Use of cystoscopy or cystourethroscopy in treating benign macroscopic hematuria caused by lower urinary tract hemorrhage in three dogs

Jessica F. Himelman 1Department of Interventional Radiology and Endoscopy, Animal Medical Center, 510 E 62nd St, New York, NY 10065.

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Allyson C. Berent 1Department of Interventional Radiology and Endoscopy, Animal Medical Center, 510 E 62nd St, New York, NY 10065.

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Chick W. Weisse 1Department of Interventional Radiology and Endoscopy, Animal Medical Center, 510 E 62nd St, New York, NY 10065.

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Demetrius H. Bagley 1Department of Interventional Radiology and Endoscopy, Animal Medical Center, 510 E 62nd St, New York, NY 10065.

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Abstract

CASE DESCRIPTION

A 5-year-old 11.5-kg (25.3-lb) castrated male Boston Terrier (dog 1), an 8-year-old 27.8-kg (61.2-lb) castrated male Boxer (dog 2), and a 10.5-year-old 15.9-kg (35.0-lb) spayed female Pembroke Welsh Corgi (dog 3) were evaluated because of severe, gross hematuria and suspected idiopathic renal hematuria.

CLINICAL FINDINGS

All 3 dogs had hematuria, anemia, blood clots in their urinary bladders, and unremarkable findings on coagulation and mucosal bleeding time assessments. With cystourethroscopy, lower urinary tract hemorrhage originating from a small lesion in the urinary bladder (n = 2) or urethra (1) and normal-appearing yellow urine jetting from both ureterovesicular junctions were visualized in each dog.

TREATMENT AND OUTCOME

Cystoscopically guided surgical resection of a hemorrhagic lesion of the urinary bladder was performed on dog 1, and histologic evaluation of the resected tissue confirmed urinary bladder telangiectasia. Dogs 2 and 3 each underwent cystourethroscopically guided laser ablation of a hemorrhagic lesion (presumptively diagnosed as hemangioma, angioma, or telangiectasia) in the urinary bladder (dog 2) or urethra (dog 3). The longest follow-up duration was 7 years, and none of the 3 dogs had subsequent recurrence of gross hematuria.

CLINICAL RELEVANCE

Findings suggested that cystourethroscopy should be considered part of the diagnostic plan for hematuria in dogs before pursuing major surgical treatment or when results of conventional diagnostic procedures do not indicate the underlying cause. In addition, histologic results for dog 1 indicated urinary bladder telangiectasia, previously an unreported cause of severe, chronic lower urinary tract hematuria in dogs.

Abstract

CASE DESCRIPTION

A 5-year-old 11.5-kg (25.3-lb) castrated male Boston Terrier (dog 1), an 8-year-old 27.8-kg (61.2-lb) castrated male Boxer (dog 2), and a 10.5-year-old 15.9-kg (35.0-lb) spayed female Pembroke Welsh Corgi (dog 3) were evaluated because of severe, gross hematuria and suspected idiopathic renal hematuria.

CLINICAL FINDINGS

All 3 dogs had hematuria, anemia, blood clots in their urinary bladders, and unremarkable findings on coagulation and mucosal bleeding time assessments. With cystourethroscopy, lower urinary tract hemorrhage originating from a small lesion in the urinary bladder (n = 2) or urethra (1) and normal-appearing yellow urine jetting from both ureterovesicular junctions were visualized in each dog.

TREATMENT AND OUTCOME

Cystoscopically guided surgical resection of a hemorrhagic lesion of the urinary bladder was performed on dog 1, and histologic evaluation of the resected tissue confirmed urinary bladder telangiectasia. Dogs 2 and 3 each underwent cystourethroscopically guided laser ablation of a hemorrhagic lesion (presumptively diagnosed as hemangioma, angioma, or telangiectasia) in the urinary bladder (dog 2) or urethra (dog 3). The longest follow-up duration was 7 years, and none of the 3 dogs had subsequent recurrence of gross hematuria.

