Perineal Urethrotomy Research Articles

Progressive urethral dilation in male horses undergoing perineal urethrotomy for cystolith removal: 22 cases

This retrospective case series describes the use of progressive urethral dilation in 22 client-owned male horses undergoing perineal urethrotomy (PU) for cystolith removal. Medical records of horses undergoing PU and urethral dilation for treatment of cystolithiasis were reviewed. Dilation of the pelvic urethra was performed following PU and using customized dilators with the same length (30cm) and with various outer diameters (25 to 45mm). Analyzed data included: signalment, cystolith size, renal ultrasound findings, method used for cystolith removal, diameter of urethral dilators, intra- and post-operative complications, and hospitalization time. Cystolith size ranged between 37mm and 90mm. Dilation of the pelvic urethra was as follows: 35mm (n=8), 25mm (n=6), 39mm (n=3), 33mm (n=2), 28mm (n=2) and 45mm (n=1). In 6 cases, the cystolith was removed without fragmentation. In the remaining 16 horses, lithotripsy was performed with forceps (n=9) or a pneumatic scaler (n=7). In 15 horses a retrieval device was used to aid in calculi removal. Hospitalization time ranged between 1 and 5 days. Intra-operative complications occurred in one horse. No post-operative complications were recorded. Follow-up information was available for 21 horses (range 1-8 years). Urethral dilation via PU may be a viable option for cystolith removal in male horses.

Spontaneous intraurethral catheter knot requiring perineal urethrotomy in a neonate: A case report with review of management and prevention

Infant feeding tubes are routinely used as urethral catheters in neonates and children. Although considered safe, it can lead to significant morbidity if the catheter knots in the bladder. We report a case of a spontaneous urinary catheter knotting in a neonate. It required a perineal urethrotomy for successful removal. A lateral oblique radiograph to characterize the complexity of knot helps in its management. Training of staff involved in the insertion, maintenance or removal of the catheters is essential to decrease catheter related complications.

Morphologic Factors Associated With Open Conversion During Holmium Laser Enucleation of the Prostate

OBJECTIVETo determine if there is an association between patient body habitus as measured by body mass index (BMI), body surface area (BSA), preoperative prostate volume, postoperative specimen weight, and open conversion with cystotomy or perineal urethrotomy (PU) during holmium laser enucleation of the prostate (HoLEP). We attempt to provide meaningful criteria to assist in preoperative patient counseling. MATERIALS AND METHODSThree hundred consecutive patients underwent HoLEP between August 3, 2018 and February 20, 2020 by a single surgeon. Patient metrics were recorded in a database including age, height, weight, preoperative prostate volume, postoperative specimen weight, catheter dependence, and transfusion requirement. Nine patients were identified who had cystotomy (8) or PU (1) performed during HoLEP secondary to inability to complete the procedure using standard endoscopic technique. Univariate and multivariate statistical analysis was performed. RESULTYounger age, higher BMI, higher BSA, and higher estimated prostate volume were associated with increased risk of open conversion during HoLEP. No patient with a BMI under 30 required open conversion. CONCLUSIONMen with BMI >30 kg/m2 or preoperative prostate volume >125 mL should be counseled on the possibility of open conversion with cystotomy or PU. Although the overall risk of conversion is low (3%), the risk may be as high as 10% for patients in the highest quartile of BMI (>30.5 kg/m2) and BSA (>2.2m2).

