2163. Recurring urolithiasis in a Shih Tzu - 5 surgeries to resolve the problem

TOA PAYOH VETS toapayohvets.com   Blk 1002, Toa Payoh Lor 8, 01-1477, Singapore 319074   Tel: 6254-3326, 9668-6469, 9668-6468.  judy@toapayohvets.com  
21 May, 2015   Focus: Small animals - dogs, cats, guinea pigs, hamsters, turtles & rabbits
Recurrent urolithiasis - 5 surgeries for a recurring bladder stone problem

Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Case written: January 7, 2013       Update:  21 May, 2015
 
Taking images of cases with the camera phone to document your cases and to do retrospective studies of your performance will make you a better veterinary surgeon.

There may be some parts of the anatomy changes which you might have missed during the examination but images taken will be there for you to review. This is time-consuming and that is why most doctors and vets don't bother as images must be taken and filed properly.

For example, in the complicated case of the Shih Tzu with 5 bladder surgeries.
He had 2 surgeries to remove the bladder stones several weeks ago. Two vets (Vet 1 and 2) removed the bladder stones in two separate surgeries.

However, the Shih Tzu had bladder stones and Vet 3 operated on him.   
 with perineal urine leakage after a bladder surgery by Vet 3 to remove urinary stones, an image of the swollen perineum (presumed with leaked urine from the traumatised perineal urethra) was taken by me. See image on the left.
This is one supporting evidence and there must be others to substantiate this urine leakage (ultrasound of scrotum filled with fluid), swelling of left inguinal area near where Vet 3 made a skin incision to access the bladder for urinary stone removal daily with blood-tinged fluid while the dog was catherised with a smaller sized urinary catheter

Note that the scrotal sac is also swollen and Vet 3 had said that ultrasound revealed fluid. According to the owner, the whole of the lower part of the inguinal area was much swollen and that was why the dog had to be hospitalised for 8 days by Vet 3 who then recommended a 2nd urethrostomy and scrotal ablation to resolve the problem of urine leakage. 

This image was taken when the dog was seen at Toa Payoh Vets on Day 9 after Vet 3's bladder surgery which had removed all bladder stones (post-op X-rays showed no stones). The owner came to Toa Payoh Vets as his daughter was a classmate of my son. So, Vet 4 (Dr Daniel) was tasked with the resolution of the dog's urinary problem. 

How to resolve this problem with the least cost to the owner? That is the tough part. Will a 2nd urethrostomy and closure of the first urethral stoma and scrotal ablation as suggested by Vet 3 resolve the problem for once and for all? 

Dr Daniel (Vet 4) at Toa Payoh Vets was asked by the owner to neuter the dog and remove the large left inguinal swelling of the size of an egg. He stitched up the urethral stoma (first urethrostomy done by Vet 1) so that the dog could pee as a normal dog, from the tip of the penis. Would this resolve the problem?

Well, it did not appear to do so as the left inguinal swelling filled with blood-tinged fluid (I presumed it was urine leakage + blood) of around 30 ml per day for the next 4 days. Vet 3 had likely ruptured the urethra leading to leakage of urine and blood in the left inguinal area.  

Large left inguinal swelling due to urine + blood accumulation	Problem and surgical solution explained by illustration for the owner
Inguinal fluid and urine for lab analysis	Surgical plan from Dr Sing Kong Yuen

"Closing the urethral stoma so that the dog could pee normally from the tip of the penis is good for the dog," I said to Dr Daniel. "But there is the daily need to aspirate the 30 ml of blood-tinged fluid from the left inguinal area. It cost the owner around $7,000 to do the past 3 surgeries to remove the bladder stone and given time, your surgical approach may work. But time means money expenditure for the owner. "

As Dr Daniel had to go overseas, I became the Vet 5 as I took over the case and reviewed the complicated urine leakage problem. This involved talking to Vet 3 as to what had been done.

Vet 3 said: "We did an ultrasound and saw fluid inside the scrotum. This was not recorded in the case report as the owner was not charged."

Ultrasound can reveal fluid in an organ but will not be able to tell whether it i urine or blood or both.

This is where the perineal swelling in this image substantiated a possible urine leakage. I proposed a dye test but it is extremely expensive to do dye test to reveal the location of the perineal urethral leakage. The surgery at Vet 3 had cost $2,000 according to the owner.

So, what's the best economical solution now? What is in the best interest of the dog? If expenses keep mounting, the dog may be put to sleep by the owner. A solution must resolve the problem to the owner's satisfaction and to the dog being able to live a normal life without difficulty in urination.

What should I do? This is a complicated urinary tract problem due to urine leakage presumed to be from a tear in the perineal urethra (see image of perineal swelling above) and subcutaneous fluid presented daily along the left side of the penile length.

I thought hard. The dog had gone through 4 anaesthesias and surgery. Veterinary expenses were considerable.

My surgical approach was to extend the urethra stoma made by Vet 1. This  had been closed by Dr Daniel as he wanted the dog to pee normally from the tip of the penis. Then I did a scrotal ablation (cut off the scrotal sac), close up the inguinal sheaths and stitch the urinary catheter to the prepuce to retain it in for around 4 days to let the perineal catheter to heal. This is the theory.

The dog still had difficulty in urination after Vet 3's surgery. My surgical approach to post-op complications from Vet 3's surgery which had removed the bladder stones
Open up the wound	Scrotal ablation
Enlarged Vet 1's  urethrotomy incision	Ensure urethra is patent
Healing of the surrounding areas	Goes home with prescription diet S/D
Dog is able to pee via the original enlarged urethrostomy for the past 3 months and as at Jan 7, 2013. Dog eats prescription diet C/D. Urinary analysis and X-rays on a regular basis are recommended. Will the owner comply?

In practice, this worked as the dog is now peeing normally with no blood in the urine when it came back for stitch removal on Sep 28, 2012, around 14 days after my surgery.

UPDATE as at Jan 7, 2013
The dog pees through the first urethrostomy without any difficulty. The owner came to buy the C/D canned food. It is good news.  Post-op urine and blood tests and X-rays are advised but owner compliance with regular monitoring will be difficult due to various reasons.

P.S.  Urethrostomy = a hole is cut into the urethra (passage for urine from bladder to the tip of the penis). 

Yearly blood and urine tests may detect early presence of bladder and kidney stones in your dog and cat.  For urinary health screening appointments, tel: 6254-3326, 9668-6468
e-mail judy@toapayohvets.com
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