Clinical History
- 6-year-old spayed female Cocker spaniel mix with stranguria, hematuria, and pollakiuria of 5 days’ duration.
- Physical examination revealed normal-sized urinary bladder. Remainder of physical examination was within normal limits.
- CBC/serum biochemical profile: within normal limits
- Urinalysis
- specific gravity: 1.040
- pH: 7.0
- 2+ blood, 2+ protein, 3–5 RBCs/hpf
- 5–10 WBCs/hpf
- 5–10 calcium oxalate crystals/hpf - Clavulanate-amoxicillin instituted at 13.75 mg/kg Q 12 H.
- Survey abdominal radiographs:
- several round opaque cystic calculi in bladder
- 1 calculus in pelvic urethra
- Kidneys/ureters free of calculi - Urine culture/susceptibility: 100,000 CFU Escherichia coli/mL
- MIC to clavulanate-amoxicillin: S < 0.5 - Owner elected cystotomy/stone removal.
- Anesthesia
- Premedication: hydromorphone (0.05 mg/kg IM) and midazolam (0.2 mg/kg IM)
- Induction: propofol (40 mg IV) to effect
- Maintenance: isoflurane inhalant - Surgery
- Exploratory laparotomy performed; incision just cranial to umbilicus continuing halfway between umbilicus and pubis.
- Bladder exteriorized/ventral cystotomy performed; incision centered near cranial aspect (apex) of bladder dome.
- Five calculi removed; bladder closed with double inverting layer using a Cushing suture pattern with 3-0 PDS. Care was taken to avoid entering lumen of bladder with sutures. - Uneventful recovery from anesthesia; patient discharged next morning with carprofen (2 mg/kg PO Q 12 H) and clavulanate-amoxicillin as previously prescribed.
- Owners instructed to manage the incision and monitor dog’s urination.
- Owner called veterinarian the following day: dog straining repeatedly/unable to pass urine for ~14 hours with signs of abdominal discomfort. Veterinarian referred case to a specialty referral center.
Physical Examination Findings
- Patient was depressed; 5% to 7% dehydration
- Severely distended, painful abdomen
Diagnostic Procedures
- CBC: within normal limits
- Serum biochemical profile abnormalities:
- BUN 90 (N 6–31 mg/dL)
- Cr 4.9 (N 0.05–1.6 mg/dL)
- K+ 8.1 (3.6–5.5 mEq/L) - Abdominocentesis: 40 cc of yellow fluid removed
- Fluid BUN: 94 (N 6–31 mg/dL)
- Fluid Cr: 8.2 (N 0.05–1.6 mg/dL) - Abdominal radiographs:
- 1 cystic calculus
- Urethral calculus lodged in pelvic urethra
- Evidence of peritoneal effusion - ECG: prolonged PR interval/absence of P wave (likely due to hyperkalemia)
- Working diagnosis: uroabdomen secondary to remnant urethral calculus
Therapeutic Procedures
- Supportive care in ICU:
- IV crystalloid fluids
- 10% dextrose bolus (4 mL/kg IV), administered twice
- Acid–base/serum electrolyte status regularly monitored; metabolic abnormalities corrected within 3 hours. Cardiac abnormalities were reversed as well. - Foley catheter placed in urethra past the calculus and into the bladder; maintained to divert urine away from urinary bladder.
- Percutaneous peritonostomy drain placed using local anesthetic and a red rubber feeding tube. Tube placed just off midline (to avoid falciform ligament) at level of umbilicus, allowing efficient drainage of urine from abdominal cavity.
- Patient was clinically improved after 6 hours; exploratory laparotomy could now be safely considered as a definitive treatment for the uroabdomen.
- Abdominal exploratory procedure:
- Anesthetic protocol identical to that of first procedure.
- Incision was extended from caudal aspect of original incision to level of pubis. Balfour self-retaining retractors used to maintain retraction of abdominal wall, allowing a complete abdominal exploratory.
- Urine suctioned from the abdominal cavity, urinary bladder exteriorized, original bladder-wall incision reopened and extended to bladder neck to facilitate removal of remnant urethral calculus.
- One calculus was removed from the bladder, 1 from the urethra, and 1 was found free floating in the peritoneal cavity.
- Bladder lavaged to ensure all calculi were removed; piece of mucosa removed for culture/sensitivity.
- Bladder closed with a single layer, simple continuous pattern using monofilament synthetic absorbable suture with a swaged-on taper needle. Sutures were placed full thickness in the bladder wall. - Recovery was uneventful; patient discharged the following day.
Clinical Outcome
At 3 months after discharge, the patient is urinating normally and has had no urinary signs.