Lach-Jennifer ppt 2014 Final Bilateral Ectopic Ureters

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