Obstructive Urolithiasis in Horse

Background: Obstructive urinary tract disease in horses is a rare and low prevalence pathology in the species, but potentially severe. It is an emergency condition that presents variable clinical signs and depends on the anatomical location of the obstruction. The bladder calculus are the most common followed by the urethra and less commonly seen are the kidney or ureteral. The main crystalloid component of uroliths in horses is calcium carbonate. The higher prevalence of urolithiasis in male horses is justified by some anatomical differences between genders. The urethra of males is narrower and longer than that of females. The tissue injury is the most important factor for the development of uroliths in horses. Desquamation of epithelial cells, presence of leukocyte and necrotic cell debris are relevant contributors to crystal growth. Urinary stasis favors nucleation by increasing the chance of contact between crystalloid material and urinary epithelium. Once crystal growth has begun, the urine alkalinity of the equines favors the crystallization and further deposition of other components, especially calcium carbonate. Typical clinical signs of urolithiasis include tenesmus, dysuria, strangury and polaquiuria. Hematuria is often present, mainly observed after exercise and at the end of urination. In addition signs of colic are quite frequent in the acute bladder and urethral urolithiasis due to bladder distension. Upper urinary tract surgery may be technically challenging due to limited structural exposure, especially in adult horses The prognosis for horses with urolithiasis depends on the location of the urolith and the degree of renal injury that occurred.Case: This report aims to describe a rare case of obstructive urolithiasis in a 8-year-old castrated male horse with 24 h evolution. The horse was expressing signs of abdominal pain and during the transretal examination through palpation, it was possible to notice great distension and turgidity of the bladder, in addition to a high pain sensitivity to the palpation of the kidneys. Was perform urethral catheterization, but it was unproductive. The diagnosis was made through perineal ultrasonography and treated surgically by perineal urethrotomy. The animal presented an excellent evolution after being discharged after 10 days of hospitalization and did not present any complication or recurrence of the disease after one year of the procedure.Discussion: Urolithiasis in horses has a prognosis dependent on the location of the urolith and the degree of renal damage. Cases of obstructive urolithiasis in horses are rare and require prompt and appropriate intervention. Therefore, a rapid and accurate diagnosis is directly related to the success of the treatment. In the present case, the animal had characteristic clinical signs of an acute abdomen. Transrectal palpation, for evaluation of the intestinal portions, was important to diagnose an excessively distended urinary vesicle with no intestinal changes. Transcutaneous ultrasonography of the perineum allowed visualization of the calculus, and then a case of perineal urolithiasis was diagnosed. The choice for perineal urethrotomy was performed because of the ease of palpation of the calculus through the skin below the anus and because it is a non-invasive technique. The urethra was sutured to guide the cicatricial process and the urethral catheter was maintained, reducing the risks of occlusion of the urethral lumen.

Perineal hypospadias: back to the future Chordee Excision & Distal Urethroplasty

Perineal hypospadias correction has swung from two-stage repair in the 1960s to one-stage repair in the 1980s and back to two-stage repair in the 2000s. The author's experience with a technique in which Chordee Excision and Distal Urethroplasty (CEDU) was performed at the first operation leaving a 1-cm segment as perineal urethrotomy to be reconstructed at the second operation is presented. Between January 2013 and December 2016, the CEDU technique was performed in 63 patients with perineal hypospadias. The records of 59 patients who maintained regular follow-up were reviewed. The principle is to excise the hypoplastic urethral plate, atretic corpus spongiosum, and longitudinal layer of tunica albuginea; split the glans in the midline; and reconstruct a healthy urethral plate using preputial and lateral skin flaps to the tip of the glans. Distal urethroplasty was performed leaving 1cm at the proximal end to be reconstructed 3-6 months later. This principle was used by Duplay in the 1880s. Patient age ranged between 6 months and 2 years (mean 8 months). All the patients had perineal hypospadias and bifid scrotum with severe deep chordee. Follow-up period ranged from 17 to 53 months (mean 36). A transurethral Silastic catheter was inserted for 4 days. Three months later, the remaining 1cm of the new urethra was reconstructed, and final adjustment of the glans and foreskin was performed. Satisfactory results were obtained in 54 patients (90%). Three children experienced glans dehiscence that was corrected in the second stage, one child developed fistula after the second operation, and one developed diverticulum. The fistula and diverticulum were corrected at the third operation successfully. It was necessary in this series to divide the urethral plate and excise the hypoplastic corpus spongiosum and the outer longitudinal layer of tunica albuginea to correct the associated deep chordee. The lateral skin flaps receive double blood supply from the base of the penis and the preputial vessels. This natural urinary diversion allows early removal of the catheter, reduces the discomfort of the patient, and allows the new urethra to heal without urine irritation for 3 months. Long-term follow-up for 15 years is necessary to assess the technique objectively. The CEDU technique diverts urine away from the site of urethroplasty for 3 months without a catheter. It reduces the hospital stay and patient discomfort. It produces satisfactory results and has become a the standard technique in perineal hypospadias.