CLINICAL RELEVANCE

Findings suggested that cystourethroscopy should be considered part of the diagnostic plan for hematuria in dogs before pursuing major surgical treatment or when results of conventional diagnostic procedures do not indicate the underlying cause. In addition, histologic results for dog 1 indicated urinary bladder telangiectasia, previously an unreported cause of severe, chronic lower urinary tract hematuria in dogs.

A 5-year-old 11.5-kg (25.3-lb) castrated male Boston Terrier (dog 1) was referred to the AMC because of a 6-week history of progressive, gross hematuria and suspected IRH. When originally examined by the referring veterinarian approximately 5 weeks prior to being examined at AMC, dog 1 had unremarkable findings on hematologic analyses. The referring veterinarian performed an exploratory cystostomy, and the only abnormality identified was a large blood clot in the urinary bladder. The blood clot was removed during surgery; however, severe, gross hematuria continued during postoperative hospitalization. Abdominal ultrasonography revealed a large, organized, nonvascular structure (consistent with a blood clot) in the lumen of the urinary bladder, but no other abnormalities, and results of tests for von Willebrand disease and factor VIII deficiency were within reference limits. Dog 1 continued to have gross hematuria, became progressively anemic (PCV, 20%; reference range, 42% to 54%), and subsequently received a transfusion of packed RBCs. Approximately 2 weeks later, dog 1 was evaluated at a referral center because of continued gross hematuria and underwent a second exploratory cystotomy. During the second cystotomy, catheterization of both ureters revealed hematuria detected in the right ureter. Therefore, a presumptive diagnosis of IRH was made. A right-sided ureteronephrectomy was recommended; however, the owner declined and wanted to investigate renal-sparing options. Hematuria and progressive anemia continued, 2 more transfusions of packed RBCs were administered during the week following surgery, and 7 days after surgery, dog 1 collapsed and was returned to the referral center. Abnormalities noted at that time included pale mucous membranes, bounding femoral pulses, tachycardia (heart rate, 140 beats/min; reference range, 70 to 120 beats/min), hyperthermia (rectal temperature, 39.1°C [102.4°F]; reference range, 37.9° to 39.9°C [100.2° to 103.8°F]), anemia (PCV, 20%), and high serum lactate concentration (3.9 mmol/L; reference range, < 2.5 mmol/L). After receiving a transfusion of 1 U of packed RBCs, dog 1 clinically improved and was discharged with prescriptions for ferrous sulfate (3.8 mg/kg [1.7 mg/lb], PO, q 24 h for 30 days) and a Chinese herbal preparation, Yunnan Baiyao (21.7 mg/kg [9.9 mg/lb], PO, q 12 h for 30 days). Gross hematuria continued, and 2 weeks later, dog 1 was evaluated at the AMC IR/IE service.

On initial examination at the AMC IR/IE service, dog 1 had vital signs within reference limits, but also had bounding femoral pulses and gross hematuria. Results of a CBC indicated severe normochromic normocytic nonregenerative anemia (Hct, 16% [reference range, 38.3% to 56.5%]; absolute reticulocyte count, 27,000 reticulocytes/μL [reference range, 10,000 to 110,000 reticulocytes/μL]). Results of serum biochemical analyses were within reference limits, and buccal mucosal bleeding time was 2.5 minutes (reference range, < 4 minutes1). Urinalysis of a naturally voided urine sample revealed gross hematuria, proteinuria (3+), trace ketones, urine pH of 7.0 (reference range, 6.0 to 7.5), and urine specific gravity of 1.046 (reference range, 1.016 to 1.060).

