Lach-Jennifer ppt 2014 Final Bilateral Ectopic Ureters

Report
Bilateral Ectopic Ureters in a
6-month-old Labrador
Retriever
JENNIFER LACH
A P R I L 9 TH, 2 0 1 4
CLINICAL ADVISOR: DR. MARINA MCCONKEY
BASIC SCIENCE ADVISOR: DR. ANTONIA
JAMESON JORDAN
The Patient
 6 month old intact female Labrador Retriever
 Referred for persistent urinary incontinence
*used with permission
Past Medical History
 Leaking urine since acquired at age 2 months
 Day and night
 Urine culture at referring veterinarian: urinary tract
infection (UTI); treated with 6-week course of cefpodoxime,
then ciprofloxacin
 Resolution of infection, but no resolution of clinical signs
Google Images: http://www.greatdogsite.com/
History
 Otherwise healthy, up-to-date on vaccines, only
medication: Advantage

excellent appetite, and owners report no
vomiting/diarrhea/sneezing/coughing
*used with permission
On presentation
 Bright, alert and responsive
 Temperature: 99.5 degrees F
 Pulse: 116 beats/min
 Respiration: 28 breaths/min
Google Images: http://hdwallpaperia.com/
Physical Exam: Abnormalities
 Genitourinary:
 Urine-soaked hindquarters
 Dribbled urine around exam room
 Integument:
 Vulvar and caudal abdominal skin: multiple pink plaques- flat
and cup shaped
 Rest of physical exam was unremarkable
Problem List
 Urinary Incontinence
 Cutaneous Plaques
Google Images: http://daytonanimallady.blogspot.com/
Differential Diagnoses: Urinary Incontinence
 Neurologic
 Non-Neurologic


Functional
Anatomic
Normal Urinary Tract
bladder
kidney
ureter
ureter
Evans HE, de Lahunta A. Figure 4-12. In: Guide to the Dissection of the Dog,
7th ed. St. Louis(MO): Saunders, Elsevier Inc. 2010:148.
Fossum TW. Ectopic Ureter. In: Small Animal Surgery, 3rd ed. St.
Louis(MO): Elsevier Health Sciences 2006:646-654.
Normal Lower Urinary Tract
ureter
Urethra
Bladder
Internal urethral sphincter
http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf
Bladder Filling
ureter
Bladder
Relaxation
-inhibition of pelvic nerve
(parasympathetic, S1-S3)
-stimulation of hypogastric nerve
(sympathetic, L1-L4)
Internal urethral
sphincter
http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf
Bladder Filling
ureter
Bladder
Internal urethral
sphincter
Contraction
-stimulation of hypogastric
nerve (sympathetic, L1-L4)
http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf
Bladder Filling
ureter
Bladder
Internal urethral
sphincter
Contraction
-stimulation of pudendal
nerve (somatic; S1-S3)
http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf
Differential Diagnoses: Urinary Incontinence
 Neurologic
Non-Neurologic
 Functional
 Anatomic
Differential Diagnoses: Urinary Incontinence
 Functional
 Urethral Sphincter Mechanism Incompetence
Congenital
 Hormonal


Inflammation/Infection
 Anatomic
Congenital: ectopic ureter, ureterocele, persistent
paramesonephric duct remnant, etc.
 Acquired: stones, neoplasia

Differential Diagnoses: Urinary Incontinence
 Functional
 Urethral
Sphincter Mechanism
Incompetence
Congenital
Hormonal
Inflammation/Infection


