A minimally invasive surgical technique for ureteral ostioplasty in two fillies with ureteral ectopia

Andrew R. E. Jones Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, WA 99164.

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Claude A. Ragle Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, WA 99164.

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Abstract

CASE DESCRIPTION 2 fillies, aged 3 months and 1 month, were examined because of urinary incontinence and urine scalding.

CLINICAL FINDINGS In horse 1, ultrasonography did not reveal any structural abnormalities of the kidneys; however, unilateral ureteral ectopia was diagnosed cystoscopically. In horse 2, CT revealed bilateral nephropathy, bilateral distended ureters (up to 3.6 cm in diameter), and bilateral ureteral ectopia. Cystoscopy revealed intramural ureteral ectopia with abnormally caudally positioned ureteral ostia in both horses.

TREATMENT AND OUTCOME Ureteral ostioplasty was performed under cystoscopic guidance. Laparoscopic scissors (horse 1) or a vessel-sealing device (horse 2) was introduced, and the tissue separating the intramural portion of the ureter from the urethra and bladder was cut longitudinally in a cranial direction toward the trigone. After surgery, both horses were continent and voided normal streams of urine for the duration of the follow-up periods of 20 and 9 months for horse 1 and horse 2, respectively.

CLINICAL RELEVANCE Cystoscopically guided ureteral ostioplasty provided an effective and minimally invasive surgical treatment option for correction of ureteral ectopia in 2 fillies.

Abstract

CASE DESCRIPTION 2 fillies, aged 3 months and 1 month, were examined because of urinary incontinence and urine scalding.

CLINICAL FINDINGS In horse 1, ultrasonography did not reveal any structural abnormalities of the kidneys; however, unilateral ureteral ectopia was diagnosed cystoscopically. In horse 2, CT revealed bilateral nephropathy, bilateral distended ureters (up to 3.6 cm in diameter), and bilateral ureteral ectopia. Cystoscopy revealed intramural ureteral ectopia with abnormally caudally positioned ureteral ostia in both horses.

TREATMENT AND OUTCOME Ureteral ostioplasty was performed under cystoscopic guidance. Laparoscopic scissors (horse 1) or a vessel-sealing device (horse 2) was introduced, and the tissue separating the intramural portion of the ureter from the urethra and bladder was cut longitudinally in a cranial direction toward the trigone. After surgery, both horses were continent and voided normal streams of urine for the duration of the follow-up periods of 20 and 9 months for horse 1 and horse 2, respectively.

CLINICAL RELEVANCE Cystoscopically guided ureteral ostioplasty provided an effective and minimally invasive surgical treatment option for correction of ureteral ectopia in 2 fillies.

A 3-month-old 157-kg (345-lb) Quarter Horse filly (horse 1) was referred to the Washington State University Veterinary Teaching Hospital because of a 2-month history of urinary incontinence, first noticed when horse 1 was 3 weeks old and lying down in the paddock. Horse 1 had been evaluated and referred by the owner's veterinarian. On examination at the veterinary teaching hospital, horse 1 was bright, alert, and responsive and had a rectal temperature of 38.5°C (101.3°F; reference range, 37.7° to 38.8°C [100.0° to 102.0°F]), heart rate of 72 beats/min (reference range, 60 to 80 beats/min), and respiratory rate of 24 breaths/min (reference range, 20 to 40 breaths/min). In addition, urine scalding was evident on the hind limbs and perineal area.

Standing sedation of horse 1 was achieved with IV administration of xylazine hydrochloride (1.0 mg/kg [0.45 mg/lb]) and butorphanol tartrate (0.03 mg/kg [0.014 mg/lb]). A flexible endoscopea was used to examine the horse's vagina, urethra, and urinary bladder. The right ureteral ostium was in a normal location, whereas the left ostium was located at the level of the urethral sphincter, and a distended left ureter (approx 1.5 cm in diameter) was evident bulging against the urinary bladder wall as the ureter coursed along the bladder (Figure 1).

Figure 1—
Figure 1—

Preoperative cystoscopic images of a 3-month-old Quarter Horse filly (horse 1; A) and a 1-month-old Gypsy Vanner filly (horse 2; B) with ureteral ectopia. Dorsal is at the top of the images, and the left and right sides of the images correspond with the left and right sides of the horses. A—Note the left ureteral ostium (black arrow) located in the region of the urethral sphincter in horse 1. B—Note the right ureteral ostium (black arrow) in the region of the urethral sphincter and the distended right ureter (white arrow) bulging against the urinary bladder as it courses along the bladder wall in horse 2.

