urethrostomy

Re: urethrostomy

Alastair Franklin — Tue, 24 Jul 2012 12:25:08 GMT

[quote user="Evelyn Barbour-Hill"]

If I've got the terminology wrong I'll stand corrected. To me: urethrotomy is making an incision for whatever purpose into the urethra. Urethrostomy is making a new "mouth" for the urethra; which could be a temporary one (to remove stones and to allow all the others in the pipeline to find their way out) or a permanent one ( call it a salvage procedure if you like).

These terms "prescrotal" and "postscrotal" are unfortunate as they have no real anatomic precision. "Before" and "after" the scrotum? One man's pre could be another man's post.

A penile urethrostomy is the place for a temporary one (since the stones lodge at the entrance to the os penis) (and never suture it) and a perineal urethrostomy is the place for a permanent one.

[/quote]

To my understanding, a urethrotomy is a temporary opening in the urethra, whereas a urethrostomy is the creation of a permanent or at least a long term opening / mouth (longer term than that required to close by normal second intention). Therefore, an incision made to remove stones, whether it is closed primarily with sutures or left to heal by second intention, is a urethrotomy.

I agree that there is the potential for confusion with pre/post scrotal, but pre-scrotal is generally accepted as being between the os penis and the scrotum - ie cranial to the scrotum.

The urethrotomy should obviously be made relative to the location of the obstruction - most commmonly this will need to be a pre-scrotal incision. (additionally the urethra is relatively superficial here and there is less corpus cavernosum). These ones can be left open (and bleed over the owners inevitably pristine white carpet for a week or so) or closed with suture. Not aware of any studies that reveal a significant difference in outcome. If its done as a perineal urethrotomy, then they should be closed. Scrotal urethrotomy is rarely required.

On the other hand, if a urethrostomy is desired, then this should ideally be scrotal in dogs (with scrotal ablation), for anatomical reasons (and in particular urine drainage reasons). Cats are fine with a perineal version, and whilst this can be done in dogs, can be messy, with high potential for complications, especially from urine scald.

Re: urethrostomy

Evelyn Barbour-Hill — Tue, 24 Jul 2012 10:32:06 GMT

[quote user="Rajat"]

Ok I am confused... are we talking urethrotomies to remove stones or urethrostomies as salvage procedures for repeated blockages (like in cats)?

[/quote]

These terms "prescrotal" and "postscrotal" are unfortunate as they have no real anatomic precision. "Before" and "after" the scrotum? One man's pre could be another man's post.

A penile urethrostomy is the place for a temporary one (since the stones lodge at the entrance to the os penis) (and never suture it) and a perineal urethrostomy is the place for a permanent one.

Re: urethrostomy

Anthony Todd — Tue, 24 Jul 2012 08:25:19 GMT

[quote user="Rajat"]Ok I am confused[/quote]

Me too, the classic urethrostomy was post-scrotal and pre-os penis surely? And they were done at that site 'cos that's the narrowest part of the urethra where the stones started to be blocked?

And if you removed the obstructing stones, cleared the urethra but didn't stitch the urethra open they invariably healed in a matter of days and blocked with a few remaining stones so you had to do it all again...

And if you didn't cut your sutures close on the urethral side they irritated like hell or trapped passing stones.

And if you didn't make the opening long and well open urine sprayed all over the ventral dog, feet, legs an' all ,and the owner was not well happy.

Re: urethrostomy

Rajat — Mon, 23 Jul 2012 23:09:49 GMT

Ok I am confused... are we talking urethrotomies to remove stones or urethrostomies as salvage procedures for repeated blockages (like in cats)?

Re: urethrostomy

Evelyn Barbour-Hill — Mon, 16 Jul 2012 13:42:22 GMT

"Prescrotal" is what we used to call "penile"....... possibly a more descriptive name? Anyway, never suture it. It seems likely to me that suturing it closed would predispose to "stricture" (which I have never encountered).

Re: urethrostomy

David Mills — Mon, 16 Jul 2012 12:57:16 GMT

There are a number of approaches.

