Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
recorded: Friday August 17, 2007
Updated: Saturday August 9, 2008 (National Day,
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
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
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
had created market awareness of Vet 2's well equipped practice without
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
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
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
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
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
11. "Clamp the bladder incision with forceps," I said.
"I will pump 20 ml of Hartmann's solution via the
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
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
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
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
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
See my review of this case at:
A Veterinary Receptionist Worth Her Weight In Gold
- Circum-anal tumours in the dog
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.