JENNIFER LACHAPRIL 9 T H , 2014

CLINICAL ADVISOR: DR. MARINA MCCONKEY

BASIC SCIENCE ADVISOR: DR. ANTONIA JAMESON JORDAN

Bilateral Ectopic Ureters in a 6-month-old Labrador

Retriever

The Patient

6 month old intact female Labrador RetrieverReferred 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 responsiveTemperature: 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 IncontinenceCutaneous Plaques

Google Images: http://daytonanimallady.blogspot.com/

Differential Diagnoses: Urinary Incontinence

Neurologic

Non-Neurologic Functional Anatomic

Normal Urinary Tract

Fossum TW. Ectopic Ureter. In: Small Animal Surgery, 3rd ed. St. Louis(MO): Elsevier Health Sciences 2006:646-654.

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.

kidney

ureter

ureter

bladder

Normal Lower Urinary Tract

Internal urethral sphincter

ureter

http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf

Bladder

Urethra

Bladder Filling

Internal urethral sphincter

ureter

Relaxation-inhibition of pelvic nerve (parasympathetic, S1-S3)-stimulation of hypogastric nerve (sympathetic, L1-L4)

http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf

Bladder

Internal urethral sphincter

ureter

Bladder Filling

Contraction-stimulation of hypogastric nerve (sympathetic, L1-L4)

http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf

Bladder

Bladder Filling

Internal urethral sphincter

ureter

Contraction-stimulation of pudendal nerve (somatic; S1-S3)

http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf

Bladder

Differential Diagnoses: Urinary Incontinence

Neurologic

Non-NeurologicFunctionalAnatomic

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

FunctionalUrethral Sphincter Mechanism Incompetence Congenital Hormonal

Inflammation/Infection

AnatomicCongenital: ectopic ureter, ureterocele, persistent

paramesonephric duct remnant, etc. Acquired: stones, neoplasia

Diagnostics and Results

CBC: unremarkableChemistry Panel: unremarkableCystocentesis

Urinalysis: urine specific gravity of 1.007 Urine Culture: pending

Dermatology Consult:DDX: cutaneous inverted papillomavirus, recommended

biopsy

Focal Urinary Tract Ultrasound

Ultrasound

dorsal

dorsal

ventral

ventral

Bilateral, Mild Renal PyelectasiaBilateral, Questionable Nephropathy

Bilateral Ectopic Ureters and Ureteromegaly

Diagnosis

Bilateral Ectopic Ureters!!

Why Urinary Incontinence?

Ectopic Ureter: inserts distally to the trigone of the bladder

Internal urethral sphincter

Ectopicureter

http://vanat.cvm.umn.edu/LUTeBook/LUTeBook.pdf

Bladder

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% intramuralMore common in female dogs, median age of

diagnosis 6-10 months

Treatment

Treatment options: Cystoscopic –guided laser ablation of ectopic ureters

(CLA-EU) Surgery Medical management

Google Images: http://denverchiropractor.com/

Cystoscopic-Guided Laser Ablation

Figure: Normal view from vestibule, dog in dorsal recumbency

http://www.gsvs.org/articles/article.asp?id=40

ventral

dorsal

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.

Cystoscopic-Guided Laser Ablation

Figure: Endoscopic images of a dog with ectopic ureters in dorsal recumbency

http://www.amcny.org/node/1029dorsal

ventral

guide wire

urethra

guide wireguide wire

bladder lumen

diode laser

Why Cystoscopic-Guided Laser Ablation?

Similar success rate to surgeryEliminates need for abdominal surgery and

its risksRisks 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

**Insert image of patient’s vestibule

*urethra

*left ectopic ureter

Cystoscopic-Guided Laser Ablation

Patient was anesthetized, clipped and prepped for cystoscopy

Cystoscope was passed retrograde through the vulva and vestibule At this point (in

vestibule) instead of two openings, saw five openings *scope in right

ectopic ureter

*PPMD

dorsal

ventral

Cystoscopic-Guided Laser Ablation

Both ureters were intramuralProcedure performed as previously

described Laser pulsations used to break down membranes

between both ectopic ureters and the urethra to the level of the bladder neckdorsal

ventral

Laser Ablation of PPMD

B. Before

C. AfterA. Normal Vestibule

A: http://www.gsvs.org/articles/article.asp?id=40

*urethra

*1 vaginal opening

*2 vaginal openings

*1 vaginal opening

*urethra *2 ectopic ureters *urethra

dorsal

ventral

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 tramadolRecheck 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 $444.80Hospitalization and Exam Fees $421Diagnostics $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 $300.44Medications $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 2011:392-395.

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 permissionBerent 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 ownersAdvisors, Drs. McConkey and Jameson JordanSupport network – friends, familyClass of 2014!

*used with permission

Questions?

*used with permission