Their successful use as temporary cystostomy tubes has been reported in 10 dogs and one cat.9 Reasons for use included urethral trauma in six cases, prostatic. In this course, John Berg, DVM, MS, DACVS, will cover cystotomy surgery in dogs and cats, including: Types/causes of uroliths in dogs and cats; Choice of. Eighty-six (81%) practitioners reported administering peri-operative antimicrobials to dogs undergoing cystotomy, while 82 (77%) used antimicrobials in cats.
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Cystostomy tubes provide a practical method of temporary or permanent urinary diversion for animals with outflow obstruction of the bladder or urethra. Surgical placement of a cystostomy tube is relatively simple and can be performed without specialized instrumentation. Options for cystostomy tubes include Foley catheters, mushroom-tip catheters, percutaneous catheters, and low-profile tubes. Potential complications include leakage of urine around the tube, accidental dislodgment, and ascending urinary tract infection.
Management requires careful handling of the tube and draining the bladder at least three or four times a day, depending on the medical condition of the animal. With good compliance from both the animal and the owner, cystostomy tubes can be maintained successfully for months if necessary. Cystostomy tubes provide a practical method for urinary diversion when more radical surgical procedures are not feasible. In humans, cystostomy tubes are used routinely to bypass urinary outflow obstruction or as an alternative to urethral catheterization.
This article reviews the indications, surgical technique, complications, and management related to use of cystostomy tubes in small animals and discusses the application of new low-profile tube systems that may offer some advantage over conventional cystostomy tubes.
Cystostomy tubes are indicated for urinary diversion in animals with either functional or mechanical obstruction of the bladder or urethra or excessive urine retention. Some fat the most common causes include trauma, calculi, inflammation, neoplasia, and neurologic diseases resulting in detrusor atony or reflex dysnergia. Examples of the former include management of traumatic injuries to the urethra or bladder, postoperative drainage after urethral repair, treatment of transient neurologic dysfunction of the bladder, or management of patients during the interim period while waiting for a response to other treatments such as chemotherapy or radiation therapy.
Cywtotomy use of cystostomy tubes is cta for management of permanent or slowly responsive neurologic conditions of the bladder or as palliative treatment for nonresectable tumors of the bladder or urethra when more radical urinary diversion procedures are not cystotmy. Several different types of tubes are available, cyetotomy Foley catheters, mushroom-tip de Pezzer catheters, and percutaneous catheters; more recently, low-profile gastrostomy tubes have been adapted for use as cystostomy tubes FIGURE 1.
Foley catheters are available in many different sizes and have an inflatable balloon at the tip that helps maintain the tube within the bladder.
Their successful use as temporary cystostomy tubes has been reported in 10 dogs and one cat. The cystostomy tubes were in place ranging from 7 to 14 days. Leakage of urine around the tube was noted in all cases; however, this problem resolved within 4 days, and no intraabdominal leakage occurred.
All cases developed nosocomial bacterial infections; however, the infections were successfully ycstotomy with antibiotics after removal of the tube. The authors concluded that short-term cystostomy with Foley catheters could be performed with few unexpected or serious complications.
However, we have experienced accidental dislodgment because of deflation or deterioration of the balloon. Mushroom-tip catheters have vystotomy more rigid tip, which makes them less likely to become dislodged, and their successful use as permanent or long-term cystostomy tubes has been described in six dogs with transitional cell carcinoma ctstotomy the bladder or urethra.
Median survival time after the cystostomy tubes were placed was days range, 28 to days. Minimal drainage around the tube was reported in all cases.
Urinary tract infection UTI was confirmed in four cases at 2- or 4-week reexaminations but was successfully treated with antibiotics.
Step-by-Step Cystotomy | Clinician’s Brief
Difficulty with draining the tube was reported in two cases because of occlusion by the tumor. All owners were satisfied with the quality of life for their dogs and the ease of tube management. The authors concluded that permanent tube cystostomy is an acceptable treatment for obstructive neoplasia when owners do not wish to pursue more aggressive surgical treatments or do not wish to euthanize their dogs because they are otherwise clinically healthy.
Malecot cystltomy over-the-needle type can be placed percutaneously for temporary diversion. The catheters can be inserted rapidly with ultrasound fat in an animal under sedation. However, because of the mobile nature of the bladder in dogs and cats, care must be taken to ensure that the catheter does not become dislodged or cause leakage of urine into the abdomen. Low-profile tubes were originally designed as gastrostomy tubes but have been adapted for use in the bladder, similar to other conventional tubes.
