Surgical Affection

Of Cystostomy
CYSTOTOMY
• Cystostomy is a surgical procedure in which an incision is made into
the urinary bladder
• Cystotomy is the general term for the surgical creation of an opening
into the bladder; Often, however, the term is used more narrowly to
refer to suprapubic cystotomy or suprapubic catheterization.
indication
• Urine retention
• Blood in urine
• Urine leakage
• Rupture of bladder
Anaesthesia
• Fluorinated gas anesthetics are nephrotoxic to some degree
methoxyflurane >enflurane > isoflurane, > halothane. Halothane is a
widely used anesthetic agent for horses.
• Xylazine is a sedative hypnotic agent commonly administered to
horses to facilitate examination or as a preanesthetic medication.
• Gentamicin IV of 6.6 mg/kg of gentamicin IV every 24 hours is
considered to be safe and efficacious in the horse.
Procedure
• The procedure can be done for many reasons
• The most common being to facilitate removal of bladder and urethral
stones.
• Other indications include helping to diagnose bladder tumors,
repairing ectopic ureters and ruptured bladders, and aiding in the
diagnosis of difficult-to treat urinary tract infections.
General Procedure
• The skin incision is made
• The bladder is gently elevated out of the abdomen and an incision is
made through its wall. Urine is suctioned away and the inside of the
bladder is examined. After opening the bladder, stones (uroliths) are
removed from the bladder or they are flushed into the bladder from
the urethra and then removed. If a tumor is suspected, a sample of
the bladder wall can be excised (cut away) and sent to the laboratory
for biopsy
Relative Procedure
• * After anesthesia induction, the horse is positioned in dorsal recumbency. A
urinary catheter is passed into the bladder and sutured in place. The prepuce is
cleaned and sutured or closed with towel clamps. The abdomen is aseptically
prepared for a ventral midline approach.
• A 20- to 25-cm skin incision is made along the caudal ventral midline of the
abdomen. In male horses, the skin incision is directed lateral to the prepuce
(see Fig. 71-8). With continued dissection of the subcutaneous tissues, the
prepuce is mobilized and retracted to expose the posterior midline. The
surgeon should identify and avoid the large superficial caudal epigastric and
external pudendal vessels when dissecting deep to the prepuce to expose the
posterior midline. In mares, the incision is made on the midline from the
umbilicus caudally to the prepubic tendon.
• The bladder is identified by palpation in the pelvic canal. Sustained gentle traction is
required to exteriorize the bladder33,45,47 (Fig. 71-16). Once it is exposed, moistened
laparotomy pads are used to pack off the bowel and elevate the bladder in the surgical
field. Large-diameter stay sutures should be positioned at the ventrolateral aspects of the
bladder to facilitate control of the cystotomy incision and to reduce urine spillage. A
transverse incision is made across the ventral bladder to expose the urolith. Frequently,
the urolith is closely adherent to the bladder mucosa, particularly in the case of a type I
urolith. The mucosal layer of the bladder must be peeled back from the urolith to permit
removal of the calculus (Fig. 71-17). After its removal, a fullthickness biopsy should be
taken from the margin of the cystotomy incision for culture and histopathology. The
bladder is lavaged extensively in an effort to remove small fragments of calcular material
and blood clots. Irrigation of the bladder by retrograde introduction of sterile saline
through the urinary catheter flushes small fragments of the urolith from the neck of the
bladder toward the incision, where they can be evacuated through suction.
Suturing Of Bladder
• The cystotomy is sutured with a two-layer closure of synthetic
absorbable suture material. Continuous inverting suture patterns such
as the Cushing and Lembert patterns are preferred. The suture should
not penetrate the urinary mucosa to the lumen. The bladder may be
distended with sterile saline to evaluate the closure for leakage. The
abdomen is lavaged with sterile balanced saline solution and
suctioned. The midline incision is closed with no. 2 synthetic
absorbable suture material in continuous or interrupted fashion. If
the caudal limit of the incision was made in a paramedian location,
the fascial closure is completed in two layers by suturing the deep and
superficial layers of the rectus sheath separately
• 2 synthetic absorbable suture material in continuous or interrupted
fashion. If the caudal limit of the incision was made in a paramedian
location, the fascial closure is completed in two layers by suturing the
deep and superficial layers of the rectus sheath separately
• Of the two layers, the superficial sheath is the more critical to the
security of the abdominal closure.