Citation: Journal of the American Veterinary Medical Association 253, 11; 10.2460/javma.253.11.1467

Abnormal results of hematologic analyses included leukocytosis (16.9 × 103 WBCs/μL; reference range, 5.5 × 103 WBCs/μL to 10.5 × 103 WBCs/μL) and hyperfibrinogenemia (plasma fibrinogen concentration, 600 mg/dL; reference range, < 400 mg/dL). No abnormalities were suggested from results of serum biochemical analyses or revealed during ultrasonographic evaluation of the umbilicus and thorax. A urine sample for urinalysis and bacterial culture was collected during the cystoscopic examination.

Two days later (day 3), hematologic testing was repeated, and the WBC count and fibrinogen concentration were within reference ranges. In addition, ultrasonographic evaluation of the kidneys was performed and revealed no abnormalities. Further, results of the urinalysis were unremarkable, and there was no growth on bacterial culture of the urine.

On day 5, ureteral ostioplasty was performed on horse 1. Cefazolin sodium (10 mg/kg [4.5 mg/lb], IV, q 6 h) and flunixin meglumine (1.1 mg/kg [0.5 mg/lb], PO, q 24 h) were administered 1 hour before surgery and for the following 36 hours. The surgical procedure was performed with horse 1 standing and sedated with an initial dose of xylazine hydrochloride (1.1 mg/kg, IV) that was later followed by an additional dose of xylazine hydrochloride (0.5 mg/kg [0.23 mg/lb], IV) and butorphanol tartrate (0.025 mg/kg [0.011 mg/lb], IV). After horse 1 was sedated, its vagina, urethra, and urinary bladder were insufflated with air via the endoscope while the vulva was held closed by hand to maintain distension. A 2% lidocaine hydrochloride solution was sprayed topically through the biopsy channel of the endoscope. With cystoscopic guidance, a Chambers catheter was advanced into the left ureteral ostium, and laparoscopic scissorsb were introduced alongside the catheter. Tissue separating the intramural portion of the ureter from the urethra and bladder was then cut in a cranial direction, starting at the ostium (Figure 2) and proceeding to a point level with the right ureteral ostium in the trigone (Figure 3).

Figure 2—
Figure 2—

Cystoscopic images obtained during ureteral ostioplasty in the horses in Figure 1. A—A Chambers catheter was positioned in the left ureter, and laparoscopic scissors were used to cut the tissue separating the intramural portion of the ureter from the urinary bladder. B—A vessel-sealing device was used to perform ureteral ostioplasty in horse 2.

Citation: Journal of the American Veterinary Medical Association 253, 11; 10.2460/javma.253.11.1467

Figure 3—
Figure 3—

Illustrations (from a ventrodorsal perspective) of the procedure for right ureteral ostioplasty in a horse with ureteral ectopia.

Citation: Journal of the American Veterinary Medical Association 253, 11; 10.2460/javma.253.11.1467

After ureteral ostioplasty was performed, horse 1 was continent and voided a normal stream of urine. Recheck cystoscopy performed 7 days after surgery (day 12) revealed that urine from the left ureter drained into the urinary bladder and that there was minimal inflammation at the transection site (Figure 4). Twenty months' worth of follow-up information was available, and no signs of urinary incontinence were observed in horse 1 during the follow-up period.

Figure 4—
Figure 4—

Cystoscopic images obtained after ureteral ostioplasty of the horses in Figure 1. A—The opening of the treated left ureter (long arrow) in the trigone of the urinary bladder is visible, along with evidence of inflammation and granulation tissue in horse 1. The unaffected right ureteral ostium (short arrow) is also visible. B—The opening of the treated right ureter (long arrow) is now in the urinary bladder, cranial to the urethral sphincter.

Citation: Journal of the American Veterinary Medical Association 253, 11; 10.2460/javma.253.11.1467

A 1-month-old 92-kg (202-lb) Gypsy Vanner filly (horse 2) was referred because of a history of urinary incontinence and urine scalding since birth. The dam of horse 2 had an uncomplicated parturition but a retained placenta. During treatment of the retained placenta, the attending veterinarian noted that horse 2 was incontinent.

Ultrasonography and CT were performed on horse 2 at another institution prior to referral to the Washington State University Veterinary Teaching Hospital. Ultrasonography revealed a dilated right ureter and a mildly lobulated left kidney that had a similar size and echogenicity as the right kidney. Computed tomography revealed that both ureters were symmetrical, markedly distended (ie, up to 3.6 cm in diameter), took tortuous paths from the kidneys toward the urinary bladder, and ran intramurally along the urinary bladder. In addition, the distal openings of the ureters could not be identified clearly; however, it was evident that the ureters continued caudally beyond the neck of the bladder to the level of the hip joints. Further, bilateral nephropathy, more pronounced in the left kidney than the right, was evident on CT images and was most likely a congenital abnormality (eg, renal dysplasia).