Dog 1 was anesthetized and underwent renal arteriography and cystourethroscopy to identify potential vascular lesions in the kidneys or hemorrhagic lesions in the lower urinary tract, respectively. For the renal arteriography, a right femoral arterial approach and modified Seldinger technique2 were used to access the renal arteries with a 0.035-inch angletipped hydrophilic guidewirea and a 4F Berenstein catheterb to inject iohexolc (3 mL) into each renal artery so that right and left renal arteriograms could be obtained. Results for both sides were normal. For the cystourethroscopy, a flexible ureteroscoped was passed through the urethra and into the bladder. Several large blood clots were observed in the bladder; however, no hemorrhage was noted coming from either ureteral orifice. It was difficult to visualize the bladder wall with the fiber-optic imaging and concurrent hematuria; therefore, percutaneous antegrade cystourethroscopy was performed as previously described3 to utilize rigid cystoscopy for improved visibility and full bladder wall examination. Normal-appearing yellow urine jets were observed from both ureteral orifices during a 10-minute observation. No hemorrhage was detected from the urethra, prostate, or either UVJs; however, a small (approx 1-mm-diameter) vascular defect in the right ventrocraniolateral aspect of the urinary bladder wall was observed to hemorrhage pulsating arterial blood (Figure 1). Because this portion of the bladder was exteriorized for the percutaneous cystourethroscopy approach, the decision was made to surgically resect the lesion, rather than treating it with laser ablation. Surgical resection of the lesion was performed with cystoscopic guidance to ensure complete removal. The bladder wall was then closed with 3–0 poliglecaprone 25 in a simple interrupted pattern, and the bladder was further observed cystoscopically to ensure all bleeding had ceased.

Figure 1—
Figure 1—

Cystoscopic image of a 5-year-old 11.5-kg (25.3-lb) castrated male Boston Terrier (dog 1) evaluated for progressive, gross hematuria of 6 weeks’ duration and suspected IRH. Notice the approximately 1-mm-diameter hemorrhagic lesion (arrow) at the right ventrocraniolateral aspect of the urinary bladder wall and the pulsatile jet of blood (black star) released into the lumen of the urinary bladder (white star).

Citation: Journal of the American Veterinary Medical Association 255, 1; 10.2460/javma.255.1.90

Dog 1 recovered uneventfully, had no evidence of gross hematuria with multiple observed urinations, and was discharged the same day with prescriptions for amoxicillin–clavulanic acid (13.8 mg/kg [6.3 mg/lb], PO, q 12 h for 5 days), tramadol hydrochloride (2.5 mg/kg [1.1 mg/lb], PO, q 8 h for 2 days), and Yunnan Baiyao (21.7 mg/kg, PO, q 12 h for 10 days). Results of histologic evaluation indicated that the resected vascular lesion was mild telangiectasia and that the adjacent urinary bladder wall had changes consistent with lymphoplasmacytic, histiocytic, and eosinophilic cystitis. In the 7 years for which follow-up was available, dog 1 had no recurrence of gross hematuria.

An 8-year-old 27.8-kg (61.2-lb) castrated male Boxer (dog 2) was referred to the AMC for a 1-year history of gross hematuria, which was first detected as macroscopic hematuria when routine annual clinicopathologic analyses were performed by the referring veterinarian. At that time, β-hemolytic Streptococcus spp were identified on bacterial culture of a urine sample obtained by urethral catheterization, and on the basis of susceptibility testing results, the referring veterinarian prescribed cephalexin (20.0 mg/kg [9.1 mg/lb], PO, q 24 h for 10 days). Over the course of the next 6 months, results of multiple recheck urinalyses indicated persistent hematuria despite various antimicrobial treatments. Urinary ultrasonography and abdominal radiography were performed, and results were unremarkable. However, results of cytologic analysis of epithelial cells obtained from the bladder and urethral mucosa by blind traumatic catheterization were consistent with epithelial hyperplasia without overt evidence of malignancy. A full-thickness biopsy of the urinary bladder was recommended, and meloxicam (0.05 mg/kg [0.02 mg/lb], PO, q 24 h for 2 weeks) was prescribed. Hematuria progressed, an episode of collapse occurred, and dog 2 was referred to a different facility for further diagnostic imaging. When evaluated at that referral facility, dog 2 had an arrhythmia and intermittent pulse deficits. On the basis of ECG results, ARVC was presumptively diagnosed. Results of urinalysis on a sample obtained by urethral catheterization confirmed gross hematuria; however, findings were unremarkable for urinary ultrasonography and for hematologic and serum biochemical analyses, including a platelet profile and coagulation panel. A laparotomy and cystotomy were performed and revealed an irregularly bordered left kidney, unremarkable ureters, and brown urine (in the urinary bladder). Both ureters were catheterized easily, and urine collected from each was submitted for urinalysis. In addition, a full-thickness biopsy sample was taken of the urinary bladder wall and submitted for histologic analysis. Recovery from anesthesia was unremarkable.