The use of pneumatic impact lithotripsy and a retrieval pouch to create a closed system for removal of cystic calculi in standing male horses

SummaryMultiple techniques exist for removal of cystic calculi in the male horse, some of which use a perineal urethrotomy (PU) to facilitate access to the urinary bladder for removal of small uroliths in the standing, sedated horse. These techniques have limited efficacy in the removal of uroliths that have a diameter larger than the PU site, typically 4–5 cm. Pneumatic lithotripsy as reported in this article provides a novel way to fragment these larger uroliths while containing the fragments and protecting the urethra and urinary bladder. Ten geldings and one stallion underwent a lithotripsy procedure to remove one (n = 10) or several (n = 1) uroliths ranging in diameter from 4 to 9 cm. A PU was performed and a laparoscopic retrieval bag was inserted into the urinary bladder through the PU site. The urolith was manipulated into the bag using blind transrectal manipulation or endoscopic guidance and the opening of the bag was exteriorised out of the PU site. A pneumatic lithotrite was used to fragment the stone. When the urolith was adequately fragmented, the fragments were removed by the use of sponge forceps and by flushing the fragments from the bag with obstetrical lube. This was continued until the bag could smoothly be withdrawn from the urinary bladder. All uroliths were successfully removed. The PU sites healed without complication and none of the horses had recurrence of presenting clinical signs. This article also discusses the difference between two types of laparoscopic retrieval bags. Pneumatic impact lithotripsy in combination with a retrieval pouch offers a safe alternative to other methods for removal of cystic calculi in the horse.

Signalment, clinical features, and outcome for male horses with urethral rents following perineal urethrotomy or corpus spongiotomy: 33 cases (1989-2013).

OBJECTIVE To describe the signalment, clinical features, and outcome for male horses with urethral rents following perineal urethrotomy (PU) or corpus spongiotomy (CS). DESIGN Retrospective case series. ANIMALS 33 horses. PROCEDURES Medical records of male horses examined because of hematuria or hemospermia caused by urethral rents that underwent PU or CS at a referral hospital between 1989 and 2013 were reviewed. Data regarding signalment, clinical features, urethroscopic findings, surgical treatment, and outcome were recorded. Long-term follow-up information was obtained by telephone interviews. RESULTS Age of the study population ranged from 3 to 18 years. Nineteen geldings and 1 stallion were examined because of hematuria, of which 13 and 7 underwent PU and CS, respectively, at a mean of 56 days after onset of clinical signs. Thirteen stallions were examined because of hemospermia, of which 7 and 6 underwent PU and CS, respectively, at a mean of 193 days after onset of clinical signs. Hematuria resolved following 1 surgical procedure in all 17 horses for which long-term information was available. Of the 12 stallions for which long-term information was available, 7 had resolution of hemospermia after 1 PU or CS and 5 developed recurrent hemospermia that required additional PUs or CSs (n = 3) or primary closure of the urethral rent (2). CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that PU and CS were reliable treatments for resolution of hematuria in male horses with urethral rents; stallions with urethral rents may require multiple PUs or CSs or primary closure of the rent for resolution of hemospermia.

Use of a laparoscopic specimen retrieval pouch to facilitate removal of intact or fragmented cystic calculi from standing sedated horses: 8 cases (2012-2015).

OBJECTIVE To evaluate the use of a laparoscopic specimen retrieval pouch for removal of intact or fragmented cystic calculi from standing horses. DESIGN Retrospective case series. ANIMALS 8 horses (5 geldings and 3 mares) with cystic calculi. PROCEDURES Physical examination and cystoscopic, ultrasonographic, and hematologic evaluations of urinary tract function were performed for each horse. A diagnosis of cystic calculus was made on the basis of results of cystoscopy and ultrasonography. Concurrent urolithiasis or other urinary tract abnormalities identified during preoperative evaluation were recorded. Horses were sedated and placed in standing stocks, and the perineum was aseptically prepared. Direct access to the urinary bladder was gained in geldings via perineal urethrotomy or in mares by a transurethral approach. Calculi were visualized endoscopically, manipulated into the retrieval pouch, and removed intact or fragmented (for larger calculi). RESULTS For 4 geldings and 1 mare, fragmentation was necessary to facilitate calculus removal. Mean duration of surgery was 125 minutes, and trauma to the urinary bladder and urethra was limited to areas of hyperemia and submucosal petechiation. No postoperative complications were encountered for any horse. When lithotripsy was required, the retrieval pouch provided an effective means of stabilizing calculi and containing the fragments for removal. CONCLUSIONS AND CLINICAL RELEVANCE Use of the laparoscopic specimen retrieval pouch was an effective, minimally traumatic method for retrieving cystic calculi from standing horses. The pouch protected the urinary bladder and urethra from trauma during calculus removal and allowed for stabilization, containment, and fragmentation of calculi when necessary.

