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 Featured Case of the Month: Oliver Twist 1-month-old Gypsy Vanner colt History: Oliver Twist presented to Southwest Equine for surgical correction of a previously diagnosed right ectopic ureter. Oliver Twist had a history of dribbling urine from his penis since he was born. He was evaluated at the University of Florida's Veterinary Medical Center where an ultrasound and double contrast Computed Topography (CT) were performed. The ultrasound revealed a large right ureter and kidney with hydronephrosis (an excessive amount of fluid within the kidney due to backward pressure caused by on obstruction of outflow). The CT showed that Oliver had a right ectopic ureter. Definition of an Ectopic Ureter: Urine is produced in the kidney and flows from the ureters to the bladder. The urine is then stored in the bladder until the bladder becomes full. Once the bladder starts to stretch, the horse will urinate which causes the urine to move from the bladder through the urethra and out of the body. In normal physiology, there are two ureters (one from each kidney) which insert onto the bladder during fetal development. An ectopic ureter is a term used to describe when a ureter inserts onto an abnormal location (does not insert in the normal location on the bladder). This condition occurs more commonly in dogs with the ureter inserting on the urethra, vagina, or the uterus. This condition is more frequently diagnosed in younger animals with typical clinical signs including: urinary incontinence (inability to control urination), dribbling urine, or frequent urination. Physical Exam:
Before surgery, Oliver Twist was started on Phenazopyridine to darken his urine and allow for easy identification of the ureter during surgery. This drug also helps to relieve irritation or spasms of the bladder mucosa. A urinary catheter was also placed to help empty the bladder. He was started on potassium-penicillin and Gentamicin as pre-operative antibiotics. Since ectopic ureters are more common in dogs and have not been reported in horses, the surgery was performed with Dr. Gilson's, a small animal surgeon with Sonora Veterinary Specialists, assistance. During the abdominal explore, a largely dilated ureter was noted on the right side of the abdomen. The ureter was traced back to try to determine it's insertion on the urethra. It was noted to coil on itself and was bluntly dissected out. The ureter's insertion point was located to far caudally and could not be identified. The ureter was transected (cut in half); the caudal portion was ligated (sutured closed) and 3cc of Oxytetracyline was injected into it to help regress the remaining tissue. The cranial portion of the ureter was then translocated to the dorsal aspect of the bladder. In order to accomplish this, a cystotomy (incision in the bladder) was performed and the ureter sutured into the bladder. The remainder of the cystotomy and abdomen were closed, and Oliver Twist recovered uneventfully from surgery. Surgical Pictures:
Post-Operative Hospitalization and Treatments: Oliver Twist did well after his surgery. The urinary catheter was kept in place to ensure his bladder would not become too full until he was able to comfortably urinate. He was given Butorphanol and Detomidine injections, as well as oral Banamine (non-steroidal anti-inflammatory) for pain control. He was also kept on the Phenazopyridine for its analgesic properties to the bladder mucosa. He was also placed on oral trimethoprim-sulfa (TMZ) twice daily to prevent infection. Furthermore, since foals are prone to gastric ulcers during periods of stress and with the use of a NSAID, Oliver Twist was placed on Gastrogard (Omeprazole) as a preventative. Oliver was closely monitored for fever, diarrhea, urination, and signs of colic. Blood work was run daily to ensure that he did not become dehydrated and that his electrolyte levels remained normal. A biochemical profile was also run to ensure that his kidneys were still functioning normally. Oliver Twist remained quiet and comfortable during the first few days after surgery. His vitals remained within normal limits, and he was seen nursing frequently and to be urinating normally around the urinary catheter. By the third day after surgery, the urinary catheter was removed and his pain medication decreased to just the oral Banamine. Oliver Twist continued to do well and urinate normally without the urinary catheter. Furthermore, he was not seen to be dribbling urine out of his penis post-operatively. At Home Instructions: Oliver Twist was sent home four days after his surgery with the instructions to continue the oral banamine and TMZ for five days, and the Gastrogard for 7 days. It was also recommended to stall rest Oliver Twist for 30 days to ensure adequate healing of the abdominal incision and his bladder. Furthermore, it was important to closely observe Oliver Twist's incision for signs of inflammation or infection including: heat, swelling, redness, drainage, or separation of the incision. Finally, Oliver Twist needed to be monitored for any fever, decreased nursing, stranguria (straining to urinate), dribbling of urine, hematuria (blood in the urine), or signs of colic. He was scheduled for a recheck blood work and ultrasound of the right kidney two weeks post-operatively to ensure the hydronephrosis was resolving and his renal values were still normal. Oliver Twist continued to do well at home and was able to urinate normally. | ||||
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