The authors present an overview of lower urinary tract obstruction (LUTO) in the fetus with a particular focus on the insult to the developing renal system. Diagnostic criteria along with the ...challenges in estimating long-term prognosis are reviewed. A proposed prenatal LUTO disease severity classification to guide management decisions with fetal intervention to maintain or salvage in utero and neonatal pulmonary and renal function is also discussed. Stage I LUTO (mild form) is characterized by normal amniotic fluid index after 18 weeks, normal kidney echogenicity, no renal cortical cysts, no evidence of renal dysplasia, and favorable urinary biochemistries when sampled between 18 and 30 weeks; prenatal surveillance is recommended. Stage II LUTO is characterized by oligohydramnios/anhydramnios, hyperechogenic kidneys but absent renal cortical cysts or apparent signs of renal dysplasia and favorable fetal urinary biochemistry; fetal vesicoamniotic shunting (VAS) or fetal cystoscopy is indicated to prevent pulmonary hypoplasia and renal failure. Stage III LUTO is oligohydramnios/anhydramnios, hyperechogenic kidneys with cortical cysts and renal dysplasia and unfavorable fetal urinary biochemistry after serial evaluation; fetal vesicoamniotic shunt may prevent severe pulmonary hypoplasia but not renal failure. Stage IV is characterized by intrauterine fetal renal failure, defined by anhydramnios and ultrasound (US) findings suggestive of severe renal dysplasia, and is associated with death in 24 h of life or end-stage renal disease (ESRD) within the first week of life; fetal vesicoamniotic shunt and fetal cystoscopy are not indicated.
Although anhydramnios due to in utero renal failure has traditionally been considered lethal, in utero interventions offer the potential for pulmonary survival. As fetal interventions become more ...common, questions arise about how to identify and counsel eligible candidates. In this report we describe the presentation and management of a 17-year-old pregnant female who presented from out-of-state with severe lower urinary tract obstruction (LUTO) with associated anhydramnios, focusing on the ethical questions that this case raised.
Background
Obstructive urolithiasis is a common disease associated with a guarded prognosis in small ruminants.
Hypothesis/Objective
The results of physical examination, laboratory analyses, and ...clinical management of male small ruminants presented to 2 referral clinics were investigated to identify variables significantly associated with disease outcome, so as to provide better recommendations to animal owners regarding the management of these patients.
Animals
Two‐hundred ten small ruminants (130 sheep and 80 goats) with confirmed diagnosis of obstructive urolithiasis.
Methods
Clinical findings (including diagnostic imaging) and laboratory results of the 210 animals were reviewed, and relevant information regarding clinical and laboratory variables recorded upon admission and clinical management was retrieved. The association of the different variables with nonsurvival was investigated by univariable and multivariable logistic regression models.
Results
Only 39% of all patients considered for treatment and 52% of those undergoing tube cystostomy survived to be released from the clinic. Nonsurvival was strongly associated with a very poor clinical condition upon presentation, obesity, castration, and evidence of uroperitoneum. Among blood variables, abnormal PCV, severely increased serum creatinine concentrations, and increased activity of the creatine kinase were associated with increased risk of nonsurvival. Presence of signs of colic or macroscopic appearance of urine was not significantly associated with outcome.
Conclusions and Clinical Importance
The prognosis of obstructive urolithiasis was guarded with survival rates of 39% (overall) to 52% (after tube cystostomy). Intact young males with normal body condition presented early in the course of disease had the best chances of survival.
Lower urinary tract (LUT) emergencies are common reasons for small animal patients to be presented to their veterinarians. Patient stabilization and management of life threatening problems is a ...priority in this population. Urethral obstruction is a common LUT emergency. Urethral stent placement has gained popularity over the past decade allowing for a minimally invasive, image-guided method for relief of urethral obstruction in some patient populations. This article focuses on candidate selection, diagnostic workup, stent placement technique, and the expected outcome and complications for patients undergoing urethral stent placement and addresses some additional strategies for interventional management of LUT emergencies.
Anterior urethral valves are a rare cause of obstructed voiding in adolescent children and are often unheard by adult urologists. In this case report, we discuss the management of two adolescent ...patients who were referred to us with obstructive voiding symptoms with a diagnosis of neurogenic bladder and posterior urethral valves respectively but on evaluation were found to have anterior urethral valves. This article highlights the need for considering anterior urethral valve as an important differential diagnosis in children and adolescents presenting with obstructive voiding symptoms so as to avoid delay in diagnosis and management in young boys.