On initial examination at the veterinary teaching hospital, horse 2 was bright, alert, and responsive and had a rectal temperature of 38.1°C (100.6°F), heart rate of 102 beats/min, and respiratory rate of 30 breaths/min. The tail and hind limbs of horse 2 were wet with urine, and no abnormalities were noted from results of hematologic or serum biochemical analyses.

Horse 2 was sedated as previously described for horse 1, and standing endoscopy was performed. A distended right ureter coursing along the urinary bladder wall (Figure 1) with the right ureteral ostium at the level of the urethral sphincter was evident. The left ureter could not be identified.

Ureteral ostioplasty was scheduled for day 2 after the initial examination, then treatment with trimethoprim-sulfamethoxazole (30 mg/kg [13.6 mg/lb], PO, q 12 h for 7 days) and flunixin meglumine (1.1 mg/kg, PO, q 24 h for 7 days) was initiated 1 hour before surgery. Horse 2 was sedated with xylazine hydrochloride (1.0 mg/kg, IV), butorphanol tartrate (0.05 mg/kg, IV), and diazepam (0.11 mg/kg [0.05 mg/lb], IV), then placed in left lateral recumbency. A multiple-access laparoscopic portc was used to aid in maintenance of air distension of the vagina and bladder during endoscopy, while allowing passage of the endoscope and instruments. A 2% lidocaine hydrochloride solution was sprayed topically through the biopsy channel of the endoscope, and under cystoscopic guidance, right ureteral ostioplasty was performed with a vessel-sealing device.d Tissue separating the intramural portion of the ureter from the urethra and bladder was transected from the level of the ureteral ostium to the approximate location of the trigone (Figure 3). Ureteroscopy was then performed, and the right ureter, other than being distended, appeared normal.

After surgery, horse 2 had no signs of urinary incontinence and voided a normal stream of urine. A recheck cystoscopy was performed on day 4 (2 days after surgery) and revealed a relatively normal-appearing right ureteral ostium, with urine draining into the urinary bladder cranial to the urethral sphincter (Figure 4); however, the left ureteral ostium was still not seen. It was recommended that the owner closely monitor urination characteristics of horse 2 and return in 2 to 3 months for a recheck cystoscopy and serum biochemical analyses. The owner was satisfied with the outcome and did not bring horse 2 back for the recheck cystoscopy and serum biochemical analyses, but commented that they would have returned if there had been recurrence of clinical signs. Nine months after surgery, horse 2 was reported as thriving and continent.

Discussion

Previously reported surgical treatment options for horses with ureteral ectopia involve major procedures that require general anesthesia and can result in high morbidity and mortality rates. Such procedures include variations of ureteral transposition and ureterocystotomy as well as unilateral nephrectomy.1–7 In previous reports1,2,5–9 involving 10 horses with ureteral ectopia treated by means of ureteral transposition or ureterocystotomy, only 6 survived. Further, treatment with ureterocystotomy failed in 2 additional horses, and these horses subsequently underwent nephrectomy.10,11 Although we were aware of 12 horses that survived after being treated with nephrectomy for ureteral ectopia, many of these horses had nonlethal complications, including incisional complications, chyloabdomen, and peritonitis.3,4,10–14 Additionally, nephrectomy is not an option for horses with bilateral ectopia. We were also aware of 4 additional horses in which surgery was not attempted because the owner declined or the surgery was thought to be extremely difficult owing to the size of the horse.15–18 The technique described in the present report, however, offers many important advantages because of its minimally invasive approach.

In dogs, > 95% of ectopic ureters are classified as intramural19 (ie, the ureter courses submucosally along the bladder and opens caudally in relation to its normal position), as opposed to extramural (ie, the ureter completely bypasses the bladder). Although this classification system has not been used in previous publications pertaining to horses, it has been reported that the distal segments of ectopic ureters run within the bladder wall (ie, intramurally) in horses.20 However, it is not known whether extramural ureteral ectopia occurs in horses.