Results of analyses on samples obtained included microscopic hematuria and urine pH of 7.0 for the ureteral urine samples, histologic evidence of erosive cystitis without characteristics of malignancy of the bladder mucosa, and isolation of Serratia marcescens (> 100,000 colony forming units/mL) from the bladder wall biopsy sample. On the basis of the susceptibility testing results, dog 2 was treated with cefpodoxime (5.4 mg/kg [2.5 mg/lb], PO, q 24 h for 6 weeks). Given the recent history of syncope and presumptive ARVC, dog 2 was also fitted with a Holter monitor and treated with sotalol (2.0 mg/kg [0.9 mg/lb], q 12 h for 90 days) and mexiletine hydrochlroide (5.0 mg/kg [2.3 mg/lb], q 8 h for 90 days).

At recheck examinations over the following 3 months, dog 2 had evidence of progressive normochromic normocytic nonregenerative anemia (Hct, 30%; absolute reticulocyte count, 29,000 reticulocites/μL) and progressive hematuria. Treatment with Yunnan Baiyao (18 mg/kg [8.2 mg/lb], PO, q 12 h) was initiated, and 1 week later, dog 2 had an Hct of 40% but continued to have gross hematuria. Two months later, an ECG was repeated and revealed that the dog's ARVC was well controlled with sotalol and mexiletine as previously prescribed. However, hematuria continued, and dog 2 was referred to the AMC IR/IE service for a third opinion.

On initial examination at the AMC IR/IE service, dog 2 had vital signs within reference limits and, other than gross hematuria, had no clinical signs of lower urinary tract abnormalities. Abdominal ultrasonography focusing on the kidneys and renal blood flow was performed and revealed a chronic renal infarct in the caudal pole of the left kidney, a small cortical cyst in the left kidney, a large blood clot (approx 10 cm in diameter) in the urinary bladder, and small splenic nodules. A venous blood sample was drawn for a CBC and serum biochemical analyses. Results of the CBC indicated mild nonregenerative anemia (Hct, 34.5%; absolute reticulocyte count, 27,000 reticulocytes/μL), whereas results of the biochemical analyses were within reference limits. In addition, buccal mucosal bleeding time (2.0 minutes) was within reference limits. A presumptive diagnosis of IRH was made.

Dog 2 was anesthetized and underwent cystourethroscopy. A flexible ureteroscoped was used to evaluate the urinary bladder, UVJs, and urethra. A large blood clot was found in the urinary bladder, and substantial blood in the bladder obscured good visualization of each ureteral orifice. With ultrasonographic and fuoroscopic guidance, retrograde perineal access was obtained for percutaneous rigid retrograde cystourethroscopy, as previously described.3 A 2.7-mm-diameter, 30° rigid cystoscopee was used through a 14F sheathf inserted into the ischial region of the urethra (Figure 2). During the procedure, irrigation fluid (5% dextrose in sterile water) was used to prevent RBC lysis and improve visualization. Both UVJs were evaluated, and normal-appearing yellow urine jets were observed from each. Blood was seen to flow around the large clot identified earlier in the urinary bladder, and the cystoscope was used to manipulate the clot, explore the entire interior surface of the bladder, and follow the flow of blood. Near the apex of the bladder and from a pinpoint lesion, measuring approximately the diameter of a 600-μm laser fiber, pulsatile hemorrhage was observed (Figure 3). The decision was made not to biopsy the bleeding lesion because of the concern for exacerbating hemorrhage and losing visibility needed to cauterize the site. Instead, a 600-μm diode laser fiberg set at 12 W was used to cauterize the bleeding lesion. No further bleeding was noted. In addition, the large blood clot was sampled for histologic evaluation, but most of it was left in the urinary bladder to break down naturally.

