Journal of Feline Medicine and Surgery

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Vaginourethroplasty as a Salvage Procedure for Management of Traumatic Urethral Rupture in a Cat

Zoeë J Halfacree, Michael S Tivers and Daniel J Brockman
Journal of Feline Medicine and Surgery 2011 13: 768
DOI: 10.1016/j.jfms.2011.05.013

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Journal of Feline Medicine and Surgery (2011) 13, 768e771
doi:10.1016/j.jfms.2011.05.013

CASE REPORT
Vaginourethroplasty as a salvage procedure for
management of traumatic urethral rupture in a cat
Zoë J Halfacree MA, Vet MB, CertVDI, CertSAS, DipECVS*, Michael S Tivers BVSc, CertSAS, DipECVS,
Daniel J Brockman BVSc, CertSAO, Cert VR, DipACVS/ECVS

Department of Veterinary Clinical This report describes a cat that suffered pelvic urethral rupture associated with
Sciences, Royal Veterinary College, multiple pelvic fractures. A vaginourethroplasty was performed as a salvage
Hawkshead Lane, North Mymms procedure, via intrapelvic anastomosis of the proximal urethra to the caudal
Hatfield, Hertfordshire, UK vagina, following failure of a primary urethral anastomosis. Urinary diversion
was achieved via tube cystostomy and a vagino-urethral catheter was
maintained for 3 days postoperatively. Anterograde cystourethrography was
performed at 7 days and 14 days postoperatively. Absence of contrast leakage
from the vagino-urethral anastomosis was documented at 14 days
postoperatively and the tube cystostomy was removed. An Escherichia coli
urinary tract infection was treated following removal of the tube cystostomy and
subsequent urine culture revealed no evidence of urinary tract infection. The cat
retained normal urinary continence and elimination behaviour during the
7-month follow-up period. Vaginourethroplasty could be considered as a salvage
option for management of traumatic pelvic urethral rupture in the neutered
female cat.
Date accepted: 13 May 2011 Ó 2011 ISFM and AAFP. Published by Elsevier Ltd. All rights reserved.

U
rethral rupture may occur following vehicu- including urinary incontinence and peristomal skin
lar trauma, bite wounds, penetrating in- irritation and necrosis, are documented.7
juries, urethral calculi or iatrogenic injury This case report describes the use of an end-to-end
during urethral catheterisation or surgery.1e4 Manage- vagino-urethral anastomosis (‘vaginourethroplasty’)
ment of urethral rupture requires patient stabilisation, to achieve permanent urinary diversion in a cat follow-
correction of metabolic disturbances and provision of ing traumatic urethral rupture and failure of primary
urinary diversion. There are three options for the urethral anastomosis.
management of urethral rupture: temporary urinary A 9-year-old female neutered domestic shorthair cat
diversion via a tube cystostomy or urethral catheter (3 kg) was referred for management of pelvic fractures,
and second intention healing of the urethra, perma- following a road traffic accident. Plain and contrast radi-
nent urinary diversion via a urethrostomy or primary ography revealed a right iliac shaft fracture, multiple pu-
urethral repair.5 Second intention healing of the ure- bic and ischial fractures and rupture of the pelvic urethra
thra is only appropriate when the urethral defect is (Fig 1). A tube cystostomy was placed to achieve urinary
small.4 Primary urethral repair is challenging due to diversion on the day of presentation using a standard
the small size of the feline urethra and is associated technique.8 Surgical exploration of the pelvic urethra
with complications of urethral dehiscence and stric- on the fourth day, documented complete urethral tran-
ture.5,6 Permanent urethrostomy may provide a satis- section, 3 cm from the bladder neck, and a primary ure-
factory outcome, however, the rate of complications thral anastomosis was performed. The right iliac shaft
can be greater following urethrostomy at more cranial fracture was stabilised using a 2.0/2.7 mm lateral veter-
sites. Prepubic and transpubic urethrostomy achieve inary cuttable plate (Synthes, Welwyn Garden City, UK)
permanent bypass of urethral lesions of the pelvic ure- on the sixth day following presentation. Anterograde
thra, however, a relatively high rate of complications, cystourethrography performed 20 days following ure-
thral anastomosis revealed a stricture and persistent
contrast leakage at the anastomosis site (Fig 2), necessi-
*Corresponding author. E-mail: [email protected] tating surgical revision.

1098-612X/11/100768+04 $36.00/0 Ó 2011 ISFM and AAFP. Published by Elsevier Ltd. All rights reserved.

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 Vaginourethroplasty for management of urethral rupture 769

