3389. 2013 Case study with follow up. The 9-year-old cat had bladder stone removed at Toa Payoh Vets

TOA PAYOH VETS toapayohvets.com Date:   12 May, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits
Case 1:  A cat has bladder stones Case 2: A cat could not pee   Dr Sing Kong Yuen, BVMS (Glasgow), MRCVSDate:   12 May, 2013	toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129
Case 1: A CAT HAS BLADDER STONES Wednesday Feb 20, 2013 "Can you operate today?" the owner of this 7-year-old with a disc-shaped bladder stone of 8 mm x 8 mm and 3 smaller stones was referred to me by his vet friend working in Biopolis.  I had asked him how he came to know about Toa Payoh Vets as presently, one salesman told me the 52nd vet clinic is about to open in Singapore. "I can operate today, but you may have a dead cat at the end of surgery," I showed him the high total white cell count and neutrophils of the cat's blood test taken earlier in the day. "These data showed that the cat has a generalised blood infection of bacteria and is not in a good health state to be under anaesthesia and surgery. He may die on the operating table." "But Vet 2 told me that my cat is suffering from a serious kidney failure. She said I should operate soon and any delay will result in death." Vet 2's blood test result show BUN as "---", creatinine and phosphorus as exceedingly high.  "---" denotes that the value is too high to be read. This indicated an acute renal failure. "It is best to stabilise this cat first," I had read the medical reports and viewed the X-ray. "Was there any antibiotic injection given to the cat? Any fluid therapy? Any urine test? Any fever?" "I don't think so," the gentleman is typical of the increasingly educated and well informed pet owners in Singapore putting vets on their toes as he would have done his internet research on his pet's urolithiasis with one click of the mouse. "Otherwise my bill will have this item charged. Vet 2 did say that the cat was slightly dehydrated." The cat was now furiously hissing and the owner could not handle him. I did not want to provoke this frightened cat further as the cat would go crazy and very aggressive. I asked the owner to hold and talk to him while I gave the Baytril antibiotic injection SC.  I assessed that this cat would not need the fluid therapy as he was drinking and peeing. Only that he was not eating for a few days and the owner had brought him to consult his regular vet (Vet 1). Vet 1 had asked him to return again if the cat had not recovered but Vet 1 closed on Wednesday and so he remembered Vet 2 whom he had consulted before. Vet 2 told him that she was not sufficiently experienced to operate and her senior vet's surgical bookings were full house. So he had to find another vet. He phoned his vet friend who works at the Biopolis. She referred him to me. I don't know this vet friend and so it was a great surprise.    The operation would be done the next day. Weighing the cat, taking the rectal temperature and giving SC drip would be out of question as the cat was quite fed up with Vet 2's blood taking and X-raying. Cats are notoriously difficult to take blood and Vet 2 had managed well. I presumed she X-rayed first, otherwise it would be very difficult to restrain this little tiger. Feb 21, 2013 The main worry was the possibility of death under anaesthesia as this cat was just not fit for surgery based on Vet 2's blood test of a severe kidney disorder. I would say it would be acute nephritis but this cat had no history of vomiting. Would this cat die on the operating table? This was one of those hot potatoes vets prefer not to handle as death may result in bad-mouthing of the vet's incompetence. Who to pass the buck to? I decided to operate myself under such negative conditions of impending death of a cat. Ideally, the cat should wait 3 or more days before surgery. But the owner was much worried and the kidney disorder may worsen to severe vomiting and death owing to delays. The kidney enzymes were exceedingly high. To wait would be risky as a cat in deteriorating health would die anyway.  So, I was holding the hot potato one way or another. To operate or to wait more than one day. What safe anaesthesia to give so that the feline patient is delivered alive to the owner? A surgeon must deliver. A cat alive at the end of surgery. No excuses.
