Topics in Compan An Med 32 (2017) 58–60
Perioperative Occlusion of a Subcutaneous Ureteral Bypass Secondary to a Severe Pyonephrosis in a Birman Cat Bertrand Vedrine, DVM Keywords: cat ureter ureterolithiasis lithiasis pyonephrosis subcutaneous ureteral bypass Clinique Vétérinaire Seinevet—5, Place Cauchoise, 76000 Rouen, France E-mail: [email protected] (B. Vedrine)
A B STR AC T A subcutaneous ureteral bypass (SUB) was placed in a 10-year-old Birman cat for management of unilateral ureterolithiasis. Perioperative occlusion of the nephrostomy tube of the SUB device happened secondary to a severe pyonephrosis. Flushing of the system throught the subcutaneous shunting port was made with saline solution after clamping the urinary bladder catheter. Repetitive flushing of the device was performed daily for 3 days to be sure of the remanent patency of the catheter. Repetitive flushing of the SUB device is a successful renal-sparing treatment for pyonephrosis in a cat and may be considered as an effective treatment option for this condition. & 2017 Elsevier Inc. All rights reserved.
Introduction Subcutaneous ureteral bypass has recently been described to manage ureteral occlusion or stricture, particularly in case of feline ureteroliths. It involves the placement of a nephrostomy tube and a cystotomy tube that are connected subcutaneously to a shunting port, allowing for urine drainage from the kidney directly to the bladder, bypassing the ureter.1-7 As compared to ureteral stents, the SUB devices have a larger bore tubing and offer the capacity to flush the system via the subcutaneous port with a reduction of the risk of subsequent occlusion.1-11 This case reports a pyonephrosis that has led to an occlusion of the nephrostomy tube of a SUB device and the restoration of the ureteral patency in the short-term follow-up in a Birman cat.
Case history A 10-year-old 3.4 kg female Birman cat was evaluated for apathy and anorexy. Clinical examination did not show abnormality. Renal insufficiency was noticed (U ¼ 90 mg/dL, C ¼ 2.6 mg/dL, P ¼ 5.4 mg/dL), and abdominal ultrasound revealed the presence of ureterolithiasis in the right ureter. Ureteral occlusion might be present on account of a pyelic dilatation. Medical management was tried firstly with analgesics, intravenous fluid therapy, and diuretics to encourage the passage of the lithiasis. Control ultrasound made 2 “days” after admission did not reveal migration of the ureteroliths, little improvement of the renal failure was present (U ¼ 80 mg/dL, C ¼ 3 mg/dL). Then, surgical management was decided. The animal was premedicated with 0.2 mg/kg morphine chlorhydrate (morphine chlorhydrate, Aguettant, Lyon, France) IV, and induced with 4 mg/kg propofol (Propovet, Axience, Pantin, France) IV. Anesthesia was maintained with a nonrebreathing Bain’s delivery system with isoflurane (Vetflurane, http://dx.doi.org/10.1053/j.tcam.2017.05.006 1527-3369 & 2017 Topics in Companion Animal Medicine. Published by Elsevier Inc.
Virbac, Carros, France) in an oxygen flow rate of 1 L/min. A midline coeliotomy was performed for placement of a SUB (SUB, Norfolk Vet Products, Skokie, IL, USA) device. When the nephrostomy catheter was placed in the right kidney, a high viscosity purulent urine elapsed with difficulty and was collected for bacterial culture and antimicrobial susceptibility testing (Fig 1). Fluoroscopic control was made to assess for any urine leakage before closure, and revealed complete occlusion of the nephrostomy catheter (Fig 2). Flushing of the system through the subcutaneous shunting port was made with saline solution after clamping the urinary bladder catheter. A large amount of purulent debris and clots were removed from the device until tube patency was restored (Fig 3). The day after surgery, control serum chemistry (U ¼ 90 mg/dL, C ¼ 2.6 mg/dL, P ¼ 5.4 mg/dL, Na þ ¼ 148 mEq/L, K þ ¼ 4.9 mEq/L, Cl ¼ 121 mEq/L) and SUB device patency test were performed. Injection of contrast agent through the subcutaneous shunting port revealed recurrence of the nephrostomy tube occlusion. Therefore, repetitive flushing of the device was performed daily for 3 days to be sure of the remanent patency of the catheter.
