Bilateral Ectopic Ureters in a 6-month-old Labrador Retriever JENNIFER LACH A P R I L 9 TH, 2 0 1 4 CLINICAL ADVISOR: DR. MARINA MCCONKEY BASIC SCIENCE ADVISOR: DR. ANTONIA JAMESON JORDAN The Patient 6 month old intact female Labrador Retriever Referred for persistent urinary incontinence *used with permission Past Medical History Leaking urine since acquired at age 2 months Day and night Urine culture at referring veterinarian: urinary tract infection (UTI); treated with 6-week course of cefpodoxime, then ciprofloxacin Resolution of infection, but no resolution of clinical signs Google Images: http://www.greatdogsite.com/ History Otherwise healthy, up-to-date on vaccines, only medication: Advantage excellent appetite, and owners report no vomiting/diarrhea/sneezing/coughing *used with permission On presentation Bright, alert and responsive Temperature: 99.5 degrees F Pulse: 116 beats/min Respiration: 28 breaths/min Google Images: http://hdwallpaperia.com/ Physical Exam: Abnormalities Genitourinary: Urine-soaked hindquarters Dribbled urine around exam room Integument: Vulvar and caudal abdominal skin: multiple pink plaques- flat and cup shaped Rest of physical exam was unremarkable Problem List Urinary Incontinence Cutaneous Plaques Google Images: http://daytonanimallady.blogspot.com/ Differential Diagnoses: Urinary Incontinence Neurologic Non-Neurologic Functional Anatomic Normal Urinary Tract bladder kidney ureter ureter Evans HE, de Lahunta A. Figure 4-12. In: Guide to the Dissection of the Dog, 7th ed. St. Louis(MO): Saunders, Elsevier Inc. 2010:148. Fossum TW. Ectopic Ureter. In: Small Animal Surgery, 3rd ed. St. Louis(MO): Elsevier Health Sciences 2006:646-654. Normal Lower Urinary Tract ureter Urethra Bladder Internal urethral sphincter http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf Bladder Filling ureter Bladder Relaxation -inhibition of pelvic nerve (parasympathetic, S1-S3) -stimulation of hypogastric nerve (sympathetic, L1-L4) Internal urethral sphincter http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf Bladder Filling ureter Bladder Internal urethral sphincter Contraction -stimulation of hypogastric nerve (sympathetic, L1-L4) http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf Bladder Filling ureter Bladder Internal urethral sphincter Contraction -stimulation of pudendal nerve (somatic; S1-S3) http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf Differential Diagnoses: Urinary Incontinence Neurologic Non-Neurologic Functional Anatomic Differential Diagnoses: Urinary Incontinence Functional Urethral Sphincter Mechanism Incompetence Congenital Hormonal Inflammation/Infection Anatomic Congenital: ectopic ureter, ureterocele, persistent paramesonephric duct remnant, etc. Acquired: stones, neoplasia Differential Diagnoses: Urinary Incontinence Functional Urethral Sphincter Mechanism Incompetence Congenital Hormonal Inflammation/Infection Anatomic Congenital: ectopic ureter, ureterocele, persistent paramesonephric duct remnant, etc. Acquired: stones, neoplasia Diagnostics and Results CBC: unremarkable Chemistry Panel: unremarkable Cystocentesis Urinalysis: urine specific gravity of 1.007 Urine Culture: pending Dermatology Consult: DDX: cutaneous inverted papillomavirus, recommended biopsy Focal Urinary Tract Ultrasound ventral Ultrasound Bilateral Ectopic Ureters and Ureteromegaly ventral dorsal Bilateral, Mild Renal Pyelectasia Bilateral, Questionable Nephropathy dorsal Diagnosis Bilateral Ectopic Ureters!! Why Urinary Incontinence? Ectopic Ureter: inserts distally to the trigone of the bladder Ectopic ureter Bladder Internal urethral sphincter http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf Abnormal Embryologic Development Bladder and urethra arise from urogenital sinus Ureters develop from ureteral bud (metanephric diverticulum) off mesonephric duct Urogenital sinus enlarges, ureters migrate caudally → ureter incorporated into sinus wall → Trigone Caudal migration of ureter → Ectopic ureter http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf Ectopic Ureters Intramural vs Extramural Fossum TW. Ectopic Ureter. In: Small Animal Surgery, 3rd ed. St. Louis(MO): Elsevier Health Sciences 2006:646-654. Ectopic Ureters >95% intramural More common in female dogs, median age of diagnosis 6-10 months Treatment Treatment options: Cystoscopic –guided laser ablation of ectopic ureters (CLAEU) Surgery Medical management Google Images: http://denverchiropractor.com/ Cystoscopic-Guided Laser Ablation ventral Figure: Normal view from vestibule, dog in dorsal recumbency Evans HE, de Lahunta A. Figure 4-24. In: Guide to the Dissection of the Dog, 7th ed. St. Louis(MO): Saunders, Elsevier Inc. 2010:158. dorsal http://www.gsvs.org/articles/article.asp?id=40 Cystoscopic-Guided Laser Ablation ventral Figure: Endoscopic images of a dog with ectopic ureters in dorsal recumbency urethra guide wire bladder lumen guide wire guide wire diode laser dorsal http://www.amcny.org/node/1029 Why Cystoscopic-Guided Laser Ablation? Similar success rate to surgery Eliminates need for abdominal surgery and