1394. Follow up. Sunday. Cat with bladder stone Before I forget, the Thursday surgery in brief is as follows: ANAESTHESIA 5 kg bodyweight. I gave xylazine 0.2 and ketamine 0.8 ml IM in one syringe. Isoflurane gas top up was necessary for a short while. Rectal temperature was 36.8 C after sedation as the cat was angry and we could not want to antagonise him more. SURGERY to remove bladder stones seen on X-rays taken by Vet 2. 1. Catherise the bladder 2. Withdraw urine for urine analysis 3. Inflate bladder with 40 ml normal saline so that it is palpable. 4. Incise skin and linea alba. 5. Press out the distended bladder. 6. Incise at apex of 8 mm as I know the stone was around this diameter. 7. I insert an artery forceps to grab and take out the stone without making too big a bladder incision. 8. My assistant Min pumps in more normal saline as I closed the wound for a while. 9. 3 small pieces of stones of around 3 mm x 2mm flowed out with the bloody mucus and blood. 10. More irrigation of the bladder. 11. I stitched the mucosa 3/0 absorbable - inverting layer 12. I stitched the serosa similarly - another inverting layer. 13. To check leakage, I asked Min to pump in more saline via the catheter to inflate the bladder. No leakage. 14. I put the bladder back into the abdomen and closed up the linea alba (2/0 absorbable) and skin (2/0 nylon). 14. I put the bladder back. 15. Post-op baytril and tolfedine 16. Cat goes home in the evening as the cat was quite ferocious and nursing at home would be better as the cat would be hand-fed food (K/D) and medication. Blood Test showed high total white cell count. X-ray showed >1bladder stones Friday - Day 1 after surgery. I phoned the cat owner. "Vomiting one hour after food and medication," the owner reported as he had given medication on the evening of the surgery. I advised not giving the tolfedine tablets, just the Baytril tablet from Vet 2 and give honey water by hand. Saturday - Day 2 after surgery Vomiting once. Drinks a lot. Pees a lot. "There could be gastric ulcers due to the high BUN kidney disorders," I said. "That would account for vomiting. Feed less amounts." Sunday Feb 24, 2013 - Day 3 after surgery. 6.23 pm Yishun public library to type this report Communications post-op is most important. The cat owner phoned me twice and left his name and phone number. My receptionist reminded me to phone him after my consultations. I was kept busy with the owners of a cat from an American couple regarding removal of the claws, a rat with nasal swelling on the right and a large skin lump on its back and a rabbit from Woodlands for "spay" from a Malay family who had stated incorrectly the gender. Two big terrapins came yesterday for Dr Jason Teo - one would not eat and the other one had puffy eyes and I had them cleaned and given eye drops and bask in the bright morning sunshine. I had to supervise a new vet technician as Mr Min would be moving on to better future after having worked two years with me, increasing his value to the new employer as an experienced vet technician. Back to the cat with the bladder stones operated 3 days ago. The owner phoned me yesterday and today to provide me feedback and that was important. "My cat did not vomit after eating food. He drank a lot, around 375 ml of water and peed a lot," he said. "He laid on his urine and so his surgical wound is very red." "It is good news that he pees a lot," I said. "This shows that his bladder is normal." I tried not to joke that this showed that his bladder was not leaking after my surgery. "What should I do to the red area of his wound?" the owner asked. "It is very difficult for me to know what you are describing," I said. "Was the cat licking the wound since you did mention about taking off the e-collar?" "No, he is still wearing the e-collar." Since the owner was working, I suggested that he changed the plaster covering the wound and replace with a new square one. "It could be the blood clot from the skin after stitching," I said. Will wait and see. It seems that the cat with the renal impairment based on blood tests taken by Vet 2 on Wednesday (4 days ago) is doing well.  He did not vomit his food. I asked the owner to give 2 cans 6 times/day instead of feeding him one can of the K/D diet yesterday. He has a good maid and with home care, this cat should thrive.
Day 7 after surgery. Feb 27, 2013 - I phoned the busy gentleman owner of the cat with the bladder stones as I was reviewing the past few days' cases. All cases done by associate vets and be me are reviewed by me as much can be learned from cases done. But this takes a lot of time and time is not much when there are many other things to do. "My cat is back to as good as normal," he said that the cat was jumping and his stools and urine were normal. He had told me the day before that the cat drank less. I explained that the cat was fed canned K/D diet and canned food has a lot of water. "Does he eat on his own?" I asked this important question. "He eats a bit and does not mind spoon-feeding by my maid." This was a moment of great joy to know that a surgical patient who was having kidney disease based on blood test by Vet 2 had recovered almost fully. The stitched bladder with a 8-mm cut by me to extract the 8-mm diameter stone must have healed well, otherwise this cat would be dead. Follow ups are much appreciated and great learning lessons for any vet but we seldom have much time to do it. It creates an excellent customer service experience. This owner loves his grandmother as he did bring her to take the cat home the day after surgery. Grandmothers are most loved as they usually spend most time with the grand children while the parents are out working and surviving in the corporate jungle. His grandmother was over 80 years old and her mind was sharp and alert. "Remember the S/D can of food given by Vet 2?" I asked the owner. "It may not be useful as the cat's urinary pH is acidic at pH=5.0. That means that the bladder stones are unlikely to be struvites as S/D is for prevention and dissolution of struvites stones. Most likely, they are calcium oxalate stones but we have to wait for the results of the stone analysis." This info was obtained when I collected urine before opening up the bladder for stone removal. It is important that the vet performs this procedure as it may not be possible to collect urine from an angry non-sedated cat earlier. That could be one reason Vet 2 did not do a urine analysis and just prescribed S/D of one can. It is best to practise evidence-based medicine by doing urine analysis. In this case, there were no crystals in the urine. A 4th year vet student from the top Portugal Vet University was with me and I asked Catarina Mateu : "No crystals in the urine test means no bladder stones. Many vets will come to this conclusion. What about you?" "Yes," she replied. "I also think this way."