Figure 2—
Figure 2—

Ultrasonographic (A) and fluoroscopic (B through D) images obtained during ultrasonographically and fluoroscopically guided retrograde perineal access for percutaneous rigid retrograde cystourethroscopy of an 8-year-old 27.8-kg (61.2-lb) castrated male Boxer (dog 2) evaluated for hematuria of 1 year's duration and suspected IRH. A—Ultrasonographic image of the ischial region of the urethra (white arrow). B—An 8F balloon-tipped Foley catheter (broad black arrows) traversing the urethra and the catheter's inflated balloon (circle) in the urinary bladder are evident. C and D—An 18-gauge IV catheter (black arrows) has punctured the Foley catheter balloon, and a 0.035-inch guidewire (white arrows) passes through the IV catheter and into the urinary bladder (cross; D). Threaded over the guidewire is a 14F sheath (white asterisks; D) that has been advanced into the urethra, and through this sheath, a 2.7-mm-diameter, 30° rigid cystoscope is used to visualize the mucosa of the urethra and bladder. The ultrasound transducer (white arrowhead; B and C) and a towel clamp (black arrowhead; B and C) are also visible. Cranial is to the right and dorsal is to the bottom of the image (B and C), and cranial is at the top of the image (D).

Citation: Journal of the American Veterinary Medical Association 255, 1; 10.2460/javma.255.1.90

Figure 3—
Figure 3—

Cystourethroscopic images of the left (A) and right (B) UVJs (black arrows) jetting normal appearing yellow urine and of the site of the hemorrhagic lesion (white arrows) on the mucosal surface of the urinary bladder wall before (C and D) and after (E and F) cystourethroscopically guided laser ablation in the dog in Figure 2. The 600-μm diode laser fiber (asterisk) is also visible.

Citation: Journal of the American Veterinary Medical Association 255, 1; 10.2460/javma.255.1.90

Dog 2 recovered uneventfully, had no evidence of gross hematuria after recovery, and was discharged the same day with a prescription for amoxicillin–clavulanic acid (13.8 mg/kg, PO, q 12 h for 5 days). Results of histologic evaluation of the blood clot obtained from the dog's urinary bladder were reported as blood with few bland transitional epithelial aggregates, and on the basis of the small hemorrhagic lesion's appearance, a presumptive diagnosis of a hemangioma was made. During the following 3 years (duration of follow-up available), dog 2 had no recurrence of gross hematuria.

A 10.5-year-old 15.9-kg (35.0-lb) female spayed Pembroke Welsh Corgi (dog 3) was referred to the AMC for chronic, progressive gross hematuria for > 1 year. When dog 3 was initially evaluated by the referring veterinarian for an acute onset of hematuria, results of a CBC and serum biochemical analyses were within reference limits; however, results of a urinalysis on a urine sample obtained by cystocentesis indicated macroscopic hematuria, proteinuria, pH of 6.5, urine specific gravity of 1.011, and 10 to 20 cocci/hpf. Therefore, the referring veterinarian prescribed amoxicillin–clavulanic acid (8.0 mg/kg [3.6 mg/lb], PO, q 12 h for 14 days). Three days later, the dog had substantial hematuria with pollakiuria. The referring veterinarian empirically changed the antimicrobial treatment from amoxicillin–clavulanic acid to enrofloxacin (8.8 mg/kg [4.0 mg/lb], PO, q 24 h for 14 days), and within 2 weeks, abnormal urinary signs at home resolved. The following week, however, dog 3 again developed hematuria and pollakiuria. No growth occurred with bacterial culture of urine obtained by cystocentesis, and abdominal radiography revealed no abnormalities. Another course of enrofloxacin (8.8 mg/kg, PO, q 24 h for 14 days) was prescribed; however, dog 3 did not improve. One week later, urinary ultrasonography was performed and revealed mildly irregular mucosal contour of the urinary bladder wall. For the following 2 months, dog 3 had intermittent hematuria and was repeatedly treated with 14-day courses of enrofloxacin (8.8 mg/kg, PO, q 24 h), resulting in short, periodic resolution of signs. However, 3 months following the last dose of enrofloxacin, hematuria worsened, and the following month, dog 3 was referred to the AMC internal medicine service for a third opinion.

