy urine. Dog's abdomen distended on arrival. Anti-spasomodic injection and antibiotics enabled dog to pee and on surgery, bladder was empty but swollen with 8 mm wall (normal bladder is around 3 mm)

2 packets of sutures 3/0 absorbable Polysorb, 3/0 nylon for skin

A: Injection of Induction Drugs 2.50 pm
B: Isoflurane gas first given: 2.55 pm
C: Isoflurane gas stopped: 3.39 pm
D: First skin incision: 3.11 pm
E: Completion of skin stitching 3.41 pm

E-D = 30 minutes for a vet with 40 years of experience.
E-A = 51 minutes
C-B = 44 minutes of isoflurane gas + oxygen used.

The female poodle surgery took a much shorter time  of 30 minutes as there is no need to reflect the penis to access the bladder and the stones were rounded struvites unlike the male Westie which took 46 minutes as the stones were spikey and stuck to the mucosal wall at the neck of the bladder and was difficult to pop out. I had to use forceps to fish them out. This took time.

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