Fig. 1. Urine sample of the right kidney. A high viscosity purulent urine was present at the time of surgery and led to occlusion of the nephrostomy catheter of the SUB.
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Discussion
Fig. 2. Fluoroscopy made at the end of the SUB placement. Contrast agent injected in the subcutaneous shunting port confirmed the cystostomy catheter patency, but did not fill the nephrostomy catheter on account of its occlusion (arrows).
The cat was discharged from the clinic 3 days after surgery because of improvement of the serum chemistry (U ¼ 60 mg/dL, C ¼ 1.9 mg/dL, P ¼ 5.8 mg/dL, Na þ ¼ 153 mEq/L, K þ ¼ 4 mEq/L, Cl ¼ 124 mEq/L) and the ability for the cat to eat and drink spontaneously. Urine culture made at the time of surgery revealed the presence of Escherichia coli. Subcutaneous injection of 8 mg/kg cefovecin (Convenia, Zoetis, Paris, France) was made, and repeated 15 days after to manage the infection. One month postoperatively the cat had won 200 g and had regained normal activity. Uremia (110 mg/dL) had increased since the last serum chemistry control but creatininemia (2.3 mg/dL) and phosphoremia (5.4 mg/dL) were stable. Fluoroscopic control of the SUB device patency with contrast agent did not reveal recurrence of the occlusion. Moreover, the ureteral patency was restored (Fig 4). Serum chemistry and SUB patency were controlled regularly during 1 year and revealed mild progression of the chronic renal insufficiency without recurrence of the SUB occlusion.
This case reports a pyonephrosis that has led to an occlusion of the nephrostomy tube of a SUB device and the restoration of the ureteral patency in the short-term follow-up in a Birman cat. Reports of complications and long-term outcomes encountered with the SUB device are lacking in the literature because of the recent development of the system and the time required to publish a long-term outcome. Allyson Berent and Chick Weisse have provided a surgical guide for the system for the manufacturer in which they give complications encountered with the placement of more than 100 SUB.12 These include leakage at the nephrostomy or cystotomy tube or shunting port ( o 5%), hemorrhage during nephrostomy tube placement ( o 1%), system occlusion with blood clots, purulent debris, or stones (5%), kinking of the catheter during placement (2%), and urinary tract infections. Perioperative occlusion of a SUB with a blood clot has been described once.5 Pyonephrosis is a dilatation of the renal pelvis with purulent material, typically associated with a ureteral outflow obstruction such as ureteroliths.13 The standard of care for pyonephrosis in human medicine involves emergency drainage of infected urine via endoscopic retrograde lavage and ureteral stent placement or insertion of a nephrostomy catheter.14-17 In dogs pyonephrosis was succefully managed with ureteral stenting in 13 dogs.18 In the case described here, fushing of the high viscosity purulent urine needed to be reapeted 4 times (perioperatively and 3 successive days postoperatively) to ensure proper patency of the device. The presence of the subcutaneous shunting port of the SUB system allowed flushing without the need of endoscopy or coeliotomy.18 Fluoroscopy allowed direct visualization of the occlusion and its progressive improvement as the flushing progressed. Restoration of the ureteral patency after placement of a SUB device has not ever been described. We postulate that the modification of intraureteral pressure following SUB placement may participate to promote the migration of ureteroliths. This case described a perioperative occlusion of the nephrostomy tube of a SUB device secondary to a severe pyonephrosis. Repetitive flushing of the system was a successful renal-sparing treatment in our case and may be considered as an effective
Fig. 3. Flushing process of the nephrostomy tube under fluoroscopic control. The cystostomy catheter was clamped and the nephrostomy catheter was aspirated and flushed with saline solution (A). The normal filling of the urinary bladder and the renal pelvis at the end of the procedure assessed the restoration of the patency (B).