The cost of low-profile tubes is considerable compared with that of conventional tubes; however, the primary advantage of low-profile tubes is that their design makes them easier to maintain and potentially less likely to be traumatized or accidentally dislodged FIGURE 2.
The exterior button or flange of the tube sits flush with the skin and contains the plug and valve system that seals the tube. The tip of the tube may be mushroom shaped or have a balloon that is inflated like a Foley catheter to maintain it within the lumen of the bladder.
Tubes are available in various diameters 14 to 24 Fr and stem lengths 0. To drain the bladder, the stopper plug cay opened and a separate drainage tube is connected to the catheter, which opens the one-way valve system and allows the bladder to empty.
A low-profile gastrostomy tube system Genie, Bard Endoscopic Technologies, Billerica, MA was used successfully as a cystostomy tube for urinary diversion in two dogs and one cat.
The tubes were in place for 3 weeks and 3 months in the two dogs and for 2 months in the cat. Owners emptied the bladder every 6 to 12 hours by using a separate drainage tube and catheter tip syringe.
Complications included mild leakage of urine around the tube just after surgery in three animals, UTI in one dog and one cat, and leakage of the one-way valve system in one dog. The authors reported positive results with the low-profile tube system and were encouraged to continue its use in selected cases.
Use of Cystostomy Tubes in Small Animals
Before surgery, the animal should be examined while it is in a standing position, and an appropriate site for exiting the tube from the body wall should be identified. When possible, the tube should exit cranial to the flank skinfold and lateral to the ventral midline for easier handling of the tube. catt
Tubes can be placed in the bladder by using either a ventral midline approach chstotomy a “mini” paramedian approach. When a ventral midline approach is used, the tube is placed through a separate incision in the body wall at the previously marked site.
When a mini paramedian approach is used, the incision is made directly over the previously marked site, and the tube is placed through the same incision. Once the abdomen has been entered, the bladder should be identified and stabilized with several stay sutures.
A purse-string suture of synthetic absorbable material should be placed in the ventrolateral aspect of the apex of the bladder wall.
For some animals, the location of the purse-string suture may have to be modified because of the condition of the bladder. For a ventral midline approach, a stab incision should be made in the body wall at the previously marked site on the skin and the tip of the cystostomy tube pulled into the abdomen. Another stab incision should be made through the purse-string suture and the tube placed into the bladder. For a low-profile mushroom-tip tube, a blunt obturator should be used to extend and narrow the tip so that it is easier to place through the body wall and into the bladder FIGURE 4.
If necessary, a second purse-string suture or several inverting sutures can be placed around the tube for an additional seal. When a Foley catheter is used, the balloon should be inflated with the appropriate volume of saline to secure the tube within the bladder.
The tube should be pulled against the body wall, and several sutures of synthetic, absorbable material should be placed between the bladder and the body wall to create a cystopexy.
Cystotomy practices and complications among general small animal practitioners in Ontario, Canada
The tube should be checked for patency and leakage by injecting enough sterile saline to achieve moderate distention of the bladder. The body wall, subcutaneous tissue, and skin are closed in routine fashion.
When a long tube is used, the end of the tube is capped with a Luer-Lock adapter or three-way stopcock and the tube is secured to the skin with a finger-trap suture or flange fashioned from additional tubing material FIGURE 5.
If necessary, a light bandage can be placed around the exit site to protect it until healthy granulation tissue has formed at the stoma. Complications involving cystostomy tubes include surgery-related problems such as urine leakage, wound infection, or dehiscence; problems with the tube itself such as irritation at the stoma site, obstruction, or accidental dislodgment; and problems related to ascending infection due to the presence of the tube.
Placing an additional purse-string suture or inverting sutures around the tube help reduce the risk of leakage should the bladder become overdistended before a secure adhesion has developed. Creating a secure fixation between the bladder and body wall should also help reduce the risk of urine leakage into the abdomen if the tube is accidentally dislodged.
Irritation at the stoma site can be minimized by keeping the stoma clean and protecting the surrounding skin with petroleum jelly or an antibiotic ointment. Unnecessary motion or traction on the tube should also be avoided by properly securing the tube to the body.
For most animals, irritation of the stoma is self-limiting and improves as the site matures.
Cystotomy practices and complications among general small animal practitioners in Ontario, Canada
Accidental tube dislodgment or damage may occur for many different reasons, including biting or chewing on the cystoomy, stepping on the tube or snagging it on various objects, and deterioration of the tube because of prolonged usage.