Cystoscopic diagnosis of ureteral ectopia in a horse was first reported in 199016 and offers the most straightforward method for diagnosis of ureteral ectopia. For the procedure, an endoscope is passed into the bladder and the ureteral ostia are identified. If 1 or both are absent, the endoscope is slowly withdrawn through the urethra so that the operator can look for the missing ostia. Air distension of the vagina and urethra, as facilitated in horse 2 by use of a multiple-access laparoscopic port, can aid in visualization of ureteral ostia, as can the use of pharmaceuticals that discolor the urine.16 During cystoscopic examination of the horses in the present report, the distended ureters were evident coursing intramurally.

In dogs, cystoscopy has been shown to successfully identify ureteral ectopia more frequently than radiography when surgery (ventral cystotomy) is used as the diagnostic standard.21 Although CT has been shown to be more useful than other imaging techniques for diagnosing ureteral ectopia in dogs, cystoscopy had the highest positive and negative predictive values of the diagnostic imaging procedures evaluated, including CT, and investigators have recommended CT in combination with cystoscopy to better allow examination of the entire urinary tract and to more frequently make the correct diagnosis.22 To our knowledge, a similar comparative analysis of diagnostic methods is not available for the procedures in horses. Nonetheless, use of CT to diagnose ureteral ectopia in horses has been reported12,23 but may be limited by availability of the equipment and any size or weight restrictions of the CT gantry and table. For horse 2 of the present report, CT was useful in diagnosing ureteral ectopia; however, the distal openings of the ureters were not evident by CT, which would have been valuable information for surgical planning.

Ultrasonography was used to evaluate the kidneys of both horses in the present report. The procedure revealed no structural abnormalities of the kidneys in horse 1 and revealed a lobulated left kidney and distended right ureter in horse 2. The nephropathy observed bilaterally on CT images from horse 2 was attributed to renal dysplasia. However, the clinical impact of these abnormal findings was not known because serum biochemical indicators of renal function were within reference ranges and the horse was reportedly healthy after discharge.

For the horses in the present report, we made the decision to perform ureteral ostioplasty because the distended ureters could be seen cystoscopically coursing through the bladder wall, indicating that they were intramural rather than extramural. The ureteral ostioplasty procedure we used would not be appropriate for treatment of extramural ectopic ureters, because cutting through the ostium of an extramural ectopic ureter would puncture the ureter and bladder wall, allowing communication with the peritoneal cavity.

Ureteral ostioplasty performed in dogs involves cystoscopy-guided laser ablation of the tissue separating the intramural portion of the ureter from the urethra and bladder24,25 because the size of the urethra prohibits introduction of additional laparoscopic instruments. The procedure performed in the present report achieved the same effect as the technique described in dogs, but with the use of sharp instruments in place of the laser. The vessel-sealing device has an advantage over laparoscopic scissors in that the device can grasp and hold targeted tissue, allowing for evaluation. If a good, safe bite of tissue was obtained, that tissue could be sealed and then cut. This resulted in a more controlled process than use of laparoscopic scissors and had the added benefit of improved hemostasis. The vessel-sealing device negates requirement for additional instruments to hold or protect the ureter during the procedure because the device can both hold the tissue and cut it. We currently plan to continue using the vessel-sealing device in future cases of ureteral ectopia in horses. Nonetheless, laser ablation, as used in small animal surgery, should be investigated to ensure it is a viable technique in horses because the technique may be preferred by veterinarians, depending on instrument availability.

Ureteral ectopia has been reported in colts1,2 less commonly than in fillies. If we had been treating a colt, we would have still performed ureteral ostioplasty; however, a perineal urethrotomy would been performed to facilitate similar access to the urinary tract. Alternatively, a laser fiber could have been passed through the instrument channel of the endoscope, and a laser ablation technique similar to that described in dogs could have been attempted.

We suspect that ureteral ostioplasty could be performed in horses that are older or larger than the horses in the present report. In adult mares, the urethra is 10 to 12 cm cranial to the ventral commissure of the vulva,26 and the ureteral ostia are an additional 4 cm cranial,27 with similar distances when a perineal urethrotomy is performed in male horses. Therefore, the working length (30 cm) of laparoscopic instruments should be sufficient, even when treating an adult horse. Additionally, given that a similar surgery can be performed in dogs as small as 2.7 kg (5.9 lb),24 no smaller-diameter size limitations would be expected in horses.

Having not identified the left ureteral ostium with CT or cystoscopy in horse 2, we decided to perform ostioplasty of the right ureter first and evaluate the clinical outcome. Because the foal became continent, we did not attempt to identify or correct the left ureteral ostium. Given the resolution of incontinence, the left ureter could have opened into the right ureter, although this was not identified during ureteroscopy, or perhaps the left ureter had no distal orifice. Intramural ectopic ureters without distal orifices have been reported in 3 of 18 dogs,19 but whether this occurs in horses is not known.

