Saturday, September 29, 2012

1123. Take images of cases to improve your veterinary skills

Taking images of cases with the camera phone to document your cases and to do retrospective studies of your performance will make you a better veterinary surgeon. There may be some parts of the anatomy changes which you might have missed during the examination but images taken will be there for you to review.

For example, in the tough case of the Shih Tzu with perineal urine leakage after a bladder surgery by Vet 3 to remove urinary stones, an image of the swollen perineum (presumed with leaked urine from the traumatised perineal urethra) was taken by me. See:

This is one supporting evidence and there must be others to substantiate this urine leakage (ultrasound of scrotum filled with fluid), swelling of left inguinal area near where Vet 3 made a skin incision to access the bladder for urinary stone removal daily with blood-tinged fluid while the dog was catherised with a smaller sized urinary catheter

Note that the scrotal sac is also swollen and Vet 3 had said that ultrasound revealed fluid. According to the owner, the whole of the lower part of the inguinal area was much swollen and that was why the dog had to be hospitalised for 8 days by Vet 3 who then recommended a 2nd urethrostomy and scrotal ablation to resolve the problem of urine leakage.  This image was taken when the dog was seen at Toa Payoh Vets on Day 9 after Vet 3's bladder surgery which had removed all bladder stones (post-op X-rays showed no stones).

How to resolve this problem with the least cost to the owner? That is the tough part. Will a 2nd urethrostomy and closure of the first urethal stoma and scrotal ablation resolve the problem for once and for all?  Vet 4 at Toa Payoh Vets was asked by the owner to neuter the dog and remove the large left inguinal swelling of the size of an egg and Vet 4 stitched up the urethral stoma (first urethrostomy done by Vet 1). Would this resolve the problem? Well, it did not appear to do so as the left inguinal swelling filled with blood-tinged fluid (I presumed it was urine leakage + blood) of around 30 ml per day for the next 4 days after Vet 4's surgery.
"Closing the urethral stoma so that the dog could pee normally from the tip of the penis is good for the dog," I said to Vet 4. "But there is the daily need to aspirate the 30 ml of blood-tinged fluid from the left inguinal area. It cost the owner around $7,000 to do the past 3 surgeries to remove the bladder stone and given time, your surgical approach may work. But time means money expenditure for the owner. "

As Vet 4 had to go overseas, I took over the case and reviewed the complicated urine leakage problem. This involved talking to Vet 3 as to what had been done. Vet 3 said that an ultrasound revealed fluid inside the scrotum and this was not recorded in the case report as the owner was not charged. Ultrasound can reveal fluid in an organ but will not be able to tell whether it i urine or blood or both.

This is where the perineal swelling in this image substantiates a possible urine leakage.  It is extremely expensive to do dye test to reveal the location of the perineal urethral leakage. The surgery at Vet 3 had cost $2,000 according to the owner.

So, what's the best economical solution now? What is in the best interest of the dog? If expenses keep mounting, the dog may be put to sleep by the owner. A solution must resolve the problem.

My approach was to extend the urethra stoma which had been closed by Vet 4, do scrotal ablation, close up the inguinal sheaths and stitch the urinary catheter to the prepuce to retain it in for around 4 days to let the perineal catheter to heal. This is the theory.

In practice, this worked as the dog is now peeing normally with no blood in the urine when it came back for stitch removal on Sep 28, 2012, around 14 days after my surgery.     

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