Two occurrences of presumptive venous air embolism in a gelding during cystoscopy and perineal urethrotomy

SummaryA 14‐year‐old Arabian gelding presented for evaluation of macroscopic haematuria. Routine cystoscopy was performed under standing sedation during which the horse collapsed with apparent seizure activity. General anaesthesia was induced and the horse recovered neurologically normal. Four days later, during a perineal urethrotomy procedure, the horse experienced a similar collapse with seizure‐like activity. General anaesthesia was again induced and cystoscopy performed through the urethrotomy incision. A ventral bladder mass was visualised and sampled. Cytology confirmed a neoplastic process and the horse was subjected to euthanasia. Histopathology confirmed transitional cell carcinoma. Air embolism was the suspected cause of loss of consciousness and seizure activity in both instances.

English

The cases of urolithiasis in caprine and sheep presented for treatment for one year to University Teaching Veterinary Clinics were managed surgically. A brief history about the clinical cases, their clinical examination, kidney function tests and ultrasonography was studied. The cases were surgically managed by performing different surgical procedures viz, excision of urethral process, urethrotomy perineal urethrotomy, tube cystotomy and cystorrhaphy and modified bladder marsupialisation as demanded by clinical situation. The postoperative management, survival rates and restoration of normal urination, rupture sites and return of normal kidney function tests of the cases has been discussed. Key words: Urine, ultrasound, urethrotomy, bladder.

Complications Associated With Perineal Urethrotomy in 27 Equids

To report the clinical findings, incidence of complications, and outcome associated with perineal urethrotomy in equids. Retrospective case series. Equids (n = 27). Medical records (January 2000 to December 2010) of equids that had a perineal urethrotomy were reviewed. Data retrieved and evaluated were breed, age, surgical technique, use of general anesthesia, complications, time from surgery to development of complications and their management, and outcome. Perineal urethrotomy was performed for urolithiasis (n = 22), for treatment of urethral rents (3), severe balanoposthitis (1), and bladder atony caused by equine protozoal myeloencephalitis (1). The incidence of complications was 52%, including recurrence of urolithiasis in 5 (23%) equids. Horses that had postoperative cystoscopy and bladder lavage were significantly less like likely to have recurrence of urolithiasis (P = .039). Of equids that had postoperative indwelling urinary catheters, 75% developed complications. Perineal urethrotomy can be an effective for treatment of urolithiasis, hematuria, and urethral trauma. Postoperative cystoscopy and bladder lavage significantly reduced the incidence of postoperative recurrence of urolithiasis.

Transitional cell carcinoma of the urinary bladder in a 12‐year‐oldBelgianWarmblood gelding

SummaryA 12‐year‐oldBelgianWarmblood gelding was examined for haematuria and dysuria of 24 h duration. Cystoscopy revealed an intraluminal multinodular soft tissue mass originating from the dorsal bladder neck. Histopathological examination of biopsies identified transitional cell carcinoma. The bladder mass was surgically debulked via a temporary perineal urethrotomy. The horse commenced treatment with oral piroxicam. Follow‐up examination 18 months post operatively revealed no evidence of tumour recurrence. Neoplasia of the equine bladder is uncommon and this case describes the successful short‐term outcome of treatment of a transitional cell carcinoma by surgical debulking and oral piroxicam.

