1150. Recurrent struvite urolithiasis: A Westie X had a fully packed bladder full of stones again

In May 2013, the Westie was operated by Dr Daniel and a few thousand small stones were removed. Stone analysis showed struvite stones.  However, the owner did not come back for review. She bought some S/D from her source and then fed Hills' Ideal Balance Natural Lamb and Brown Rice Adult age 1-6 years dry dog food.

Recently the dog passes blood in the urine. The bladder X-ray from another vet yesterday showed it was packed to the gills with bladder stones. The other vet sampled the urine and stated the pH was 8.0 but did not check for urinary crystals. The vet proposed surgery and feeding of S/D cans.

handphone image from owner. Vet had given him a CD. This image does not show the kidneys which may have stones.
The dog had excellent appetite (stools in intestines). Loves to eat.  Image below is from the handphone. Appearance of stones after surgery quite likely struvites. 

  The stones were in more than 1000 pieces and weighed 87 grams. 


SURGERY ON DEC 23, 2014

I share my surgical experiences with this dog
The owner brought in the dog in the morning and was operated in the afternoon at 4 pm. The other vet had said urine pH was 8.0 and lots of white blood cells, but had not done urinary crystal tests.

The surgery took 92 minutes as the dog did not accept IV drip or injection without hard struggles. She peed and pooped in the process. I decided to give the sedation by IM using domitor 0.2 ml + ketamine 0.25 ml in one syringe. The dog struggled again after intubation and I had to switch to the gas mask and stabilise her.  This took up a lot of time. I injected atropine 0.5 ml and fursemide 1.0 ml IM after sedation.  

She was an old dog and a high anaesthetic risk.  She had survived one bladder stone removal operation 1.5 years ago and now, another similar one with the bladder packed with stones.  I could see the bladder wall thickened to 5 mm from the X-ray and this meant that the dog had chronic cystitis. Surprisingly this dog was still active and eating.

I flushed out any smaller stones. Usually I do two layers of sutures for bladder closure. I did 3 layers for this thickened wall. The dog was given drip SC post-op and peed a lot of urine after that. This showed that the bladder was not leaking.

As at Dec 24, 2014, some 18 hours after surgery, the dog is OK. This type of fully packed bladder is rare from over 100 cases operated at Toa Payoh Vets in my past 30 years of practice.

From sedation to the last stitch, the surgery took 92 minutes (E-A).  The first skin incision to last stitch (E-D) took 69 minutes. Isoflurane gas was given for 77 minutes (C-B). 

CONCLUSION
Visualise what you need. Get all equipment ready e.g. 20-ml syringes to flush out the small bladder stones, so as to minimise anaesthetic and operating time.

ADVICE TO OWNER ON DEC 24, 2014
The owner wanted the dog home on the 2nd day. Advices to prevent recurrences are:
1. S/D for 2-3 months
2. Change to C/D
3. Urine test monthly for 3 months at least with your vet
4. X-rays bladder and kidneys 6 monthly
5. No other food and treats 

Dec 27, 2014  2 pm. Tel owner.
Dog crated to prevent running around apartment. Active, ate 1/2 can S/D and wanted more. Had pooped. Very thirsty and peed a lot. No vomiting. Licks wound which is wet (but wears E-collar) and vulval area.
Had medication and tolfedine 60mg (1/2 tab/day).
Advised not too much water intake as bladder is affected. Ration to 1/2 bowl of water 3x/day. Previously drinks around 1 bowl of water per day.
Keep wound clean. 1/2 can S/D 2x/day. To call me when necessary.

--------------------------------------------------------------------------------------------------------------------------FLASHBACK-

FIRST SURGERY IN MAY 21, 2013 DONE BY DR DANIEL

STONE ANALYSIS ON MAY 21, 2013

MAP (Magnesium Ammonium Phosphate). However, the owner did not come back once for review or consulation.  One and a half years went by.......The dog was active and had an excellent appetite. Drinking was normal. But she passed blood in the urine and vomited once yesterday (Dec 22, 2014). Another vet took an X-ray and it showed a bladder full of stones.


She  quoted around $1,800 for surgery. The parents wanted Toa Payoh Vets to operate. To reduce medical costs, no stone analysis would be done. Blood test and urine tests were declined.