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      Date:   08 June, 2010  
Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits.

Toa Payoh Vets Clinical Research
Making veterinary surgery alive
to a veterinary student studying in Australia
using real case studies and pictures

 
A mother asked me to mentor a  young veterinarian
on his first cystotomy
toapayohvets.com 
Be Kind To Pets
Veterinary Education
Project 2010-0129
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
First recorded: Friday August 17, 2007
Updated: Saturday August 9, 2008 (National Day, Singapore).
Updated:  08 June, 2010


"The catheter just could not be pulled out," Vet 1 said at the end of the bladder stone removal surgery in August 2007. I had stopped the gas anaesthesia so that the 3-year-old male Miniature Schnauzer would wake up at the last stitch.

"How can that happen?" I could not believe this unprecedented situation. "In all my past bladder surgery cases, the catheter just slips out too easily from the bladder and urethra when I pull it from the penile tip."

The dog winced in a painful reflex as Vet 1 pulled the catheter again. The catheter was stuck. More accurately, it was as if another being was sucking it into the bladder instead. A tug-of-war with a spirit if you are the superstitious type.  What should I do? I was the mentor for Vet 1 whose mother, an ex-colleague of mine in the government veterinary service some 20 years ago had requested me to help her son in veterinary surgery. This strange occurrence of a catheter being firmly anchored inside the urethra and bladder was never encountered by me.

"I don't think I had stitched the catheter to the bladder," Vet 1 said. 

"No," I said. "I saw you stitching up the bladder wall after removal of the stones. In any case, the catheter is thick and it is not so easily stitched up by mistake." The catheter made up of a thick translucent material of around 2mm. It takes much resistance to put a needle into it if the vet wants to stitch it to the bladder or skin.

Still there was this problem. I could not pass the buck further as I was the mentor.

What happened? Why? As if there was something pulling the catheter back into the bladder. It was like a vacuum suction if you have ever felt the suction force when vacuuming the carpet. 

The catheter was elastic. But it could only come out 1/4 of its length from the penile tip.

What to do now?

"Push the catheter back into the bladder," I advised.

Vet 1 did it and pulled again. It was still stuck.

What could be done? There was a problem. I normally don't advise leaving the catheter inside the bladder after urinary stone removal. Some vets prefer leaving it inside the bladder for 1 week to relieve the healing bladder of the pressure of urine accumulating inside. The catheter would be stitched to the skin around the penile area and then taped for 7 days (see some pictures of my previous urinary stone cases). In this way, any urine produced would just leak out, relieving pressure on the newly stitched bladder. 

"Think hard", my mind raced to think of how to solve this problem?

I went back to the basics of veterinary anatomy and physiology. Could the bladder sphincter be in spasm since the dog was awake now and could feel some pain.  A painful muscular spasm clamped the catheter very tightly. Such that the catheter could not be pulled out. What to do to resolve this problem?

"OK, I will give the dog a higher dosage of isoflurane anaesthesia gas again," I said to Vet 1. 

A bit of history as to how I got involved in this case. Vet 1's receptionist had a Miniature Schnauzer which was passing blood. Vet 1 then referred the young girl to Vet 2, a competitor of Vet 1 and myself as he had no X-ray machine. Vet 2 diagnosed urinary stones. However, Vet 2 would not permit the young girl to take the X-rays to be shown to Vet 1. Ironically, Vet 1's mother who is the founder of a veterinary practice and a practising vet had referred numerous cases over the 20 years to Vet 2's practice. To me, it seemed that it was a one-way street as Vet 2 knew how to take but not how to reciprocate as evident in this case.  

As part of community education and sharing, I try to help young vets who request help whenever possible.

Vet 1's mother had requested my help to mentor her son when necessary. He had not done bladder stone surgery before and was grateful for my assistance.     

"You are unable to get the X-rays for your receptionist" I shook my head at the mean behaviour of Vet 2. I mean, Vet 2's practice gets thousands of feeder cases from Vet 1's mother. And when there is a need to reciprocate, Vet 2 held his ground by retaining the X-rays which had been paid for by the girl.