On initial examination at the AMC, dog 3 had vital signs within reference limits and had hematuria without other abnormal lower urinary tract signs. Abdominal ultrasonography revealed a left adrenal gland nodule and a large amount of echogenic mobile material, consistent with blood clots, in the urinary bladder. A venous blood sample was drawn for a CBC, coagulation panel, and serum biochemical analyses. Results of the CBC indicated mild, normochromic, normocytic regenerative anemia (Hct, 36.4%; absolute reticulocyte count, 265,000/ μL); however, results of the coagulation panel and biochemical analyses were within reference limits, except for low serum albumin concentration (2.6 g/dL; reference range, 2.7 to 3.9 g/dL). Results of urinalysis and bacterial culture performed on urine obtained by cystocentesis indicated macroscopic hematuria, pyuria (WBC count, 30 to 50 WBCs/hpf), proteinuria, urine specific gravity of 1.018, and no growth on bacterial culture. Yunnan Baiyao (31.4 mg/kg [14.3 mg/lb], PO, q 14 h, for 30 days) and fenbendazole (50.0 mg/kg [22.7 mg/lb], PO, q 24 h for 3 days) were prescribed.

Two weeks later, dog 3 had persistent hematuria and progressive anemia (PCV, 29%) and therefore underwent cystourethroscopy. A 2.7-mm-diameter rigid cystoscopee was used to evaluate the urethra, urinary bladder, and UVJs. The only abnormal findings were a large, linear blood clot (6 cm long) in the urinary bladder and a small, mildly erythematous pedunculated mass on the mucosa of the left dorsolateral aspect of the urethra, approximately 1 cm caudal to the UVJs. This mass was friable and bled continuously. Because of concern for progressive bleeding, the lesion was not biopsied. Instead, dog 3 was recovered from anesthesia, discharged the same day with amoxicillin–clavulanic acid (12.5 mg/kg [5.7 mg/lb], PO, q 12 h for 5 days), and referred to the AMC IR/IE service for laser ablation of the urethral lesion.

Four days later, dog 3 was evaluated at the AMC IR/IE service. On physical examination, a grade II/VI left apical systolic heart murmur was detected; however, the remainder of the examination was unremarkable. Results of the preanesthetic point-of-care serum electrolyte assessment were within reference limits, and the dog's PCV was 32%, an improvement from 29% 4 days earlier. The buccal mucosal bleeding time was 2.2 minutes. A blood sample was submitted for von Willebrand factor antigen assay by ELISA, and results were 130% (reference range, 70% to 180%). Results of echocardiography indicated degenerative mitral valve disease, stage B1 according to classification guidelines of the American College of Veterinary Internal Medicine.4

Dog 3 was anesthetized for cystourethroscopy and laser ablation of a urethral lesion. A 2.7-mm rigid integrated cystoscopee was used to evaluate the urinary bladder, UVJs, urethra, and vagina. In the urethra, a small, irregularly shaped bleeding mass was located along the left dorsolateral aspect of the bladder wall, approximately 1 cm caudal to the UVJs. A diode laser with a 600-μm laser fiberh and set at 5 W was used to ablate the bleeding mass. After ablation, no further bleeding was noted (Figure 4). A large blood clot was visualized in the urinary bladder; however, the bladder mucosa appeared clinically normal. Both UVJs were monitored and observed to jet normal-appearing yellow urine. The vagina had a moderate amount of white fibrous tissue, samples of which were obtained for histologic evaluation.

Figure 4—
Figure 4—

Cystourethroscopic images of the site of a hemorrhagic lesion (arrow) on the mucosal surface of the urethra before (A) and after (B) cystourethroscopically guided laser ablation treatment in a 10.5-year-old 15.9-kg (35.0-lb) spayed female Pembroke Welsh Corgi (dog 3) evaluated for chronic, progressive gross hematuria of over > 1 year's duration and suspected IRH.