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B. Vedrine / Topics in Companion An Med 32 (2017) 58–60
Fig. 4. Fluoroscopy made 1 month after surgery. Both catheters (nephrostomy and cystostomy) were patents (A). Filling of the ureter with the contrast agent revealed restoration of the ureteral patency too (arrows) (B).
treatment option for this condition. Outcome following SUB placement is lacking for the moment. Further follow-ups are needed to know if restoration of ureteral patency is a common finding after SUB placement, as observed in our case. References 1. Berent AC. Ureteral obstructions in dogs and cats: a review of traditional and new interventional diagnostic and therapeutic options. J Vet Emerg Crit 21:86–103, 2011 2. Berent A, Weisse C, Bagley D. The use of a subcutaneous ureteral bypass device for ureteral obstructions in dogs and cats. European College of Veterinary Internal Medicine Congres, Seville, Spain; 2011 3. Defarges A, Berent A, Dunn M. New alternatives for minimally invasive management of uroliths: nephroliths. Compend Contin Educ Vet 35:E1–E7, 2013 4. Berent A. Interventional radiology and interventional endoscopy of the urinary tract (endourology). J Feline Med Surg 16:51–65, 2014 5. Horowitz C, Berent A, Weisse C, et al. Predictors of outcome for cats with ureteral obstructions after interventional management using ureteral stents or a subcutaneous ureteral bypass device. J Feline Med Surg 15:1052–1062, 2013 6. Kulendra E, Kulendra N, Halfacree Z. Management of bilateral ureteral trauma using ureteral stents and subsequent subcutaneous ureteral bypass devices in a cat. J Feline Med Surg 16:536–540, 2014 7. Garcia de Carellan Mateo A, Brodbelt D, Kulendra N, et al. Retrospective study of the perioperative management and complications of ureteral obstruction in 37 cats. Vet Anaesth Anal 42:570–579, 2015
8. Nicoli S, Morello E, Martano M, et al. Double-J ureteral stenting in nine cats with ureteral obstruction. Vet J 194:60–65, 2012 9. Berent AC, Weisse CW, Todd K, et al. Technical and clinical outcomes of ureteral stenting in cats with benign ureteral obstruction: 69 cases (2006-2010). J Am Vet Med Assoc 244:559–576, 2014 10. Kulendra NJ, Syme H, Benigni L, et al. Feline double pigtail ureteric stents for management of ureteric obstruction: short- and long-term follow-up of 26 cats. J Feline Med Surg 16:985–991, 2014 11. Manassero M, Decambron A, Viateau V, et al. Indwelling double pigtail ureteral stent combined or not with surgery for feline ureterolithiasis: complications and outcome in 15 cases. J Feline Med Surg 16:623–630, 2014 12. Berent A and Weisse C. The SUB: a subcutaneous ureteral bypass system, a surgical guide. www.norfolkvetproducts.com 13. McLoughlin MA. Surgical emergencies of the urinary tract. Vet Clin North Am Small Anim Pract 30:581–601, 2000 14. Yoshimura K, Utsunomiya N, Ichioka K, et al. Emergency drainage for urosepsis associated with upper urinary tract calculi. J Urol 173:458–462, 2005 15. Ramsey S, Robertson A, Ablett M, et al. Evidence-based drainage of infected hydronephrosis secondary to ureteric calculi. J Endourol 24:185–189, 2010 16. Pearle MS, Pierce HL, Miller GL, et al. Optimal method of urgent decompression of the collecting system for obstruction and infection due to ureteral calculi. J Urol 160:1260–1264, 1998 17. Mokhmalji H, Braun PM, Martinez Portillo JF, et al. Percutaneous nephrostomy versus ureteral stents for diversion of hydronephrosis caused by stones: a prospective, randomized clinical trial. J Urol 165:1088–1092, 2001 18. Kuntz JA, Berent AC, Weisse CW, et al. Double pigtail ureteral stenting and renal pelvic lavage for renal-sparing treatment of obstructive pyonephrosis in dogs: 13 cases (2008-2012). J Am Vet Med Assoc 246:216–225, 2015
Perioperative Occlusion of a Subcutaneous Ureteral Bypass Secondary to a Severe Pyonephrosis in a Birman Cat Bertrand Vedrine, DVM Keywords: cat ureter ureterolithiasis lithiasis pyonephrosis subcutaneous ureteral bypass Clinique Vétérinaire Seinevet—5, Place Cauchoise, 76000 Rouen, France E-mail: [email protected] (B. Vedrine)
A B STR AC T A subcutaneous ureteral bypass (SUB) was placed in a 10-year-old Birman cat for management of unilateral ureterolithiasis. Perioperative occlusion of the nephrostomy tube of the SUB device happened secondary to a severe pyonephrosis. Flushing of the system throught the subcutaneous shunting port was made with saline solution after clamping the urinary bladder catheter. Repetitive flushing of the device was performed daily for 3 days to be sure of the remanent patency of the catheter. Repetitive flushing of the SUB device is a successful renal-sparing treatment for pyonephrosis in a cat and may be considered as an effective treatment option for this condition. & 2017 Elsevier Inc. All rights reserved.