 Anatomic
 Congenital: ectopic ureter, ureterocele, persistent

paramesonephric duct remnant, etc.
Acquired: stones, neoplasia
Diagnostics and Results
 CBC: unremarkable
 Chemistry Panel: unremarkable
 Cystocentesis
 Urinalysis: urine specific gravity of 1.007
 Urine Culture: pending
 Dermatology Consult:
 DDX: cutaneous inverted papillomavirus, recommended biopsy
 Focal Urinary Tract Ultrasound
ventral
Ultrasound
Bilateral Ectopic Ureters and
Ureteromegaly
ventral
dorsal
Bilateral, Mild Renal Pyelectasia
Bilateral, Questionable Nephropathy
dorsal
Diagnosis
Bilateral Ectopic Ureters!!
Why Urinary Incontinence?
 Ectopic Ureter: inserts distally to the trigone of the
bladder
Ectopic
ureter
Bladder
Internal urethral sphincter
http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf
Abnormal Embryologic Development
 Bladder and urethra arise
from urogenital sinus
 Ureters develop from
ureteral bud (metanephric
diverticulum) off
mesonephric duct
 Urogenital sinus enlarges,
ureters migrate caudally
→ ureter incorporated
into sinus wall → Trigone
 Caudal migration of
ureter → Ectopic ureter
http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf
Ectopic Ureters
 Intramural vs
Extramural
Fossum TW. Ectopic Ureter. In: Small Animal Surgery, 3rd ed.
St. Louis(MO): Elsevier Health Sciences 2006:646-654.
Ectopic Ureters
 >95% intramural
 More common in female dogs, median age of
diagnosis 6-10 months
Treatment
 Treatment options:
 Cystoscopic –guided laser ablation of ectopic ureters (CLAEU)
 Surgery
 Medical management
Google Images: http://denverchiropractor.com/
Cystoscopic-Guided Laser Ablation
ventral
Figure: Normal view from vestibule,
dog in dorsal recumbency
Evans HE, de Lahunta A. Figure 4-24. In: Guide to the Dissection of the Dog,
7th ed. St. Louis(MO): Saunders, Elsevier Inc. 2010:158.
dorsal
http://www.gsvs.org/articles/article.asp?id=40
Cystoscopic-Guided Laser Ablation
ventral
Figure: Endoscopic
images of a dog with
ectopic ureters in
dorsal recumbency
urethra
guide wire
bladder lumen
guide wire
guide wire
diode laser
dorsal
http://www.amcny.org/node/1029
Why Cystoscopic-Guided Laser Ablation?
 Similar success rate to surgery
 Eliminates need for abdominal surgery and its risks
 Risks of procedure: anesthesia, UTI, perforation of
bladder/urethra/ureter, iatrogenic stricture
formation, bleeding
 Limits of procedure: intramural only; specialized
equipment, steep learning curve
Prognosis
 Guarded-poor prognosis
 25-58% success rate with surgery or CLA-EU
 Success: partial or complete resolution of urinary incontinence
 Half of patients that don’t respond to surgery, may respond to
medical management
Back to Our Patient
 Owners elected laser ablation therapy if possible
 Patient admitted into hospital for cystoscopy +/-
laser ablation following morning
Cystoscopic-Guided Laser Ablation
dorsal
 Patient was
*left ectopic ureter
anesthetized, clipped
and prepped for
cystoscopy
 Cystoscope was passed
retrograde through the
vulva and vestibule

*PPMD
**Insert image of patient’s
vestibule
At this point (in
vestibule) instead of two
openings, saw five
openings
*urethra
*scope in right
ectopic ureter
ventral
Cystoscopic-Guided Laser Ablation
 Both ureters were intramural
 Procedure performed as previously described
 Laser pulsations used to break down membranes between
both ectopic ureters and the urethra to the level of the
bladder neck
dorsal
ventral
Laser Ablation of PPMD
dorsal
*2 vaginal
openings
*1 vaginal
opening
*urethra
*urethra
A. Normal Vestibule
*2 ectopic ureters
B. Before
*1 vaginal
opening
*urethra
C. After
ventral
A: http://www.gsvs.org/articles/article.asp?id=40
Last but not least..
 Three of the perivulvar plaques were biopsied with a
6mm punch biopsy and submitted for histopathology
 Patient recovered uneventfully from anesthesia.
*used with permission
Post-Op Plan
 Discharged on carprofen and tramadol
 Recheck with referring veterinarian in 1 week for
repeat urine culture and sensitivity
Outcome
 3 days post-op continent!
 Urine culture negative
 Dilute urine: incidental or early kidney dysfunction?
 Recommended regular monitoring of urinalysis, blood urea nitrogen,
creatinine
 Histopathology of Skin Plaques: Moderate, multifocal,
lichenoid lymphoplasmacytic interface dermatitis