Citation: Journal of the American Veterinary Medical Association 255, 1; 10.2460/javma.255.1.90

Dog 3 recovered uneventfully, had no evidence of gross hematuria after recovery, and was discharged the same day with a prescription for amoxicillin–clavulanic acid (16 mg/kg [7.2 mg/lb], PO, q 12 h for 5 days). A presumptive diagnosis of a urethral hemangioma was made. Three months after laser ablation of the urethral lesion, dog 3 had no recurrence of gross hematuria.

Discussion

Gross hematuria is a common reason for which veterinarians examine dogs and cats. The most common pathological processes resulting in hematuria in animals include urinary tract infections, urolithiasis, cystitis, neoplasia, trauma, and coagulopathy.5 When results of standard diagnostic procedures (eg, clinicopathologic analyses, radiography, and ultrasonography) do not indicate the underlying cause of hematuria, less common causes (eg, IRH) should be considered.6 Each of the 3 dogs of the present report was referred to the AMC for treatment of suspected IRH.

In humans, IRH is reported7–10 to be caused by a ruptured, benign renal pelvic vascular abnormality, such as an angioma or hemangioma, and such lesions have also been identified in dogs6 at our practice. In humans, IRH is typically treated in a minimally invasive manner with ureteroscopy and electocautery,10,11 and in veterinary patients, IRH has more recently been treated with topical sclerotherapy with silver nitrate and povidone iodine infusions, alone or in combination.6,12 In human medicine, cystoscopy, particularly to evaluate the entire mucosa of the bladder, is considered part of a complete urologic evaluation for hematuria.13,14 However, in veterinary medicine, cystoscopy is often reserved for use in animals for which routine diagnostic imaging failed to indicate the underlying cause of hematuria. Cystourethroscopy allows the operator to image the entire urethra, urinary bladder mucosa, UVJs, vestibule, and vagina, and to identify whether the source of hemorrhage is from the upper urinary tract, lower urinary tract, or genital tract.15 Although cystourethroscopy in male dogs can be more technically challenging for visualization of the UVJs and small lesions of the bladder wall, rigid cystoscopy can be accomplished in male dogs with either perineal rigid retrograde access or percutaneous rigid antegrade cystoscopy access. Results for the 3 dogs of the present report further supported that cystourethroscopy is a superior method for accurate visualization of the urogenital tract (including UVJs) in dogs with chronic hemorrhage. For instance, on the basis of findings from surgical ureteral catheterization, 2 of the 3 dogs of the present report were referred for suspected hemorrhage from the upper urinary tract, whereas cystourethroscopy revealed that all 3 dogs actually had chronic hemorrhage from their lower urinary tracts. Vesicular hemorrhage encountered during an exploratory cystotomy may have been overlooked for the 2 dogs in which the hemorrhagic source was misclassifed. In addition, catheterization of a ureter could result in blunt trauma and iatrogenic hemorrhage, also contributing to misclassification of the hemorrhagic source in affected patients.

Each of the 3 dogs in the present report was treated with cystoscopically guided ablation or resection for a chronic hemorrhagic lesion in the lower urinary tract. Although use of cystoscopically guided cauterization for treatment of bleeding lesions ranging from small benign vascular anomalies of the urinary bladder to large bleeding tumors of the urinary bladder mucosa, ureter, and renal pelvis in humans has been reported,16–19 the present report was the first to our knowledge to describe such use in veterinary patients. Because of concern for exacerbation of hemorrhage with biopsy for 2 of the 3 dogs of the present report, biopsy samples were not obtained from dogs 2 and 3 in which hemangioma was presumptively diagnosed on the basis of lesion appearance and similar reports20–26 in human medicine.

Hemangioma of the urinary bladder is a rare finding in human medicine, representing 0.6% of primary tumors of the urinary bladder.20,21 Also in humans, the most common clinical symptom with urinary bladder hemangiomas is recurrent hematuria,22,23 and most (66%) bladder hemangiomas are solitary, small, and sessile with a predilection for the dome, trigone, and posterior wall of the bladder.20 Similarly, dogs 1 and 2 had solitary, small sessile lesions in locations described for bladder hemangiomas in humans. Treatment for urinary bladder hemangioma in humans includes invasive procedures (eg, partial or complete cystectomy) and noninvasive procedures (eg, transurethral endoscopic resection, injection of sclerosing agents, electrocoagulation, and radiation therapy).20–26 Similarly, vaginal hemangioma in 2 young dogs was confirmed by results of histologic evaluation of biopsy samples obtained from the surgically excised lesions,27 for which vaginoscopy was required to localize the sources of ongoing vulvar hemorrhage and for which surgical excision of the lesion was curative in 1 of those 2 dogs.27

