JENNIFER LACH APRIL 9 TH, 2014 CLINICAL ADVISOR: DR. MARINA MCCONKEY BASIC SCIENCE ADVISOR: DR....
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Transcript of JENNIFER LACH APRIL 9 TH, 2014 CLINICAL ADVISOR: DR. MARINA MCCONKEY BASIC SCIENCE ADVISOR: DR....
JENNIFER LACHAPRIL 9 T H , 2014
CLINICAL ADVISOR: DR. MARINA MCCONKEY
BASIC SCIENCE ADVISOR: DR. ANTONIA JAMESON JORDAN
Bilateral Ectopic Ureters in a 6-month-old Labrador
Retriever
The Patient
6 month old intact female Labrador RetrieverReferred 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 responsiveTemperature: 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 IncontinenceCutaneous Plaques
Google Images: http://daytonanimallady.blogspot.com/
Differential Diagnoses: Urinary Incontinence
Neurologic
Non-Neurologic Functional Anatomic
Normal Urinary Tract
Fossum TW. Ectopic Ureter. In: Small Animal Surgery, 3rd ed. St. Louis(MO): Elsevier Health Sciences 2006:646-654.
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.
kidney
ureter
ureter
bladder
Normal Lower Urinary Tract
Internal urethral sphincter
ureter
http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf
Bladder
Urethra
Bladder Filling
Internal urethral sphincter
ureter
Relaxation-inhibition of pelvic nerve (parasympathetic, S1-S3)-stimulation of hypogastric nerve (sympathetic, L1-L4)
http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf
Bladder
Internal urethral sphincter
ureter
Bladder Filling
Contraction-stimulation of hypogastric nerve (sympathetic, L1-L4)
http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf
Bladder
Bladder Filling
Internal urethral sphincter
ureter
Contraction-stimulation of pudendal nerve (somatic; S1-S3)
http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf
Bladder
Differential Diagnoses: Urinary Incontinence
Neurologic
Non-NeurologicFunctionalAnatomic
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
FunctionalUrethral Sphincter Mechanism Incompetence Congenital Hormonal
Inflammation/Infection
AnatomicCongenital: ectopic ureter, ureterocele, persistent
paramesonephric duct remnant, etc. Acquired: stones, neoplasia
Diagnostics and Results
CBC: unremarkableChemistry Panel: unremarkableCystocentesis
Urinalysis: urine specific gravity of 1.007 Urine Culture: pending
Dermatology Consult:DDX: cutaneous inverted papillomavirus, recommended
biopsy
Focal Urinary Tract Ultrasound
Ultrasound
dorsal
dorsal
ventral
ventral
Bilateral, Mild Renal PyelectasiaBilateral, Questionable Nephropathy
Bilateral Ectopic Ureters and Ureteromegaly
Diagnosis
Bilateral Ectopic Ureters!!
Why Urinary Incontinence?
Ectopic Ureter: inserts distally to the trigone of the bladder
Internal urethral sphincter
Ectopicureter
http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf
Bladder
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% intramuralMore common in female dogs, median age of
diagnosis 6-10 months
Treatment
Treatment options: Cystoscopic –guided laser ablation of ectopic ureters
(CLA-EU) Surgery Medical management
Google Images: http://denverchiropractor.com/
Cystoscopic-Guided Laser Ablation
Figure: Normal view from vestibule, dog in dorsal recumbency
http://www.gsvs.org/articles/article.asp?id=40
ventral
dorsal
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.
Cystoscopic-Guided Laser Ablation
Figure: Endoscopic images of a dog with ectopic ureters in dorsal recumbency
http://www.amcny.org/node/1029dorsal
ventral
guide wire
urethra
guide wireguide wire
bladder lumen
diode laser
Why Cystoscopic-Guided Laser Ablation?
Similar success rate to surgeryEliminates need for abdominal surgery and
its risksRisks 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
**Insert image of patient’s vestibule
*urethra
*left ectopic ureter
Cystoscopic-Guided Laser Ablation
Patient was anesthetized, clipped and prepped for cystoscopy
Cystoscope was passed retrograde through the vulva and vestibule At this point (in
vestibule) instead of two openings, saw five openings *scope in right
ectopic ureter
*PPMD
dorsal
ventral
Cystoscopic-Guided Laser Ablation
Both ureters were intramuralProcedure performed as previously
described Laser pulsations used to break down membranes
between both ectopic ureters and the urethra to the level of the bladder neckdorsal
ventral
Laser Ablation of PPMD
B. Before
C. AfterA. Normal Vestibule
A: http://www.gsvs.org/articles/article.asp?id=40
*urethra
*1 vaginal opening
*2 vaginal openings
*1 vaginal opening
*urethra *2 ectopic ureters *urethra
dorsal
ventral
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 tramadolRecheck 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 $444.80Hospitalization and Exam Fees $421Diagnostics $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 $300.44Medications $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 2011:392-395.
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 permissionBerent 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 ownersAdvisors, Drs. McConkey and Jameson JordanSupport network – friends, familyClass of 2014!
*used with permission
Questions?
*used with permission