The process of surgery must be systematic so that a high standard of care is achieved.
1. Bladder is taken out and is packed and surrounded by gauze swabs so that there is no backflow of urine into the abdomen (seen in the video).
2. Two anchor sutures on either side of the incision. (I don't find this process necessary but some surgery books show this).
3. A syringe to take out a urine sample for analysis (this is done by me) if no urine sample had been collected earlier.
4. Bladder incision below the apex of the bladder away from blood vessels.
5. Stone removal using forceps.
6. I do a 360-degree sweep of the inside of the bladder using artery forceps to feel for more stones. A gritty feeling. (However, X-rays will show the number of radio-dense stones).
6. Irrigate the bladder with normal saline (via urinary catheter or syringe in saline).
7. Pass a catheter from inside the bladder into the urethra to ensure no stones obstruct the urethra, especially in the female cat (seen in the video) or dog.
8. 2 layers of inverting sutures. I find that artery forceps to anchor one end of the first continuous layer which is knotted at both ends. Then another artery forceps to anchor the other end of the 2nd continuous layer. These forceps are useful in providing traction in tightening the continuous sutures.
*9. A syringe of saline is injected into the cat's bladder to ensure that there is no leak from the sutured area (seen in the video). Or syringe in saline from the penile urethra end catheter in male cats or dogs.
Dogs with stones behind the os penis may need to be syringed with a 20-ml syringe of saline to push the stones into the bladder so that they are removed via the bladder incision.
10. I account for all stones removed as shown in the X-rays. The stones are shown to the owner and the numbers are recorded in the medical records. Unless there are thousands. It will be good to take digital images for recording.
11. Some clinics do another X-ray of the bladder after stone removal to prove that no stones are present. This is an additional cost but may be wise in defensive medicine. X-rays show include the kidneys.
12. I make it mandatory for all my vets to send the stones for chemical analysis even if the owner does not agree to it.
13. Advices on the regular monitoring of urine and special diet are ignored by most owners for various reasons. So, some cases of bladder stones do recur.
P.S. 1. I have a video produced on the cost of bladder stone surgery in the dogs and cats in Singapore. The video is at: Video: Costs of bladder stone surgery. The costs just for anaesthesia and surgery are from $800 to $2,000 depending on the time taken to do the surgery.
P.S 2. It is like feast and famine. Sometimes bladder stone cases come together to Toa Payoh Vets. Images of 5 recent bladder stone surgeries done by Dr Daniel at Toa Payoh Vets are shown below:
Case 1. Female dog pees out urinary stones recently
6138 - 6141. Multiple bladder stones. As the dog pees outdoors, the owner said she did not notice any stones being urinated out, till recently when the dog was indoors. Analysis showed they were struvites.
Case 3. Female dog vomits and has a large abdominal distension
6135 - 6136. Bladder rupture in a 12-year-old Maltese. The urethra had been obstructed with stones for some weeks. The dog presented as a swollen abdomen. Blood tests in the vomiting dog showed kidney failure. The owners requested euthanasia after Dr Daniel had repaired the bladder.
Case 4. Male dog has blood in the urine
6170. Urinary stones in a Shih Tzu. The surgery was done on June 4, 2013. The bladder mucosa was 1-cm thick as the owner procrastinated on doing X-rays and surgery for many weeks. The big stone was >2 cm across. The case report is at: Urinary stones in a Shih Tzu
Case 5. Male dog with fits had blood in the urine
6179. A fifth case of another Shih Tzu with fits had calcium oxalate bladder stones removed. He was a rare type who howled for a long time, as if he was being abused. He does it at home too.
He had bruised his surgical area extensively after surgery despite wearing an e-collar. "It is not subcutaneous bleeding," I said to Dr Daniel. "Somehow he used his e-collar's edge to traumatise the surgical area." NSAID painkiller injections and oral tablets were given
Case 6. Female dog with recurring blood in the urine initially had no "crystal" in the urine.
A female poodle with blood in the urine around 2 weeks after consultation with Dr Daniel who had done a urine analysis. "No crystals" were seen in the urine. The dog went home on antibiotics and was OK for around 2 weeks.
I asked the owner why he did not want an X-ray done as I had written that he did not want an X-ray on the urine analysis report. This was done after I had checked with Dr Daniel whether he had advised X-ray. The owner said he was not advised to X-ray his dog and Dr Daniel told him that the haematuria could be due to infection, tumour or stones.
I do review all cases done by my associate vets. In this case, the vet ought to have recorded in his writing in the medical case sheet that the owner did not accept his advice to X-ray.
I got the dog X-ray using air contrast radiography showing a large bladder stone but no mucosal bladder tumours. The dog was catherised to empty the bladder. Then 30 ml of air was syringed into the bladder just before the X-ray.
As the dog had fever and the total white cell count was very high at 41, I advised that the dog be on antibiotics for 7 days and surgery to be done when the dog could eat and is active. Urine tests showed triple phosphate crystals this time. My intern will be producing this case an educational video. This case illustrated the need for writing down "AMA" (Against Medical Advices) when the owner declined X-rays.
Sometimes we want to save money for the owner by not advising X-rays for urinary stones for blood in the urine. Or just take the lateral view.
However, this may not be a best practice in haematuria cases. In this case, I took the ventro-dorsal views too and this view show whether the left kidney has stones. The right kidney has stones as well as the bladder. Without the ventro-dorsal view, it will be hard to tell the owner who actually wanted to know whether the left kidney has stones.
I had two views of the air-contrasted bladder and could use evidence-based medicine to show him that the left kidney was the one with stones. That means that removal of the bladder stones may still result in blood in the urine as the left kidney has stones.
Sometimes I do one view to lower medical costs for the owner but this is not a best practice. Some vets just X-ray the bladder, forgetting the kidneys. Some vets don't analyse the urine. A systematic process is best.
This case illustrated that "NO crystals" do NOT mean no urinary stones and that most owners want to know what is happening to his dog but desire to pay the least medical cost. The cost of living is very high in Singapore and vets do understand the need to provide least cost medicine for the heartlanders. But sometimes, vet get sued or complaints for not doing a proper diagnosis owing to this mindset of least costs to help the average man.