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JENNIFER LACH APRIL 9 TH, 2014 CLINICAL ADVISOR: DR. MARINA MCCONKEY BASIC SCIENCE ADVISOR: DR. ANTONIA JAMESON JORDAN Bilateral Ectopic Ureters in a 6-month-old.

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Presentation on theme: "JENNIFER LACH APRIL 9 TH, 2014 CLINICAL ADVISOR: DR. MARINA MCCONKEY BASIC SCIENCE ADVISOR: DR. ANTONIA JAMESON JORDAN Bilateral Ectopic Ureters in a 6-month-old."— Presentation transcript:

1 JENNIFER LACH APRIL 9 TH, 2014 CLINICAL ADVISOR: DR. MARINA MCCONKEY BASIC SCIENCE ADVISOR: DR. ANTONIA JAMESON JORDAN Bilateral Ectopic Ureters in a 6-month-old Labrador Retriever

2 The Patient 6 month old intact female Labrador Retriever Referred for persistent urinary incontinence *used with permission

3 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:

4 History Otherwise healthy, up-to-date on vaccines, only medication: Advantage  excellent appetite, and owners report no vomiting/diarrhea/sneezing/coughing *used with permission

5 On presentation Bright, alert and responsive Temperature: 99.5 degrees F Pulse: 116 beats/min Respiration: 28 breaths/min Google Images:

6 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

7 Problem List Urinary Incontinence Cutaneous Plaques Google Images:

8 Differential Diagnoses: Urinary Incontinence Neurologic Non-Neurologic  Functional  Anatomic

9 Normal Urinary Tract Fossum TW. Ectopic Ureter. In: Small Animal Surgery, 3rd ed. St. Louis(MO): Elsevier Health Sciences 2006: Evans HE, de Lahunta A. Figure In: Guide to the Dissection of the Dog, 7th ed. St. Louis(MO): Saunders, Elsevier Inc. 2010:148. kidney ureter bladder

10 Normal Lower Urinary Tract Internal urethral sphincter ureter Bladder Urethra

11 Bladder Filling Internal urethral sphincter ureter Relaxation -inhibition of pelvic nerve (parasympathetic, S1-S3) -stimulation of hypogastric nerve (sympathetic, L1-L4) Bladder

12 Internal urethral sphincter ureter Bladder Filling Contraction -stimulation of hypogastric nerve (sympathetic, L1-L4) Bladder

13 Bladder Filling Internal urethral sphincter ureter Contraction -stimulation of pudendal nerve (somatic; S1-S3) Bladder

14 Differential Diagnoses: Urinary Incontinence Neurologic Non-Neurologic  Functional  Anatomic

15 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

16 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

17 Diagnostics and Results CBC: unremarkable Chemistry Panel: unremarkable Cystocentesis  Urinalysis: urine specific gravity of  Urine Culture: pending Dermatology Consult: DDX: cutaneous inverted papillomavirus, recommended biopsy Focal Urinary Tract Ultrasound

18 Ultrasound dorsal ventral Bilateral, Mild Renal Pyelectasia Bilateral, Questionable Nephropathy Bilateral Ectopic Ureters and Ureteromegaly

19 Diagnosis Bilateral Ectopic Ureters!!

20 Why Urinary Incontinence? Ectopic Ureter: inserts distally to the trigone of the bladder Internal urethral sphincter Ectopic ureter Bladder

21 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

22 Ectopic Ureters Intramural vs Extramural Fossum TW. Ectopic Ureter. In: Small Animal Surgery, 3rd ed. St. Louis(MO): Elsevier Health Sciences 2006:

23 Ectopic Ureters >95% intramural More common in female dogs, median age of diagnosis 6-10 months

24 Treatment Treatment options:  Cystoscopic –guided laser ablation of ectopic ureters (CLA- EU)  Surgery  Medical management Google Images:

25 Cystoscopic-Guided Laser Ablation Figure: Normal view from vestibule, dog in dorsal recumbency ventral dorsal Evans HE, de Lahunta A. Figure In: Guide to the Dissection of the Dog, 7th ed. St. Louis(MO): Saunders, Elsevier Inc. 2010:158.

26 Cystoscopic-Guided Laser Ablation Figure: Endoscopic images of a dog with ectopic ureters in dorsal recumbency dorsal ventral guide wire urethra guide wire bladder lumen diode laser

27 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

28 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

29 Back to Our Patient Owners elected laser ablation therapy if possible Patient admitted into hospital for cystoscopy +/- laser ablation following morning

30 **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

31 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

32 Laser Ablation of PPMD B. Before C. AfterA. Normal Vestibule A: *urethra *1 vaginal opening *2 vaginal openings *1 vaginal opening *urethra*2 ectopic ureters*urethra dorsal ventral

33 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

34 Post-Op Plan Discharged on carprofen and tramadol Recheck with referring veterinarian in 1 week for repeat urine culture and sensitivity

35 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

36 Outcome Nine Months Later: Patient still doing well; occasionally leaks when excited but owners very happy *used with permission

37 Cost Cystoscopy and Laser Ablation Procedure $ Hospitalization and Exam Fees $421 Diagnostics $  CBC $42.56  Chemistry Panel $48.89  Ultrasound $140  Cystocentesis $21  Urinalysis $23.22  Urine Culture $28.14  Skin Biopsy $80.10 Anesthesia $ Medications $ TOTAL BILL: $ Google Images:

38 References Berent AC. Endoscopic Treatment of Ectopic Ureters: Short & Long Term Outcomes Using Cystoscopic-Guided Laser Ablation (CLA-EU). ACVS Vet Symposium Proceedings 2011: 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): Cote E. Cystoscopy. In: Clinical Vet Advisor, 2 nd ed. St. Louis(MO): Mosby Inc, Elsevier 2011: Cote E. Incontinence, Urinary. In: Clinical Vet Advisor, 2 nd ed. St. Louis(MO): Mosby Inc, Elsevier 2011: Cote E. Urethral Sphincter Mechanism Incompetence. In: Clinical Vet Advisor, 2 nd ed. St. Louis(MO): Mosby Inc, Elsevier 2011: Fossum TW. Ectopic Ureter. In: Small Animal Surgery, 3rd ed. St. Louis(MO): Elsevier Health Sciences 2006: Fletcher TF. Applied Anatomy & Physiology of Dog-Cat Lower Urinary Tract. CVM U Minnesota May 2012: Fletcher TF, Weber AF. Veterinary Developmental Anatomy (Veterinary Embryology). CVM : 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: Smith AL, Radlinsky MG, Rawlings CA. Cystoscopic diagnosis and treatment of ectopic ureters in female dogs: 16 cases ( ). J Am Vet Med Assoc 2010; 237(2):

39 References: Images Only Google Images, Accessed Feb 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: Evans HE, de Lahunta A. Figure In: Guide to the Dissection of the Dog, 7th ed. St. Louis(MO): Saunders, Elsevier Inc. 2010:148. Evans HE, de Lahunta A. Figure 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:

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

41 Questions? *used with permission


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