UPDATE ON MARCH 1, 2013. Day 9 after surgery I phoned the owner to inform him that stone analysis revealed calcium, oxalate and magnesium in the bladder stone. I advised canned C/D food for at life. But it is relatively expensive compared to the usual canned foods.  He said: "My cat is ok now. Only that he is inactive when he wears the e-collar. When do I come for stitch removal?" "Your cat has never worn e-collars before. Once the skin stitches are removed on this Sunday, your cat will be free of the burden of this collar." UPDATE ON MARCH 5, 2013, Day 13 after surgery The cat's nylon skin stitches were removed by me. The owner said that the cat was withdrawn and quiet when he was wearing the e-collar but would be more active when he was not wearing it. "No need to wear the collar now since I had removed the stitches." UPDATE ON MARCH 10, 2013. Day 18 after surgery The cat with the bladder stone surgery came for stitch removal on Sunday, March 3, 2013. No need to wear e-collar. The owner got 48 cans of C/D for his cat and will buy from the vet near his apartment later.  No further news from the owner.  As for the cat with urethral obstruction, no recurrence and no news from the owner. UPDATE ON MARCH 22, 2013, Day 22 after surgery7.22 am from home, as I review this case to be produced as an educational video. No news or complaint from the owner. No news is good news in the case of the cat with the bladder stones removed. It is good to know that the cat is back to normal. The owner will be buying his feline C/D from Vet 2 as the surgery is across his home. UPDATE ON APRIL 21, 2013. Day 52 after surgeryNo news is good news or phone call from the owner. The owner complies with the medical instruction to feed the cat only C/D and nothing else. I did not phone him as I had much work to do and much time was expended on my "dying" car. My 8-year-old Mercedes E200 had leaked coolant again and had cost me over $6,000 of repairs in the last 2 years and spending time in car workshops.  My mechanic had told me that it would cost $4,000 to repair and there was no guarantee of leakage or other faults as the car was aged. If I de-register it by April 30, 2013, before Feb 2015, I would get a COE rebate of S$33,600. I decided to scrap it. I could sell the body for S$2,000 and a vet friend bought it from me. He would get it repaired in Malaysia. This car reminded me of aged sick dogs that have no cure. Now I rented a Mitsubishi for $1,500 per month and need not bother about installment payments, insurance and repairs.   UPDATE ON APRIL 22, 2013. Day 53 after surgery Whenever I am free, I will be present at around 7-8 pm during weekdays as some of my interesting cases present themselves.  I would ask Dr Daniel to go home since there is no need to have two vets at one time. At 7.45 pm today, Monday April 23, 2013, the gentleman suddenly came in while his mother waited inside the car. He was in his usual rush to buy the feline cans of CD for next 14 days. His cat ate around one can/day and he is now out of stock.   "How's the cat?" I asked. "Back to his naughty self. Scratching everywhere and jumping. He has put on weight. He still has loose skin below his belly." "It is good news." I said. "I discussed your case with Dr Daniel recently comparing the outcome of treatment of a Pomeranian with right perineal hernia of 2-3 months' duration. The Pomeranian had similar very high abnormal kidney disorders based on blood test. He passed away 4 days after surgery. In this case, the owner had waited 2-3 months before seeking veterinary attention and the bladder had herniated and been trapped inside the perineal hernia." "Your cat had a very high Blood Urea Nitrogen (Vet 2's machine could not read values as they were excessive) and creatinine >30+ (normal 0.3 to 2.1). Phosphorus was >20+ (normal 3.4-8.5). Dr Daniel said to me yesterday that this cat could not have survived the surgery! His creatinine level was >15X the higher range of normal! Yet he is fine today." The gentleman was the one who was most worried about the serious kidney disorder and wanted immediate surgery. I had postponed the surgery for one day and given antibiotics to the cat as the other vet did not do so. The cat survived the surgery and is very naughty now, 60 days later. "You can buy the C/D from the other vet near your house," I said as this man complained of distance of my surgery from his home. "You don't need a prescription letter from me. I am sure he will understand as he had treated your cat before. I don't stock up C/D as they expire. Demand is not high. I will fax the prescription to your vet when you need to buy from him. "You are an exceptional owner in that most cat owners could not be bothered with feeding the special food and get recurrence of stones again!" "You advised feeding 3 months of C/D" he said. "If you do regular 3-monthly urine tests," I said. "You may be able to stop feeding feline C/D and give commercial cat food. If not, give canned C/D. The cat is thriving on C/D. Perhaps, you can mix it with dry C/D which is less expensive as one can of C/D costs S$5.00." "It is a miracle," he said. "I prayed for him before surgery." "Yes, it was a miracle as he had a serious kidney disorder and was operated early before he gets chronic kidney failure."