• The subcutaneous tissues and skin are closed in routine fashion.
 muscles
•  The urethra is a tube that connects the urinary bladder to the urinary meatus for the
removal of fluids from the body.
• Arteries
• Inferior Vesicle Artery
• Medial Rectal artery
• Internal pudendal Artery
• Veins
• Inferior Vesicle Vein
• Medial Rectal Vein
• Internal pudendal Vein
• Nerves
• Pudednal Nerve
• Pelvic splenchnic nerve
• Inferior hypogastric plexus
Different Approaches
• 2 types of pproches are there
• Parainguinal Approach
• Laparoscopic Techniques
Approach 1
• Parainguinal Approach:
• Another surgical approach to the urinary bladder in the
adult male horse has been described—the parainguinal approach.71 This
approach eliminates the need to reflect the prepuce and reduces the chances
of encountering large vessels prior to gaining access to the urinary bladder.
With the horse in dorsal recumbency and the penis sterilely catheterized, the
inguinal region is clipped and prepared for aseptic surgery. A 12- to 14-cm skin
incision is made starting 2 cm cranial to the left external inguinal ring and
continuing in a caudomedial direction toward the midline (Fig. 71-18).
Subcutaneous tissues and fat are bluntly and sharply dissected to reveal the
aponeurosis of the external abdominal oblique muscle. The aponeurosis is
sharply incised, starting
• Double-layer closure of the bladder is recommended. Closure of the
abdomen is routine, with attention paid to the aponeurosis of the
external abdominal oblique muscle. An interrupted cruciate, nearfar-
far-near, or a simple-interrupted pattern is recommended. None of
the nine geldings that underwent this approach developed incisional
complications, including herniation.
• Laparoscopic techniques have been described for repair of
cystorrhexis, persistent urachus, and umbilical infections in the
foal.72,73 Patient preparation including appropriate diagnostic
examinations and perioperative therapeutics do not differ from those
used for foals undergoing conventional surgical approaches. Foals are
placed in dorsal recumbency with the pelvic limbs elevated. This
position usually demands that intermittent positive-pressure
ventilation be available. The ventral midline is prepared routinely for
aseptic surgery.
• Because the foal’s body wall is thin, it is recommended that
insufflation be done with a teat cannula and that lower (1 to 2
L/minute) insufflation rates be used. A 1.5-cm incision is made 5 cm
lateral to ventral midline and 10 to 15 cm cranial to the umbilicus for
placement of the laparoscopic cannula. A 30-degree laparoscope
telescope is used to explore the abdomen. Additional portals are
made 8 to 10 cm lateral and 5 cm cranial to the umbilicus.
complications
• Clinically significant complications of bladder surgery are rare. The most acute and
striking complication is the development of severe ventricular arrhythmias in the
anesthetized foal with uroperitoneum.3,5 Postoperative myositis resulting in death has
also been documented.75 Correction of electrolyte and acid–base status before surgery
minimizes the risk of developing these problems. In foals, contamination of the
peritoneal cavity with urine is common and may result in the development of chemical
peritonitis.18 Although most foals with cystorrhexis have a chronic history of
uroperitoneum and presumably some degree of chemical peritonitis, the incidence of
septic peritonitis is low16 unless concurrent septic omphalophlebitis or other septic
processes are present simultaneously.17,18 In one retrospective study of celiotomy for
the treatment of uroperitoneum, several foals had positive culture results for Mucor and
Candida species.18 All foals with uroperitoneum and concurrent septic disease should be
monitored closely for clinical evidence of septicemia or septic arthritis and physitis after
surgery.
• Contamination of the midline incision with urine or bacteria may lead
to the formation of incisional edema and drainage. In adult male
horses operated on for cystic calculi, preputial edema occurs
occasionally.47 Although generally responsive to anti-inflammatory
agents and local wound therapy, it may require temporary placement
of periincisional drains. Surgical failures of the cystotomy incision
after cystoplasty and exploratory cystotomy have been reported.8,19