Wake up to the real world. "X-rays are not necessary since Vet 2 is an experienced veterinarian and would have made an accurate  diagnosis." To confirm the presence of urinary bladder stones inside the bladder, I put the dog on the examination table and palpated the bladder using my left hand. I could hear the crunching sounds of small stones rubbing against each other. This is called crepitus in medical language. The gas inside the bladder vibrated against my fingers. Yes, there were bladder stones. No X-rays were necessary in the first place if the vet is experienced enough in palpation of the bladder and abdomen. The feeling of crepitus inside the is an excellent clue.  

For some small surgeries, it is actually not worth investing in an X-ray machine as there are usually less than 1 X-ray per month. They refer X-rays to the bigger practice and lose clientele to the big boys. Some of the veterinary technicians in such bigger practice would say to the client: "We are well equipped. That practice can't even afford an X-ray. So, come to my place."  

In this case, it was Vet 2's unprofessional behaviour that angered me. If I were Vet 2, I would be most pleased to let the competition use my X-ray services. I would sincerely offer all the small surgeries my X-ray facilities. Why?

My competitors had no choice but to advertise that I have the equipment and confidence in me. I generate good will. I catch the attention of the competitor's clientele and possibly their patronage. Well, if not all, at least some of the clientele would come to me due to their visit to my practice for X-rays. At least, I had their attention and their recall of my practice's name.

Financially, I could recover the investment faster and generate a new source of income. I will buy newer X-ray equipment to be one up the competition who has X-ray machines. 

Increase my bottom line and create market awareness. Sustain the growth of my practice. And that is what business is all about.

By referring her clients to me to X-ray the dog and major surgeries, Vet 1's mother   is at a grave disadvantage of losing her clientele. She has had created market awareness of Vet 2's well equipped practice without Vet 2 having to spend money to advertise...So much to gain, nothing to lose... Yet Vet 2 hoarded the X-ray of this young girl so that she would have to go to him for surgery. I just could not  believe this was happening.   

I am sorry to have digressed. Back to the problem of the stuck catheter. After less than 2 minutes of inhaling the gas anaesthesia, Vet 1 pulled out the catheter easily.

As to the cause of this problem, it could be that I had sucked out the residual saline and stones using a 20-ml syringe. This suction could have created a vacuum preventing release of the catheter.

Most likely it was muscular spasm of the bladder sphincter gripping the catheter. In any case, the resolution of the problem was satisfying. 

MANAGEMENT OF THIS UROLITHIASIS CASE

1. 10 days of antibiotics prior to surgery to kill all the bacteria inside the bladder.

2. X-rays to be done if necessary.

3. Although X-rays were not given, I could feel crepitus (gas) inside the bladder and a solid lump of around 1 cm in diameter.

4. Temperature 38.4C before surgery meant that the dog had no fever. Dog was eating and behaving normally. Blood tests preferred but not done to decrease the veterinary cost for the young girl.  

5. "No blood in the urine," the young girl had said after the dog had been given 10 days of antibiotics.  When I put the catheter into the bladder, bloody urine flowed out of the bladder.

6. Vet 1 was apprehensive about the penis being in the way of the access to the bladder. How to incise the skin to get to the midline linea alba? I pulled away the penis while he incised the skin beside the prepuce/penis. He separated the fascia and looked for the linea alba.

7. "Feel the pelvic rim", I said. "Make more than 10 cm length in your incision. Otherwise it will be difficult to get the bladder out."  Vet 1 did not encounter any bleeding in the fascia. He was careful and proceeded slowly. Where was the bladder after incising the linea alba and opening up the abdomen? The bladder had shrunk due to the release of the urine when I used the catheter to release residual urine inside the bladder. 