The present report was the first, to our knowledge, to describe a minimally invasive technique for correction of ureteral ectopia in horses. No complications were encountered in either horse; however, the main complication associated with this minimally invasive technique in dogs is continued incontinence requiring medical treatment and is attributed to concurrent urethral, sphincter, and vesicular abnormalities.24

Our treatment technique avoided entry into the abdominal cavity, which is particularly advantageous in foals because they may be more prone to adhesion formation.28–31 Further, renal tissue should be maintained if possible32; therefore, nephrectomy, although associated with higher success rates than other surgical treatments, is not an ideal surgical solution.

Another advantage of ureteral ostioplasty in horses is that the procedure can be performed with affected horses in a standing position, which avoids the expenses and risks of general anesthesia. In addition, because of the dorsal location of the ureteral ostia, cystoscopy and ureteral ostioplasty are ideally performed with affected horses in a standing position. Although both horses of the present report tolerated a standing position for cystoscopy, only horse 1 tolerated it well for ureteral ostioplasty. Horse 2 was younger and less amenable to be treated in a standing position; thus, left lateral recumbency was chosen for the surgical procedure so that the right ureter was uppermost. General anesthesia was still avoided by use of a combination of drugs that provide sedation, muscle relaxation, and analgesia.33

Surgery of the genitourinary tract with instruments passing through the vagina is classified as a clean-contaminated surgery, according to National Research Council criteria.34,35 Although antimicrobial prophylaxis can be a controversial topic, administration of antimicrobials has been recommended for surgeries that are clean-contaminated or worse.36 We recognized that the horses of the present report received different antimicrobial treatments; however, the pharmaceutical products used were satisfactory choices for urinary tract surgery, because cefazolin has been recommended for genitourinary surgery34,35 and potentiated sulfonamides concentrate in the urine.37

As mentioned previously, we were aware of only 4 reports15–18 of horses with ureteral ectopia for which surgery was not attempted, and this could be a substantial underestimate. Either euthanasia or persistent urine scalding is the most likely outcome of not attempting treatment, and neither is satisfactory. A minimally invasive procedure such as the one described in the present report offers a treatment option for horses with ureteral ectopia that avoids the traditional, more invasive procedures. No complications were encountered in either horse of the present report, although the numbers were limited. We hope that more surgeons will use this technique in treatment of horses with ureteral ectopia and that further investigations will be pursued with larger numbers of cases.

Acknowledgments

The authors thank McKayla Wixom for assistance with illustrations.

Footnotes

a.

EG-2731 gastroscope, PENTAX of America Inc, Montvale, NJ.

b.

Endo Shears 176643, Medtronic, Minneapolis, Minn.

c.

SILS port SILSPT12TA, Covidien Ltd, New Haven, Conn.

d.

LigaSure LF1500, Medtronic, Minneapolis, Minn.

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  • Figure 1—

    Preoperative cystoscopic images of a 3-month-old Quarter Horse filly (horse 1; A) and a 1-month-old Gypsy Vanner filly (horse 2; B) with ureteral ectopia. Dorsal is at the top of the images, and the left and right sides of the images correspond with the left and right sides of the horses. A—Note the left ureteral ostium (black arrow) located in the region of the urethral sphincter in horse 1. B—Note the right ureteral ostium (black arrow) in the region of the urethral sphincter and the distended right ureter (white arrow) bulging against the urinary bladder as it courses along the bladder wall in horse 2.

  • Figure 2—

    Cystoscopic images obtained during ureteral ostioplasty in the horses in Figure 1. A—A Chambers catheter was positioned in the left ureter, and laparoscopic scissors were used to cut the tissue separating the intramural portion of the ureter from the urinary bladder. B—A vessel-sealing device was used to perform ureteral ostioplasty in horse 2.

  • Figure 3—

    Illustrations (from a ventrodorsal perspective) of the procedure for right ureteral ostioplasty in a horse with ureteral ectopia.

  • Figure 4—

    Cystoscopic images obtained after ureteral ostioplasty of the horses in Figure 1. A—The opening of the treated left ureter (long arrow) in the trigone of the urinary bladder is visible, along with evidence of inflammation and granulation tissue in horse 1. The unaffected right ureteral ostium (short arrow) is also visible. B—The opening of the treated right ureter (long arrow) is now in the urinary bladder, cranial to the urethral sphincter.

  • 1. Christie B, Haywood N, Hilbert BJ, et al. Surgical correction of bilateral ureteral ectopia in a male Appaloosa foal. Aust Vet J 1981;57:336340.

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