Prescrotal is just proximal to os penis. Scrotal is just behind the scrotum and is generally not used anymore d/t the urethra being thinnest here and hence high chance of stricture. Perineal is higher than the scrotum, closer to the anus.

According to the texts I have available, closure of the urethra can be attempted if visible (i.e. not deeply embedded in corpus cavernous) or can be left to heal by 2y intention. The latter carries a higher theoretical risk of stricture d/t urine leakage around the site causing greater inflammation. I don't know the 'fashion' at the moment, hence discussion - there is very little evidence out there for this sort of thing.

Re: urethrostomy

Martin Atkinson — Mon, 16 Jul 2012 12:44:03 GMT

It seems there may be some confusion in use of terminology here: I assume pre-scrotal means just proximal to the os-penis and scrotal is the same as perineal i.e. you may need to castrate the dog first if not already done? If so I'm with Evelyn, I've never sutured a pre-scrotal urethrostomy they just bleed like stink every time they pee for 2 weeks but I understand this approach is now frowned on due to the risk of stricture formation and we should all be performing scrotal (perineal) urethrostomies.

Re: urethrostomy

Evelyn Barbour-Hill — Mon, 16 Jul 2012 00:07:41 GMT

Have fashions changed?

I have never sutured closed a temporary urethrostomy. It closes by itself, over 2-3 weeks.

Re: urethrostomy

KathW — Sun, 15 Jul 2012 20:07:33 GMT

Must be the time of year for them . I had one last night acutely blocked with a whole line of small stones along the urethra - at the ischual arch/scrotal area. Plus lots in the bladder of varying sizes. Couldnt retropulse either. Did try but not too hard as there were so many stones along the urethra. I did a scrotal urethrostomy to remove the stones in the urethra - got most of them but some were still cranial to the opening. So I did cystotomy at the same time to remove the bladder ones - some were fairly large and then managed to flush down the urethra to dislodge the few that were left. I wasn't happy leaving the bladder ones even for now as some looked fairly large and there were so many stones already lodged along the urethra.

Have been wondering today if I did need to do both ops at once but at the time it seemed the best option as I didn't want to risk any more of the larger stones moving out of the bladder in the next few days and lodging above the urethrostomy site.

Re: urethrostomy

David Mills — Sun, 15 Jul 2012 19:46:27 GMT

Colleague's case so details are a little sparse and I wasn't present but it was a discussion today when I took over care.

Stone wasn't pulsable. Urethra was opened ventrally and stone removed (spiky) next to os penis, closed with 5-0 monocryl and sub cut tissues sutured up. Appears it's now a game of waiting and seeing for a stricture.

Cystotomy was performed at same time as the stones were small and urethra-permissbale. There are a number of different approaches to this, we were just wondering what people's general consensus was, and whether the stricture rate is high enough to make prescrotal urethrostomy a more risky choice.

Re: urethrostomy

Evelyn Barbour-Hill — Sun, 15 Jul 2012 19:17:29 GMT

[quote user="David Mills"]Question was whether this dog would have been better having a temporary abdo cytso tube placed with removal of rest of stones and perineal urethrostomy at a later date [/quote]

I can't see why that would have been better. Because [quote user="David Mills"]urethrostomy is associated with a reasonably good outcome.[/quote] isn't it?

I'm assuming this was a temporary urethrostomy. I can't really see the point of doing a permanent prescrotal one. If you're doing a permanent one, why not put it in the obvious place, perineal?

At some stage in this case I expect the dog will need a cystotomy, but that is not urgent.

It has never occurred to me to leave a catheter in place after a prescrotal urethrostomy. Why would one do that? You want urine flowing through the stoma, surely? Have I missed something?

Re: urethrostomy

Rob Loxley — Sun, 15 Jul 2012 18:45:38 GMT

Was it impossible to retropulse the stones into the bladder and do a cystotomy?

Did you do a temporary or permanent scrotal urethrostomy?

How well do dogs do with perineal vs. prescrotal urethrostomies (I've only done the former in cats and the latter in dogs)?