Endoscopic‐Assisted Electrohydraulic Shockwave Lithotripsy in Standing Sedated Horses

To report use of transendoscopic electrohydraulic shockwave lithotripsy for fragmentation of urinary calculi in horses. Case series. Male horses (n = 21). Fragmentation of cystic calculi (median, 6 cm diameter; range, 4-11 cm diameter) was achieved by transurethral endoscopy in standing sedated horses using an electrohydraulic shockwave fiber introduced through the biopsy channel of an endoscope. The fiber was advanced until it contacted the calculus. Repeated activation of the fiber was used to disrupt the calculus into fragments <1 cm diameter. Visibility within the bladder was maintained by repeated lavage with saline solution. Complete calculus removal was achieved in 20 horses (95%) with mean total surgical time of 168.6 minutes (range, 45-450). In the 20 horses with single calculi, 1-6 sessions were required to completely fragment the calculus. Except for 1 horse, in which perineal urethrotomy was eventually performed for complete fragment removal, fragments calculi were excreted via the urethra. Postoperative complications included hematuria because of severe mucosal erosion (n = 2), dysuria because of a trapped urethral fragment (2), small amount of urinary debris (1). One horse was euthanatized because of bladder rupture. Complete clearance of calculi and urinary debris was confirmed endoscopically 20 (3-45) days after the last session. Telephone follow-up (mean, 18.8 months; range, 7-24 months) revealed that horses had returned to previous activity levels without recurrence of clinical signs. Transendoscopic electrohydraulic lithotripsy appears to be an effective method for fragmentation of low-density calcium carbonate cystic calculi in male horses.

Use of a Laparoscopic Retrieval Device for Urolith Removal through a Perineal Urethrotomy

To report the use of a laparoscopic retrieval device for removal of uroliths via a perineal urethrotomy. Case report. A 12-year-old Konenklijk Warmbloed Paardenstamboek Nederland (KWPN) gelding and a 15-year-old Holsteiner gelding. Perineal urethrotomy was performed on 2 standing sedated geldings and the urolith was removed using a laparoscopic retrieval device. In both cases, uroliths were removed successfully with no short- or long-term complications. The larger of the 2 uroliths measured 6 cm in length and 4.6 cm in width. Removal of a urolith via a perineal urethrotomy using a laparoscopic retrieval device was an expedient and minimally traumatic method that obviated the need for fragmentation before removal.

Spontaneous Urethral Catheter Kinking or Knotting in Male Dogs: Four Cases

Four dogs were diagnosed with urethral catheter malfunction. The catheter was kinked in three dogs and knotted in one dog. In two dogs, kinking of the catheter was associated with presence of urethroliths in the perineal urethra. Diagnosis was based on the difficulty encountered retrieving the catheter in all dogs and swelling in the scrotal or perineal area in two dogs. Diagnosis of catheter kinking or knotting was confirmed after catheter retrieval. Catheter removal was achieved in two dogs after traction under anesthesia, whereas scrotal or perineal urethrotomy were used in the other two dogs. No complications associated with urination were reported in any of the dogs after 7 to 12 mo.

Balanitis Xerotica Obliterans: An experience with Buccal Mucosa Onlay Flap Graft.

Background: Balanitis Xerotic obliterans (BXO) or Penile Lichen Sclerosus is a dermatological condition affecting the genitalia and associated with chronic, progressive, sclerosing inflammatory dermatosis of unclear etiology. It was first described by Stuhmer in 1928, as being a rare condition but causes severe tissue destruction and often causes meatal stenosis and urethral stricture. Our objective is to present the experience of treatment of urethral stricture caused by Balanitis Xerotic Obliterans in our hospitals. Methods: Between 2003 and 2008 eighteen patients with LUTS caused by BXO were referred to our hospitals for management. All patients were adults with the age range from 17 to 84 years. One of the patients had diabetes mellitus. Three patients presented with retention of urine, four had difficulty in passing urine and two patients presented with painful erection. One of the patients who had retention of urine presented with “ watering cane” perineum due to fistula and sinuses as a complication of long standing unattended stricture. The majority of the patients had strictures confined to the distal urethra and meatus. Six patients were treated with buccal mucosa onlay graft while one patient was offered for perineal urethrotomy. Results: A total of eighteen (18) patients were attended, two patients were lost to follow up while 5 patients had a mean follow up of 22 months ranging from 8 to 60 months. Fifteen patients are reporting good progress while one patient is being treated with clean intermittent self catheterization and dilatation. Conclusion: BXO is a rare cause of urethral stricture in our institution and buccal mucosa graft offers satisfactory intermediate term results.