most consistent with contact dermatitis secondary to chronic urinary
incontinence
Immunohistochemical stains for papillomavirus were negative
Outcome
 Nine Months Later: Patient still doing well;
occasionally leaks when excited but owners very
happy
*used with permission
Cost
 Cystoscopy and Laser Ablation Procedure $444.80
 Hospitalization and Exam Fees $421
 Diagnostics $383.91
 CBC $42.56
 Chemistry Panel $48.89
 Ultrasound $140
 Cystocentesis $21
 Urinalysis $23.22
 Urine Culture $28.14
 Skin Biopsy $80.10
 Anesthesia $300.44
 Medications $72.72
------------------------------------------------------------------------ TOTAL BILL: $1622.87
Google Images: http://amarillocollege.info/
References











Berent AC. Endoscopic Treatment of Ectopic Ureters: Short & Long Term Outcomes Using
Cystoscopic-Guided Laser Ablation (CLA-EU). ACVS Vet Symposium Proceedings 2011:392395.
Berent AC, Weisse C, Mayhew PD, et al. Evaluation of cystoscopic-guided laser ablation of
intramural ectopic ureters in female dogs. J Am Vet Med Assoc 2012;240(6):716-725.
Cote E. Cystoscopy. In: Clinical Vet Advisor, 2nd ed. St. Louis(MO): Mosby Inc, Elsevier
2011:1239-1241.
Cote E. Incontinence, Urinary. In: Clinical Vet Advisor, 2nd ed. St. Louis(MO): Mosby Inc,
Elsevier 2011:599-601.
Cote E. Urethral Sphincter Mechanism Incompetence. In: Clinical Vet Advisor, 2nd ed. St.
Louis(MO): Mosby Inc, Elsevier 2011:1134-1135.
Fossum TW. Ectopic Ureter. In: Small Animal Surgery, 3rd ed. St. Louis(MO): Elsevier Health
Sciences 2006:646-654.
Fletcher TF. Applied Anatomy & Physiology of Dog-Cat Lower Urinary Tract. CVM U
Minnesota May 2012: http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf.
Fletcher TF, Weber AF. Veterinary Developmental Anatomy (Veterinary Embryology). CVM
6903 2013:41-48. http://vanat.cvm.umn.edu/vanatpdf/EmbryoLectNotes.pdf.
Full A. Neurology and Neuropharmacology of Urination. VTMED 5510 Fall 2012:1-7.
Reichler IM, Specker CE, Hubler M, Boos A, et al. Ectopic Ureters in Dogs: Clinical Features,
Surgical Techniques and Outcome. Vet Surg 2012;41:515-522.
Smith AL, Radlinsky MG, Rawlings CA. Cystoscopic diagnosis and treatment of ectopic ureters
in female dogs: 16 cases (2005-2008). J Am Vet Med Assoc 2010; 237(2):191-195.
References: Images Only
 Google Images, Accessed Feb 2014.
 Patient’s owners, used with permission
 Berent AC, Weisse C. Figure 1 and 3. In: Case Study:
Cystoscopic-guided Laser Ablation for Ectopic Ureters.
Accessed Feb 2014: http://www.amcny.org/node/1029.
 Evans HE, de Lahunta A. Figure 4-12. In: Guide to the
Dissection of the Dog, 7th ed. St. Louis(MO): Saunders,
Elsevier Inc. 2010:148.
 Evans HE, de Lahunta A. Figure 4-24. In: Guide to the
Dissection of the Dog, 7th ed. St. Louis(MO): Saunders,
Elsevier Inc. 2010:158.
 Henderson A. Figure 1. Normal View from Vestibule. In:
Advances in Veterinary Cystoscopy. Feb 2007:
http://www.gsvs.org/articles/article.asp?id=40.
Thank You to:
 My patient and her owners
 Advisors, Drs. McConkey and Jameson Jordan
 Support network – friends, family
 Class of 2014!
*used with permission
Questions?
*used with permission

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