Most of these difficulties can be prevented by ensuring that the tube is handled carefully and remains covered when not cystotmy use. Low-profile tubes offer an advantage over longer conventional tubes because they do not protrude as far from the body and are potentially less likely to become dislodged.
Ascending UTIs are an inevitable complication of cystostomy tubes. The consequences of chronic or recurrent infections should be considered before the tube is placed, and the owners should be made aware of the potential difficulties of managing catheter-related UTI.
Owners should be instructed to empty the bladder at least three or four times a day to prevent overdistention of the bladder and stagnation of urine. The cystostomy tube should be kept as clean as possible, and owners should wear examination-type gloves when cysttomy the tube to protect themselves and minimize contamination of the tube. The stoma site should also be monitored cag and cleaned as necessary to prevent local irritation or infection. A long cystostomy tube should be secured with a light bandage, jacket, or T-shirt to prevent accidental dislodgment.
Also, the animal’s temperament may require that an Elizabethan collar or neck fystotomy be worn to prevent tube damage. Because of the risk of ascending infection, animals should be monitored carefully for such signs as fever, abdominal pain, hematuria, pyuria, or discharge from the stoma site urethra. However, some of these signs may develop due to the underlying disease process or the presence of the tube and may not necessarily be an indication of infection. When infection is suspected, urinalysis and aerobic bacterial culture and sensitivity should be conducted to detect the presence of bacteria and to direct appropriate antibiotic treatment.
The urine sample should be obtained via sterile technique; however, with neoplastic conditions such as transitional cell carcinoma, cystocentesis in the area of the tumor should be avoided to cywtotomy the chance of seeding the abdomen during sampling. Ctstotomy use of systemic antibiotics in an animal with an indwelling urinary catheter cystotpmy controversial because of concerns about development ccat drug-resistant bacteria. After removal of the tube, a urinalysis and culture and sensitivity should be conducted to determine whether an infection has developed and to direct appropriate antibiotic therapy, if necessary.
For animals with cystostomy tubes in place for longer periods, it becomes much more difficult to determine when antibiotic treatment is appropriate because routine urine samples will inevitably reveal bacteriuria. As a rule, infections should be treated only when accompanied by significant clinical signs; however, the decision to fystotomy an animal should be based on multiple factors such as the severity of clinical signs, the anticipated length of time the tube will be in place, the species vystotomy bacteria and degree of antibiotic resistance, the presence of pyelonephritis or preexisting renal disease, the presence of other systemic problems, and the type and cystootomy of the underlying disease process.
Animals that xystotomy clinical signs of chronic infection should have a complete blood count and serum biochemistry profile evaluated periodically to identify renal insufficiency or other systemic problems. Accidental dislodgment of the tube is a potential complication with any animal. Whether a tube can be replaced through the same stoma depends on the size and condition of the stoma, the length of time that the tube has been out, and the size of the replacement tube.
Dislodged tubes should be replaced promptly because granulation tissue that forms within the stoma may make it difficult or impossible to replace the tube after 48 hours.
If the original tube had been in place long enough to establish a mature stoma, a new tube of similar or slightly smaller size may be placed through the same stoma. Replacing the tube should be done under sterile conditions with the animal sedated or anesthetized. The stoma should be carefully probed to identify the direction of the tract and, if necessary, gently dilated with a hemostat.
A cyxtotomy or blunt obturator can be used, if needed, to make a tube more rigid and easier to pass. The tube is then cystofomy inserted into the bladder taking care to avoid disruption of the adhesion. After the tube is replaced, the animal should be observed for signs of urine leakage and peritonitis and the stoma site should be monitored and cleaned.
If necessary, correct placement of the tube can be confirmed by injecting an aqueous contrast medium through the tube and obtaining a lateral abdominal radiograph. When a tube cannot be replaced through the same stoma or when the original tube has been in place for such a short time less cystotpmy 7 to 10 days that the adhesion between the bladder and cjstotomy wall has not fully developed, a surgical approach should be used to replace the tube.
Cystostomy tubes should remain in place for at least 14 days before removal to ensure an adequate adhesion between the bladder and body wall and cystogomy reduce the possibility of urine leakage or peritonitis. Tubes can usually be removed without the need for general anesthesia. For a Foley catheter, the balloon should be deflated and the catheter can easily be removed from the bladder.