Wednesday, September 12, 2012

1089. Follow up: No further leakage into SC area - blocked bladder Shih Tzu

A bright sunny morning on Thursday, Sep 13, 2012. I went to the Surgery at 8.45 am as usual. Dr Daniel is in Langkawi yesterday. I handled his post-op cases including this Shih Tzu with complications of blocked bladder. As his mentor, I took over the case as it was too complicated for him, being a recent graduate, to handle.

In any case, every vet has his or her own approach to resolving a challenging post-operation problem and his was to stitch up the original urethrostomy so that the dog could pee from the normal penile opening when he took over the case around 5 days ago from the other vet who had done a bladder surgery. But after the bladder surgery, there was large swelling in the prepuce and scrotal sac and possibly in the left inguinal area but this was denied.

But the other vet said that the scrotal sac was filled with fluid as found out on ultrasound. As to whether the fluid was urine (from a damaged urethra at the bend of the urethra via difficult initial catherisation) or pus and blood or all 3, she said that ultrasound would not be able to by thdifferentiate. Ultrasound would indicate the presence of fluid. I did not ask if she had aspirated the scrotal sac. In any case, she had recommended a 2nd hole (2nd urethrostomy) to be opened up and closed the first hole which was obstructed with pus and fibrous tissue. The owner did not want another surgery costing $1,200 and so, the case came to Dr Daniel.

He did a castration (testicles abnormally small) and removed white fatty tissue in the swollen left inguinal area (size of 6 cm x 6 cm containing around 30 ml of blood + fluid aspirated daily for the past 4 days) as requested by the owner. I had asked him why he did it as this dog already had much complications of not being able to pee normally. He ought not have done it but the owner had asked for this service.

After his excision of the left inguinal area fat, fluid + blood of around 30 ml (aspirated daily) accumulate every day for the next 3 days. Why? What was it? The urine was passed via the cathether and did not contain blood. He irrigated the bladder daily and the dog was OK, till on Day 4 when the dog had fever and there was some tissues inside the urine passed out.

As he would be going on leave and in any case, this was such a complicated emotional expensive case (the owner having spent over $2000 on the blocked bladder surgery and more money on the earlier 2 related urinary stone surgeries, excluding expenses at Toa Payoh Vets,  I took over the case. There is so much time spent on commuicating with the owner who visited every evening and this time spent are not billed though young vets don't realise it.

Yesterday, from 10 am, I did a 2-hour surgery to cut off the hard scrotal sac and opened up the first urethra hole done by a vet some months ago. I extended the incision. My hypothesis is that the SC fluid in the left inguinal area could have come from the bladder via the leakage from the urethral opening (lst urethrostomy) which, though stitched up with 2 interrupted sutures, was found to still be opened in between the two stitches. The opening was around 3mm in length and I suspected the leakage over 24 hours would be from there into the SC area.

However the lab could NOT determine whether the SC fluid + blood sent by me was urine or not and so this part of the mystery could not be resolved.

The important thing is that the SC area should not again be filled with 30 ml of fluid + blood every morning as in the past 4 days leading to pain for the dog and fever on the 4th day before Dr Daniel left for Langkawi (ie. on Tuesday). My hypothesis is that the urethra further up, at the bend was damaged and caused pain during urination. Therefore the dog could not pee properly and the other vet had suggested a 2nd urethrostomy nearer to the bend and scrotal ablation (cut off the scrotal sac).

Where's the leak? Was it from the damaged urethra at the bend? This was most consistent with the filling up of the scrotal sac after the blocked bladder surgery and difficult catherisation of the urethra (the other vet said a cat catheter - smaller in diameter had to be used as it was difficult to catherise the urethra due to blockage by pus and fibrous tissue around the first hole). So, urine leaked into the scrotal sac which had two testicles. The testicles became smaller due to compression of the testicles by urine and blood from the urethra damage at the bend (ultrasound had been done to show fluid inside the scrotal sac, as said by the other vet.). Urine also back-flowed to the big left inguinal area where the mass of fat had been removed.

Therefore, in theory, if I extended the first hole, the urine leakage from the bend into the SC tissues into the scrotal sac (no fluid on needle aspiration yesterday. Filled with reddish brown hard tissues and pockets of pus, with testicles already removed by Dr Daniel 3 days ago).

So, in hypothesis, if I did the above surgery (extended the first urethrostomy and do scrotal ablation), the SC fluid inside the inguinal area should not be present.

At 9 am today, I checked the dog and took some images. The hypothesis was verified and there was no swelling. The dog was much happier in the behaviour that when he was turned upside down to examine his inguinal area and do dressing, he did not protest and cried loudly as in the past 4 days.

It was good news. I hope this article will help other vets with similar complications. Never open another hole in the urethra. Just unblock the first hole and extend it. Never suture the first urethra and hope it will close as it might not. In any case, a continuous inverting suture would be needed as in uterine or gastric closing, not interrupted sutures. In any case, this area was infected badly and so, it is doubtful that it would heal well, without stricture and causing obstruction again. A dye would reveal the urine leakage area but the owner would never pay for this and the other vet said she had done nothing wrong and why should her management pay for this test?

In practical terms, resolve the owner's dog complications at the least cost. It is easy for me to criticise.

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