Introduction Subcutaneous ureteral bypass has recently been described to manage ureteral occlusion or stricture, particularly in case of feline ureteroliths. It involves the placement of a nephrostomy tube and a cystotomy tube that are connected subcutaneously to a shunting port, allowing for urine drainage from the kidney directly to the bladder, bypassing the ureter.1-7 As compared to ureteral stents, the SUB devices have a larger bore tubing and offer the capacity to flush the system via the subcutaneous port with a reduction of the risk of subsequent occlusion.1-11 This case reports a pyonephrosis that has led to an occlusion of the nephrostomy tube of a SUB device and the restoration of the ureteral patency in the short-term follow-up in a Birman cat.
Case history A 10-year-old 3.4 kg female Birman cat was evaluated for apathy and anorexy. Clinical examination did not show abnormality. Renal insufficiency was noticed (U ¼ 90 mg/dL, C ¼ 2.6 mg/dL, P ¼ 5.4 mg/dL), and abdominal ultrasound revealed the presence of ureterolithiasis in the right ureter. Ureteral occlusion might be present on account of a pyelic dilatation. Medical management was tried firstly with analgesics, intravenous fluid therapy, and diuretics to encourage the passage of the lithiasis. Control ultrasound made 2 “days” after admission did not reveal migration of the ureteroliths, little improvement of the renal failure was present (U ¼ 80 mg/dL, C ¼ 3 mg/dL). Then, surgical management was decided. The animal was premedicated with 0.2 mg/kg morphine chlorhydrate (morphine chlorhydrate, Aguettant, Lyon, France) IV, and induced with 4 mg/kg propofol (Propovet, Axience, Pantin, France) IV. Anesthesia was maintained with a nonrebreathing Bain’s delivery system with isoflurane (Vetflurane, http://dx.doi.org/10.1053/j.tcam.2017.05.006 1527-3369 & 2017 Topics in Companion Animal Medicine. Published by Elsevier Inc.
Virbac, Carros, France) in an oxygen flow rate of 1 L/min. A midline coeliotomy was performed for placement of a SUB (SUB, Norfolk Vet Products, Skokie, IL, USA) device. When the nephrostomy catheter was placed in the right kidney, a high viscosity purulent urine elapsed with difficulty and was collected for bacterial culture and antimicrobial susceptibility testing (Fig 1). Fluoroscopic control was made to assess for any urine leakage before closure, and revealed complete occlusion of the nephrostomy catheter (Fig 2). Flushing of the system through the subcutaneous shunting port was made with saline solution after clamping the urinary bladder catheter. A large amount of purulent debris and clots were removed from the device until tube patency was restored (Fig 3). The day after surgery, control serum chemistry (U ¼ 90 mg/dL, C ¼ 2.6 mg/dL, P ¼ 5.4 mg/dL, Na þ ¼ 148 mEq/L, K þ ¼ 4.9 mEq/L, Cl ¼ 121 mEq/L) and SUB device patency test were performed. Injection of contrast agent through the subcutaneous shunting port revealed recurrence of the nephrostomy tube occlusion. Therefore, repetitive flushing of the device was performed daily for 3 days to be sure of the remanent patency of the catheter.