8. I pumped 20 ml of Hartmann's solution into the bladder. He could get the bladder popped out. It was inflamed badly.

9. Vet 1 incised 1 cm of the ventral aspect of the bladder where there were no large blood vessels seen. The Hartmann's solution flushed out into a bowl. Only a small piece of stone was flushed out.

10. "Use artery forceps to feel 360 degrees inside bladder", I said. Vet 1 encountered crunchy sounds at 2 sides - the apex and near sphincter of the bladder. He gripped many pieces of spiky stones from inside the bladder. 

11. "Clamp the bladder incision with forceps," I said. "I will pump 20 ml of Hartmann's solution via the catheter now".

12. Vet 1 unclamped the forceps. Residual stones were flushed out with the solution into bowl. I repeated the procedure till there were no stones flushed out.

13. One more step would be to insert the catheter from the bladder into the urethra. Pump Hartmann's solution several times to flush out the small stones inside the length of the urethra. 

14. The bladder incision was sutured. I advised the  Lambert and Cushing.

15. I pump 20 ml of Hartmann's solution into the  bladder via the catheter from the penile opening to the bladder. The bladder distended. "No leakage," I commented. "Your suture is excellent."

"That's cool," the Vet 1 said. The skin was sutured. The whole process took around 2 hours, twice as long. Mentoring will always take time. There were numerous small urinary stones but the spiky one was prominent and interesting.  Vet 1 sent the stones for analysis of its composition.

Miniature Schnauzer. Struvite urinary stones. Crepitus in bladder.  Haematuria. Toa Payoh Vets. tpvets_logo.jpg (2726 bytes)
822. The skin to the side of the penis/prepuce has been incised to access the bladder. This is the traditional surgical approach to cystotomy. The other approach is to incise the skin cranial to the prepuce (see my other cases). This is not mentioned in the veterinary text books but it is possible to do it. It looks less traumatic to the owner?  
UPDATE AS AT AUGUST 9, 2008 (National Day, Singapore)

Vet 1 told me that the stones were struvite on analysis. His receptionist was advised to give home-cooked food and never to give dry dog food. 

The receptionist had gone to study at the University. She was quite happy to see me one day when I dropped by to visit Vet 1's mother at the surgery. A  reticent slim fair Chinese lady in her early twenties, she was working temporarily in the Surgery.  I wished she could say hello to me but she was the girl of few words. A girl of no words.  

There was no complaint of difficulty of passing urine or blood in the urine for the past year. How fast time flies. I presume that the dog had no recurrence, otherwise Vet 1 would have told me. However I seldom see him even once a month. His mum does present me moon-cakes at my surgery during moon-cake festival once a year. I would have to go and buy some moon-cakes and bring them to her surgery to reciprocate. The beneficiary would be the maker of moon-cakes. Vet 1's mother represent the best in motherhood as she opens the paths to get help for her son's professional growth and development by making an effort to network with me and others.   

UPDATE AS AT JUNE 7, 2010
No recurrence of urinary stones despite being fed dry dog food for the past 3 years. Miniature Schnauzers are one breed predisposed to urinary stone formation and so I was surprised that nothing had happened. Veterinary medicine and surgery is always full of surprises to the practising vet.

See my review of this case at: A Veterinary Receptionist Worth Her Weight In Gold - Circum-anal tumours in the dog


Some employed younger vets in a big practice feel arrogant when cases are referred to them in my experience. It is as if they are not hungry and want less shit on their doorstep. The good news in 2010 is that Vet 2's practice vets do release X-rays to clients who want them to seek a second opinion. The interest of the dog or pet must come first. Ideally, a vet must uphold integrity and high professional standards in the practice of veterinary medicine and surgery. This is easier said than done.    

 

To make an appointment: e-mail judy@toapayohvets.com
tel: +65 9668-6469, 6254-3326

toapayohvets.com 
Be Kind To Pets
Veterinary Education
Project 2010-0129
tpvets_logo.jpg (2726 bytes)Toa Payoh Vets
Clinical Research
 

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