In addition to hemangioma, vascular ectasia28–31 of the urinary bladder was also considered a differential diagnosis for the bleeding lesions in the 3 dogs of the present report. However, reported descriptions of vascular ectasia as being a single, clearly defined, small, raised papilla protruding from mucosal surfaces28 or as a focal cluster of dilated tortuous mucosal blood vessels32 did not match the lesions observed in the 3 dogs of the present report. In addition, we were aware of only a single clinical report31 of successful noninvasive treatment (use of argon-plasma coagulation) of vascular ectasia of the colon in a dog, whereas all remaining reports28–30 of vascular ectasia in veterinary patients discuss surgical treatment for ongoing hemorrhage at the site. In the present report, however, the hemorrhagic lesions of 2 dogs were successfully treated with cystoscopically guided laser ablation alone, and the lesion of the remaining dog was successfully treated with surgical resection under cystoscopic guidance.

Telangiectasia of the urinary bladder was histologically diagnosed in dog 1. Telangiectasia of the urinary bladder is extremely rare and has only been reported in humans with ataxia-telangiectasia disease,33,34 Osler-Weber-Rendu disease (a hereditary disorder),35 or a history of cyclophosphamide treatment,36 but not as a primary disease entity. No matter the underlying cause of the telangiectasia, chronic and recurrent hematuria is a consistent symptom in humans.33–36 Electrocauterization has been used to treat telangiectasia of the urinary bladder in humans when recurrence was deemed unlikely or when immediate need for hemostasis was required.33 Dog 1 had no recurrence of hematuria during the 7 years for which follow-up was available, indicating successful treatment of telangiectasia of the urinary bladder with cystoscopically guided surgical resection in a dog. In addition, to our knowledge, the present report was the first regarding successful treatment with cystoscopically guided ablation or resection of benign hemorrhagic lesions in the lower urinary tract in dogs. Although rare, such lesions should be added to the differential diagnosis list for dogs with severe, recurrent hematuria.

Findings indicated that for the 3 dogs of the present report, cystoscopically guided ablation or resection was more successful than exploratory surgery alone. These findings underscored the possibility that surgically assisted ureteral catheterization alone for the diagnosis of renal hematuria may not accurately identify the source of hemorrhage and that full exploration of the urinary bladder, urethra, and UVJs with cystourethroscopy should be considered part of the diagnostic plan for hematuria, especially prior to major surgical treatment, when conventional diagnostic procedures do not indicate the underlying cause, or when appropriate antimicrobial treatment is ineffective. Rigid cystoscopy can be performed in any size dog or cat if perineal access or percutaneous antegrade access is considered in addition to the more typical retrograde cystourethroscopy.

ABBREVIATIONS

AMC

Animal Medical Center, NY

ARVC

Arrhythmogenic right ventricular cardiomyopathy

IRH

Idiopathic renal hematuria

IR/IE

Interventional radiology and interventional endoscopy

UVJ

Ureterovesicular junction

Footnotes

a.

Weasel Wire, Infiniti Medical LLC, Menlo Park, Calif.

b.

Infiniti Medical LLC, Menlo Park, Calif.

c.

Omnipaque 240, GE Healthcare, Wauwatosa, Wis.

d.

Flex X2 ureteroscope, 2.7-mm, Karl Storz SE & Co KG, Tuttlingen, Germany.

e.

Karl Storz SE & Co KG, Tuttlingen, Germany.

f.

Peel-Away sheath, Cook Medical, Bloomington, Ill.

g.

Vectra diode laser, 980-nm wavelength, Convergent Laser Technologies, Alameda, Calif.

h.

T-1470 Lite Touch diode laser, Convergent Laser Technologies, Alameda Calif.

References

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