Fig. 1. Urine sample of the right kidney. A high viscosity purulent urine was present at the time of surgery and led to occlusion of the nephrostomy catheter of the SUB.
B. Vedrine / Topics in Companion An Med 32 (2017) 58–60
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Discussion
Fig. 2. Fluoroscopy made at the end of the SUB placement. Contrast agent injected in the subcutaneous shunting port confirmed the cystostomy catheter patency, but did not fill the nephrostomy catheter on account of its occlusion (arrows).
The cat was discharged from the clinic 3 days after surgery because of improvement of the serum chemistry (U ¼ 60 mg/dL, C ¼ 1.9 mg/dL, P ¼ 5.8 mg/dL, Na þ ¼ 153 mEq/L, K þ ¼ 4 mEq/L, Cl ¼ 124 mEq/L) and the ability for the cat to eat and drink spontaneously. Urine culture made at the time of surgery revealed the presence of Escherichia coli. Subcutaneous injection of 8 mg/kg cefovecin (Convenia, Zoetis, Paris, France) was made, and repeated 15 days after to manage the infection. One month postoperatively the cat had won 200 g and had regained normal activity. Uremia (110 mg/dL) had increased since the last serum chemistry control but creatininemia (2.3 mg/dL) and phosphoremia (5.4 mg/dL) were stable. Fluoroscopic control of the SUB device patency with contrast agent did not reveal recurrence of the occlusion. Moreover, the ureteral patency was restored (Fig 4). Serum chemistry and SUB patency were controlled regularly during 1 year and revealed mild progression of the chronic renal insufficiency without recurrence of the SUB occlusion.
This case reports a pyonephrosis that has led to an occlusion of the nephrostomy tube of a SUB device and the restoration of the ureteral patency in the short-term follow-up in a Birman cat. Reports of complications and long-term outcomes encountered with the SUB device are lacking in the literature because of the recent development of the system and the time required to publish a long-term outcome. Allyson Berent and Chick Weisse have provided a surgical guide for the system for the manufacturer in which they give complications encountered with the placement of more than 100 SUB.12 These include leakage at the nephrostomy or cystotomy tube or shunting port ( o 5%), hemorrhage during nephrostomy tube placement ( o 1%), system occlusion with blood clots, purulent debris, or stones (5%), kinking of the catheter during placement (2%), and urinary tract infections. Perioperative occlusion of a SUB with a blood clot has been described once.5 Pyonephrosis is a dilatation of the renal pelvis with purulent material, typically associated with a ureteral outflow obstruction such as ureteroliths.13 The standard of care for pyonephrosis in human medicine involves emergency drainage of infected urine via endoscopic retrograde lavage and ureteral stent placement or insertion of a nephrostomy catheter.14-17 In dogs pyonephrosis was succefully managed with ureteral stenting in 13 dogs.18 In the case described here, fushing of the high viscosity purulent urine needed to be reapeted 4 times (perioperatively and 3 successive days postoperatively) to ensure proper patency of the device. The presence of the subcutaneous shunting port of the SUB system allowed flushing without the need of endoscopy or coeliotomy.18 Fluoroscopy allowed direct visualization of the occlusion and its progressive improvement as the flushing progressed. Restoration of the ureteral patency after placement of a SUB device has not ever been described. We postulate that the modification of intraureteral pressure following SUB placement may participate to promote the migration of ureteroliths. This case described a perioperative occlusion of the nephrostomy tube of a SUB device secondary to a severe pyonephrosis. Repetitive flushing of the system was a successful renal-sparing treatment in our case and may be considered as an effective
Fig. 3. Flushing process of the nephrostomy tube under fluoroscopic control. The cystostomy catheter was clamped and the nephrostomy catheter was aspirated and flushed with saline solution (A). The normal filling of the urinary bladder and the renal pelvis at the end of the procedure assessed the restoration of the patency (B).
