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:
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
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/
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 bladder
Why Urinary Incontinence? Ectopic Ureter: inserts distally to the trigone of the bladder Internal urethral sphincter Ectopic ureter 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% intramural More 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/1029 dorsal ventral guide wire urethra guide wire bladder lumen diode laser
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
**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 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 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 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
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, 2 nd ed. St. Louis(MO): Mosby Inc, Elsevier 2011:1239-1241. Cote E. Incontinence, Urinary. In: Clinical Vet Advisor, 2 nd ed. St. Louis(MO): Mosby Inc, Elsevier 2011:599-601. Cote E. Urethral Sphincter Mechanism Incompetence. In: Clinical Vet Advisor, 2 nd 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.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