Congenital penile urethral aplasia in a 4-day-old bull calf

Summary A 4-day-old Holstein bull calf with considerable oedema of the belly (water belly) was referred to the Veterinary Teaching Hospital of the School of Veterinary Medicine, Shiraz University. The owner did not observe any urination since birth. Rupture of the urethra was suspected. Perineal urethrotomy was performed. Subsequently, catheterization of urethra revealed the obstruction near the external urethral orifice. Urethrotomy showed a three cm long rupture of urethra proximal to the penile orifice. Surgical exploration showed the penile urethral aplasia which confirmed by histopathological findings. Permanent perineal urethrostomy was the surgical treatment of choice. Fluid and antibiotic therapy were administrated postoperatively. Postoperative follow-up showed a healthy calf without any signs of water belly.

TRAUMATIC URINARY DIVERSION CAUSED BY GUNSHOT INJURY IN A STALLION

Summary A seven-year-old stallion with diversion of urinary pass to the thigh due to a urethral fistula caused by gunshot perineal injury was presented to the Urmia University, Veterinary Teaching Hospital. No signs of urinary obstruction or renal failure were observed. Because of inaccessible location of the injured urethra, through a perineal urethrotomy incision, a urinary catheter was effectively advanced to repel the obstruction into the bladder. Retrograde urethral catheterization was adopted for 5 days to assist mucosal healing. Healing was uneventful and no complications were observed during one month postoperative. Key words: Fistula, Urethra, Gunshot, Stallion Introduction The urethra, a muscular tube lined by mucosa, serves as the normal conduit for urine flow to the exterior of the body after birth. The male urethra connects the bladder to the glans penis and consists of pelvic and extrapelvic segments (Sisson and Grossman, 1975). Disorders of the equine penis and urethra that require surgery are principally limited to conditions involving urolithiasis, soft tissue obstructions, contusions, and lacerations (Trotter

Use of Holmium:YAG Laser to Facilitate Removal of Intravesical Foreign Bodies

Foreign bodies in the bladder present a challenge to the urologist. Previously, endoscopic extraction, with or without perineal urethrotomy, or open cystotomy were the only treatment choices. We describe a novel use of the Ho:YAG laser for the removal of intravesical foreign bodies. We further tested the laser on objects that have been reported in the literature to necessitate open cystotomy to determine their suitability for endoscopic removal. The Ho:YAG laser is introduced through the cystoscope and used to cut large foreign bodies into a size that can be extracted through the urethra. We tested the Ho:YAG laser ex vivo on other objects that have been reported as intravesical foreign bodies. We removed a large complex foreign body with the laser that would otherwise have necessitated open cystotomy. No injury or sequela was observed. Many commonly reported intravesical foreign objects seem amenable to similar treatment. The Ho:YAG laser should be considered for use to facilitate removal of foreign bodies from the bladder.

Self-Inflicted Male Urethral Foreign Body Insertion: Endoscopic Management and Complications

OBJECTIVE To evaluate the cause, diagnosis, management and complications of self-inserted urethral foreign bodies in men, reviewing a 17-year experience. PATIENTS AND METHODS From November 1986 to January 2004, 17 men were treated for self-inflicted urethral foreign bodies; the records were analysed retrospectively for presentation, diagnosis, management and complications. RESULTS In all 17 patients the foreign bodies were clearly palpable. Objects included speaker wire, an AAA battery, open safety pins, a plastic cup, straws, a marble, and a cotton-tipped swab. The most common symptom was frequency with dysuria, but there was sometimes gross haematuria and urinary retention. The cause for inserting the foreign body varied; psychiatric disorder was the most common, followed by intoxication, and erotic stimulation was the cause in only five patients. All patients had diagnostic imaging; plain pelvic images were sufficient in 14, ultrasonography or computed tomography was needed in three. Endoscopic retrieval was successful in all but one patient, where a perineal urethrotomy was required. The most common complications were mucosal tears and false passages. Urethral strictures were associated with multiple attempts to insert the foreign body. CONCLUSION Self-inflicted urethral foreign-body insertion in men is unusual. A radiological evaluation is necessary to determine the exact size, location and number of foreign bodies. Endoscopic retrieval is usually successful, and antibiotic coverage is necessary. A psychiatric evaluation is recommended for all patients, with appropriate medical therapy when indicated. Late manifestation has included urethral stricture disease, and a close follow-up, albeit difficult in these patients, is desirable.