First recorded: Friday August 17, 2007
9.30 am - 12 noon
Updated: Saturday August 9, 2008 (National Day, Singapore).

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

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

The dog winced in reflex as Vet 1 pulled the catheter again. The catheter was stuck. What should I do? I was the mentor. This was unprecedented.

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

"No," I said. "I saw you stitching and the wall of the catheter is thick and not so easily stitched up by mistake. The catheter was nowhere inside the bladder anyway."

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.

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 although some vets advised leaving it in for 1 week to relieve the healing bladder of the pressure of urine accumulating inside. 

"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 anaesthesia gas again," I said to Vet 1. 

A bit of history as to how I got involved in this case. A young girl had sent the dog to Vet 2, a competitor of Vet 1 and myself. 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.

The young girl worked as a veterinary receptionist for Vet 1. Vet 1 did not possess an X-ray machine.

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

Vet 1 requested my help to remove the bladder stones for his receptionist. He had many years of surgical experience in sterilisation of dogs and cats. But he often refers cases to the practice of which Vet 2 was one of the vets. He had not done this bladder stone surgery before.     

"No X-rays for your poor girl?" I shook my head. "This is not necessary since Vet 2 is an experienced veterinarian and would have made an accurate  diagnosis."

I palpated the bladder. There were stones as there were crunching sounds of small stones rubbing against each other. Crepitus sounds of gas inside the bladder vibrated against my fingers. Yes, there were bladder stones. No X-rays was necessary in this case.  

For some small surgeries all over the world, 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 big boys and girls. 

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 advertise that I have had the equipment and confidence in me. I generate good will. I catch the competitor's clientele attention and possibly their patronage. Well, if not all, at least some of the clientele would come to me due to the visit to my practice for X-rays. At least, I had their attention and their recall of my practice.

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

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

By referring his clients to me to X-ray the dog, Vet 1  is at a grave disadvantage of losing his client. He has had created market awareness of my practice without me having to spend money to advertise...So much to gain, nothing to lose...   

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 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 nflamed 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.