by advancing the Foley catheter into the distal opening

of the proximal urethra (Fig 3). The anastomosis was
sutured using a simple interrupted pattern of 5e0 pol-
ydioxanone on a round bodied needle circumferen-
tially; eight sutures were placed and surgical Loupes
(3.5) were used for magnification. The vagino-
urethral anastomosis site was omentalised prior to rou-
tine abdominal closure.
Continued urinary diversion was provided via the
tube cystostomy and the vagino-urethral Foley cathe-
ter was closed and left in situ for 3 days post-
operatively. Anterograde cystourethrography was
performed under general anaesthesia at 7 days and
14 days postoperatively by injection of a 2 ml/kg bo-
lus of iohexol (Omnipaque; GE Healthcare AS, Oslo,
Norway, 300 mg I/ml) diluted in a 1:1 ratio with ster-
Fig 1. Retrograde vaginourethrocystogram performed on ile saline via the tube cystostomy. Leakage of contrast
the day of presentation. This demonstrates contrast leakage agent was documented from the vagino-urethral anas-
from the pelvic urethra, consistent with urethral rupture. tomosis site at 7 days postoperatively but was not
present by 14 days (Fig 4) and the tube cystostomy
was, therefore, removed. Urinalysis and culture at
Under general anaesthesia the cat was prepared for
this time revealed an active urine sediment and a pro-
a vaginourethroplasty surgery via a ventral midline
fuse growth of Escherichia coli. A 4-week course of en-
laparotomy and pubic symphysiotomy, including anti-
rofloxacin (5 mg/kg po q 24 h) was prescribed on the
septic lavage of the vulva which was draped within the
basis of sensitivity testing.
sterile field. An 8 Fr nylon catheter was passed nor-
The cat was re-examined 4 and 16 weeks postoper-
mograde, via a stab incision in the urinary bladder,
atively. The owners observed that she urinated nor-
through the proximal urethra allowing improved visu-
mally with no evidence of dysuria and that she
alisation of the site of urethral stricture. A 5 Fr Foley
retained normal urinary continence. There was no ev-
catheter was inserted in a retrograde fashion per va-
idence of perineal urine scald or vulval inflammation.
gina. The vagina was then transected and spatulated
A urine sample was obtained via cystocentesis 1 week
at the level adjacent to the previous urethral anastomo-
following cessation of antibiotic treatment and the
sis, allowing the tip of the Foley catheter to exit the dis-
urine sediment was unremarkable and culture yielded
tal vagina at this point. The cervical remnant and
no bacterial growth. The cat was represented at
proximal portion of the vagina were resected. A
24 weeks postoperatively following a 2-week history
5 mm portion of urethra, at the site of previous anasto-
of vomiting. Abdominal ultrasonography revealed
mosis, was resected and the distal urethra was ligated
a grossly thickened gastric wall with complete loss
using an encircling ligature of 3e0 polydioxanone. The
of layering. The owners declined further investiga-
proximal urethra and distal vagina were then apposed
tions and the cat was euthanased 1 month later due
to progression of her disease; post-mortem examina-
tion was not performed.
The majority of published literature regarding man-
agement of feline urethral rupture describes the con-
dition in the male cat.1e5 Literature regarding
urethral rupture in the female cat is very limited.1,9
Extrapolating from the canine literature, the optimal
management of transection of the pelvic urethra is pri-
mary urethral anastomosis over a urethral stent with
concurrent urinary diversion.5,10,11 Following failure
of this technique, revision of the urethral anastomosis
was considered unfeasible due to the risk of tension at
the anastomosis site following excision of the stric-
ture. Vaginourethroplasty was performed as an
alternative salvage option to prepubic,7 subpubic12
or transpelvic13 urethrostomy, to maintain greater ure-
Fig 2. Anterograde cystourethrogram performed via the
thral length and normal elimination behaviour.
tube cystostomy 20 days following primary repair of the The vaginourethroplasty technique employed in
complete pelvic urethral rupture. This demonstrates leakage this cat was modified from that previously described
of contrast material and the presence of a stricture at the for management of urethral neoplasia in the bitch14,15
anastomosis site. to account for anatomical species differences. In the

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770 ZJ Halfacree et al

Fig 3. A schematic diagram of the caudal abdomen and pelvis of the cat demonstrating the stages of the vagino-urethral
anastomosis procedure to create the vaginourethroplasty.

bitch, the luminal disparity between the vagina and cystostomy and an indwelling closed vagino-urethral
urethra necessitates resection of the ventral vaginal catheter was left in place as a stent for 72 h. Urinary
wall and closure over a catheter to create a narrow diversion to bypass the anastomotic site is associated
‘vaginourethra’15; however, in contrast, the narrow lu- with improved urethral healing and reduced inci-
men of the feline vagina allowed a direct anastomosis dence of dehiscence and stricture.16,17 The period for
of the proximal urethra to the distal vaginal. In fact, which a catheter was used for vagino-urethral stent-
the end of the distal vagina was spatulated in this ing was similar to the previous canine case series in
cat to increase the luminal diameter of the vagina. which the catheter was retained for 48 h.15 The ratio-
The small size of the feline urethra and vagina pres- nale for use of a catheter as a vagino-urethral stent
ents a technical challenge during both primary ure- is based upon a canine experimental study in which
thral anastomosis and vaginourethroplasty; however, minimal urethral stricture was demonstrated follow-
magnification was used to ameliorate this problem. ing suturing of a urethral anastomosis over a catheter
Whilst the primary urethral anastomosis failed, suc- compared to other non-sutured anastomoses, or those
cessful healing of the vagino-urethral anastomosis without an indwelling catheter.10 It has been demon-
was achieved. This is likely to be due to improved strated in experimental dogs that urothelial regenera-
urethral tissue characteristics following a delay post- tion occurs rapidly across urethral defects if some
trauma, in addition to use of the non-traumatised dis- mucosal continuity is present,16 however, it is unclear
tal vagina which provided a tension free site for how mucosal healing would occur at the vagino-
anastomosis. urethral interface.
Following the vaginourethroplasty procedure, con- A urinary tract infection was documented in this
tinued urinary diversion was employed via the tube cat, however, resolution occurred following antibiotic
treatment and it is recognised that the use of a tube
cystostomy18 and indwelling urethral catheter19 pre-
dispose to urinary tract infection. There was no indi-
cation that the cat was predisposed to urinary tract
infection during the follow-up period; however, lon-
ger term follow-up of this technique in additional
cats is required.
This report describes the modification of an existing
technique of vaginourethroplasty for permanent uri-
nary diversion in a female neutered cat with a trau-
matic pelvic urethral rupture associated with pelvic
fractures. The technique allowed retained continence
and elimination behaviour and was not associated
with any complications. This report highlights an al-
ternative salvage option to urethrostomies in neutered
female cats for management of urethral trauma.

Fig 4. Anterograde cystourethrogram 15 days following

vaginourethroplasty demonstrating the healed anastomosis References
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