Objectives
The aim of this study was to determine if male cats treated with 7 days of prazosin following relief of urethral obstruction (UO) experienced decreased rates of recurrent urethral ...obstruction (rUO) within 30 days vs those treated with 7 days of placebo.
Methods
All castrated male cats presenting for the first time with UO from May 2014 to August 2017 were eligible for enrollment. Exclusion criteria included the administration of medications or passage of a urinary catheter prior to referral, the presence of heart disease or hypertension requiring medication, prior treatment with glucocorticoids, non-steroidal anti-inflammatory medications, prazosin or phenoxybenzamine, or radiographic identification of cystoliths. Cats were treated with standardized anesthetic and analgesic protocols, standardized indwelling urinary catheter management, and were hospitalized for care. A random numbers table was generated prior to study initiation and cats were randomized to receive either prazosin (0.5 mg PO q12h for 7 days) or placebo in a blinded fashion. A 30-day follow-up with owners via telephone was performed to identify the rate of rUO. Cats that did not receive the full course of study medication were removed from the analysis. The study was unblinded at the end of data collection.
Results
Eighty cats were enrolled and 65 cats completed the study; 12 were excluded because they did not receive the study medication. Sixteen of 65 cats experienced rUO (25%). Of the 16 cats experiencing rUO, five received placebo (n = 5/28 18%) and 11 received prazosin (n = 11/37 30%). Ten of the cats that experienced rUO reblocked while still hospitalized. There was no significant difference in frequency of rUO in cats treated with prazosin vs placebo (P = 0.27).
Conclusions and relevance
Prazosin administered at 0.5 mg PO q12h did not decrease the rate of rUO in this population of obstructed male cats vs placebo. These results further support evidence suggesting that prazosin may not be beneficial in prevention of feline rUO.
Primary valve ablation is preferred to vesicostomy in the initial management of posterior urethral valves. However, some neonates have a prohibitively small urethra. We describe our experience with a ...preoperative urethral catheter regimen to enhance the likelihood of neonatal valve ablation.
We performed a retrospective review of 126 neonates with posterior urethral valves treated between 2003 and 2019 with valve ablation prior to 10 weeks of age. The preoperative indwelling catheter either was gradually upsized to an 8Fr (progressive urethral dilation), was not upsized (nondilated) or was initially larger bore (8Fr only). The primary outcome was the ability to perform primary ablation by neonatal resectoscope. The secondary objective was to establish the parameters for considering progressive urethral dilation as well as its associated risks.
Overall 97% could be ablated. The progressive urethral dilation group had the lowest mean weight (p <0.001). Only a larger catheter at the time of ablation was significantly associated with feasible ablation (p <0.001) and not urethral dilation, the infant's weight or his gestational age. Progressive urethral dilation was associated with a longer duration of catheterization as well as double the rate of febrile urinary tract infections (8.5%) over the nondilated group (3.6%).
A much higher rate of primary ablation is feasible (97%) than previously reported (82%). More important than the infant's weight is whether a 6Fr to 8Fr catheter is in place at ablation. If an initial 6Fr to 8Fr catheter cannot be placed, urethral dilation to 8Fr should be performed before attempting ablation. This is both a technique and preoperative assessment that is useful for operative planning.
Objective
To evaluate the occurrence of abdominal effusion and its association with decompressive cystocentesis in male cats with urethral obstruction.
Design
Prospective observational clinical ...study.
Animals
Forty‐five male neutered, client‐owned cats with naturally occurring urethral obstruction.
Procedures
Laboratory testing and point‐of‐care ultrasonography were performed. Presence of abdominal effusion was evaluated using the Focused Assessment with Sonography for Trauma (FAST) technique at presentation. Decompressive cystocentesis was then performed prior to catheterization by a standardized technique. Repeat FAST examination was performed 15 minutes after cystocentesis and the following day to further assess for the presence of abdominal effusion.
Results
A mean volume of 92.3 ± 35.2 mL of urine was removed from each cat via cystocentesis prior to catheterization. At presentation, 15 of 45 (33%) had abdominal effusion (13/15 with scant effusion, 2/15 with mild), with an additional 7 cats developing scant effusion 15 minutes post‐cystocentesis. By the following day, 4 cats still had scant effusion present. No significant complications secondary to cystocentesis were reported. No association was found between severity of azotemia, or volume removed by cystocentesis, and the presence of effusion at presentation or after decompressive cystocentesis was performed.
Conclusions and Clinical Relevance
A single decompressive cystocentesis prior to catheterization did not lead to development of clinically significant abdominal effusion or other discernable complications and appears to be a safe procedure in this population of patients. Abdominal effusion may be found at presentation in cats with urethral obstruction. The significance of this effusion remains to be determined.
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