its risks Risks of procedure: anesthesia, UTI, perforation of bladder/urethra/ureter, iatrogenic stricture formation, bleeding Limits of procedure: intramural only; specialized equipment, steep learning curve Prognosis Guarded-poor prognosis 25-58% success rate with surgery or CLA-EU Success: partial or complete resolution of urinary incontinence Half of patients that don’t respond to surgery, may respond to medical management Back to Our Patient Owners elected laser ablation therapy if possible Patient admitted into hospital for cystoscopy +/- laser ablation following morning Cystoscopic-Guided Laser Ablation dorsal Patient was *left ectopic ureter anesthetized, clipped and prepped for cystoscopy Cystoscope was passed retrograde through the vulva and vestibule *PPMD **Insert image of patient’s vestibule At this point (in vestibule) instead of two openings, saw five openings *urethra *scope in right ectopic ureter ventral Cystoscopic-Guided Laser Ablation Both ureters were intramural Procedure performed as previously described Laser pulsations used to break down membranes between both ectopic ureters and the urethra to the level of the bladder neck dorsal ventral Laser Ablation of PPMD dorsal *2 vaginal openings *1 vaginal opening *urethra *urethra A. Normal Vestibule *2 ectopic ureters B. Before *1 vaginal opening *urethra C. After ventral A: http://www.gsvs.org/articles/article.asp?id=40 Last but not least.. Three of the perivulvar plaques were biopsied with a 6mm punch biopsy and submitted for histopathology Patient recovered uneventfully from anesthesia. *used with permission Post-Op Plan Discharged on carprofen and tramadol Recheck with referring veterinarian in 1 week for repeat urine culture and sensitivity Outcome 3 days post-op continent! Urine culture negative Dilute urine: incidental or early kidney dysfunction? Recommended regular monitoring of urinalysis, blood urea nitrogen, creatinine Histopathology of Skin Plaques: Moderate, multifocal, lichenoid lymphoplasmacytic interface dermatitis most consistent with contact dermatitis secondary to chronic urinary incontinence Immunohistochemical stains for papillomavirus were negative Outcome Nine Months Later: Patient still doing well; occasionally leaks when excited but owners very happy *used with permission Cost Cystoscopy and Laser Ablation Procedure $444.80 Hospitalization and Exam Fees $421 Diagnostics $383.91 CBC $42.56 Chemistry Panel $48.89 Ultrasound $140 Cystocentesis $21 Urinalysis $23.22 Urine Culture $28.14 Skin Biopsy $80.10 Anesthesia $300.44 Medications $72.72 ------------------------------------------------------------------------ TOTAL BILL: $1622.87 Google Images: http://amarillocollege.info/ References Berent AC. Endoscopic Treatment of Ectopic Ureters: Short & Long Term Outcomes Using Cystoscopic-Guided Laser Ablation (CLA-EU). ACVS Vet Symposium Proceedings 2011:392395. Berent AC, Weisse C, Mayhew PD, et al. Evaluation of cystoscopic-guided laser ablation of intramural ectopic ureters in female dogs. J Am Vet Med Assoc 2012;240(6):716-725. Cote E. Cystoscopy. In: Clinical Vet Advisor, 2nd ed. St. Louis(MO): Mosby Inc, Elsevier 2011:1239-1241. Cote E. Incontinence, Urinary. In: Clinical Vet Advisor, 2nd ed. St. Louis(MO): Mosby Inc, Elsevier 2011:599-601. Cote E. Urethral Sphincter Mechanism Incompetence. In: Clinical Vet Advisor, 2nd ed. St. Louis(MO): Mosby Inc, Elsevier 2011:1134-1135. Fossum TW. Ectopic Ureter. In: Small Animal Surgery, 3rd ed. St. Louis(MO): Elsevier Health Sciences 2006:646-654. Fletcher TF. Applied Anatomy & Physiology of Dog-Cat Lower Urinary Tract. CVM U Minnesota May 2012: http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf. Fletcher TF, Weber AF. Veterinary Developmental Anatomy (Veterinary Embryology). CVM 6903 2013:41-48. http://vanat.cvm.umn.edu/vanatpdf/EmbryoLectNotes.pdf. Full A. Neurology and Neuropharmacology of Urination. VTMED 5510 Fall 2012:1-7. Reichler IM, Specker CE, Hubler M, Boos A, et al. Ectopic Ureters in Dogs: Clinical Features, Surgical Techniques and Outcome. Vet Surg 2012;41:515-522. Smith AL, Radlinsky MG, Rawlings CA. Cystoscopic diagnosis and treatment of ectopic ureters in female dogs: 16 cases (2005-2008). J Am Vet Med Assoc 2010; 237(2):191-195. References: Images Only Google Images, Accessed Feb 2014. Patient’s owners, used with permission Berent AC, Weisse C. Figure 1 and 3. In: Case Study: Cystoscopic-guided Laser Ablation for Ectopic Ureters. Accessed Feb 2014: http://www.amcny.org/node/1029. Evans HE, de Lahunta A. Figure 4-12. In: Guide to the Dissection of the Dog, 7th ed. St. Louis(MO): Saunders, Elsevier Inc. 2010:148. Evans HE, de Lahunta A. Figure 4-24. In: Guide to the Dissection of the Dog, 7th ed. St. Louis(MO): Saunders, Elsevier Inc. 2010:158. Henderson A. Figure 1. Normal View from Vestibule. In: Advances in Veterinary Cystoscopy. Feb 2007: http://www.gsvs.org/articles/article.asp?id=40. Thank You to: My patient and her owners Advisors, Drs. McConkey and Jameson Jordan Support network – friends, family Class of 2014! *used with permission Questions? *used with permission