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B. Vedrine / Topics in Companion An Med 32 (2017) 58–60
Fig. 4. Fluoroscopy made 1 month after surgery. Both catheters (nephrostomy and cystostomy) were patents (A). Filling of the ureter with the contrast agent revealed restoration of the ureteral patency too (arrows) (B).
treatment option for this condition. Outcome following SUB placement is lacking for the moment. Further follow-ups are needed to know if restoration of ureteral patency is a common finding after SUB placement, as observed in our case. References 1. Berent AC. Ureteral obstructions in dogs and cats: a review of traditional and new interventional diagnostic and therapeutic options. J Vet Emerg Crit 21:86–103, 2011 2. Berent A, Weisse C, Bagley D. The use of a subcutaneous ureteral bypass device for ureteral obstructions in dogs and cats. European College of Veterinary Internal Medicine Congres, Seville, Spain; 2011 3. Defarges A, Berent A, Dunn M. New alternatives for minimally invasive management of uroliths: nephroliths. Compend Contin Educ Vet 35:E1–E7, 2013 4. Berent A. Interventional radiology and interventional endoscopy of the urinary tract (endourology). J Feline Med Surg 16:51–65, 2014 5. Horowitz C, Berent A, Weisse C, et al. Predictors of outcome for cats with ureteral obstructions after interventional management using ureteral stents or a subcutaneous ureteral bypass device. J Feline Med Surg 15:1052–1062, 2013 6. Kulendra E, Kulendra N, Halfacree Z. Management of bilateral ureteral trauma using ureteral stents and subsequent subcutaneous ureteral bypass devices in a cat. J Feline Med Surg 16:536–540, 2014 7. Garcia de Carellan Mateo A, Brodbelt D, Kulendra N, et al. Retrospective study of the perioperative management and complications of ureteral obstruction in 37 cats. Vet Anaesth Anal 42:570–579, 2015
8. Nicoli S, Morello E, Martano M, et al. Double-J ureteral stenting in nine cats with ureteral obstruction. Vet J 194:60–65, 2012 9. Berent AC, Weisse CW, Todd K, et al. Technical and clinical outcomes of ureteral stenting in cats with benign ureteral obstruction: 69 cases (2006-2010). J Am Vet Med Assoc 244:559–576, 2014 10. Kulendra NJ, Syme H, Benigni L, et al. Feline double pigtail ureteric stents for management of ureteric obstruction: short- and long-term follow-up of 26 cats. J Feline Med Surg 16:985–991, 2014 11. Manassero M, Decambron A, Viateau V, et al. Indwelling double pigtail ureteral stent combined or not with surgery for feline ureterolithiasis: complications and outcome in 15 cases. J Feline Med Surg 16:623–630, 2014 12. Berent A and Weisse C. The SUB: a subcutaneous ureteral bypass system, a surgical guide. www.norfolkvetproducts.com 13. McLoughlin MA. Surgical emergencies of the urinary tract. Vet Clin North Am Small Anim Pract 30:581–601, 2000 14. Yoshimura K, Utsunomiya N, Ichioka K, et al. Emergency drainage for urosepsis associated with upper urinary tract calculi. J Urol 173:458–462, 2005 15. Ramsey S, Robertson A, Ablett M, et al. Evidence-based drainage of infected hydronephrosis secondary to ureteric calculi. J Endourol 24:185–189, 2010 16. Pearle MS, Pierce HL, Miller GL, et al. Optimal method of urgent decompression of the collecting system for obstruction and infection due to ureteral calculi. J Urol 160:1260–1264, 1998 17. Mokhmalji H, Braun PM, Martinez Portillo JF, et al. Percutaneous nephrostomy versus ureteral stents for diversion of hydronephrosis caused by stones: a prospective, randomized clinical trial. J Urol 165:1088–1092, 2001 18. Kuntz JA, Berent AC, Weisse CW, et al. Double pigtail ureteral stenting and renal pelvic lavage for renal-sparing treatment of obstructive pyonephrosis in dogs: 13 cases (2008-2012). J Am Vet Med Assoc 246:216–225, 2015
