Cystotomy, Partial Cystectomy, and Tube Cystostomy

Karen K. Cornell, DVM, PhD, DACVS

Knowledge of the regional anatomy and healing characteristics of the urinary bladder are crucial to successful surgical intervention in common disorders of the bladder. Innervation and blood supply enter the neck region of the bladder on the dorsal surface. Surgical approach to the bladder is via a ventral midline incision. Cystotomy ~s most commonly performed on the ventral surface of the bladder and the incision is closed using absorbable suture material in a single-layer, appositional closure. Removal of urinary calculi is the most common indication for cystotomy and should be accompanied by mucosal b~opsy and culture. After cystotomy for removal of calculi, a lateral radiograph should be made to confirm removal of all calculi. Partial cystectomy is indicated for bladder trauma, neoplasia, patent urachus, and urachal diverticula. A large percentage of the bladder wall can be excised with gradual return to near normal function when the trigone region is preserved. Complete cystectomy is not recommended because of the patient morbidity and client dissatisfaction with these procedures. Tube cystostomy is performed routinely for temporary or permanent urinary diversion. Temporary diversion may be performed concurrently with surgical repair of urethral trauma or to relieve acute urethral obstructions. Permanent cystostomy may be performed m cases of neurogenic bladder atony or bladder cancer. Copyright 2000 by W.B. Saunders Company

bladder is via the pelvic nerve. Sympathetic innervation of the bladder and urethra is via the hypogastric nerves. Somatic innervauon to the striated musculature of the urethra is from the pudendal nerve. Innervation and blood supply enter the bladder neck region on the dorsal surface. Bladder blood supply is provided by the cranial vesicle artery and the caudal vesicle artery, which are terminal branches of the internal pudendal artery.

Surgical Techniques
Approach
The majority of procedures involving the urinary bladder are performed via a caudal ventral midline incision. In the male dog, flush the prepuce with dilute betadine solution and include the prepuce in the surgical preparation of the surgical field, in the event that urmary catheterization is required during the surgical procedure. Begin the skin incision in the region of the umbilicus and curve laterally to avoid the prepuce. When performing a parapreputial incision, ligate and transect the necessary branches of the caudal superficial epigastric vessels. After making the skin and subcutaneous tissue incisions, reflect the prepuce laterally and make a midline incision through the linea alba.

urgery of the urinary bladder is common in both general and referral practice. The most common indication for urinary bladder surgery is removal of cystic calculi. Other indications include traumatic bladder rupture, bladder entrapment, suspicion of urinary bladder neoplas~a, need for urine diversion, and correction of congenital abnormalities including ectop]c ureters and urachal anomahes. Special considerations when performmg urinary bladder surgery include bladder anatomy, bladder environment (such as presence of infection), and viability of urinary bladder tissue.

Cystotomy After completion of the ventral midline approach, identify the urinary bladder and isolate it from the abdomen by using saline-moistened laparotomy sponges. Place stay sutures at the bladder apex and at the caudal extent of the proposed incision to mmimize urine leakage and provide adequate visualization within the bladder (Fig 2). Before the cystotomy, empty the urinary bladder by catheterization or intraoperative cystocentesis using a 22-gauge needle and syringe. Alternatively, the surgeon may empty the bladder after the initial stab incision if a suctmn apparatus is available. Use a scalpel to perform a stab incision and use scissors to extend the incision cranially and caudally.

Anatomy
Important anatomic considerations for bladder surgery include the bladder structure, mnervation, and blood supply (Fig 1). The bladder is &vided into the apex, the body, and the neck. The neck joins the body of the bladder with the urethra. Within the neck, the ureters enter the bladder dorsally in the region called the trigone. Parasympathetic mnervation of the

Dorsal Versus Ventral

The surgeon may perform the cystotomy on the dorsal or ventral surface of the urinary bladder. Gravity dependent urine leakage, increased adhesion to the abdominal wall, and likelihood of calculi formation after precipitation on exposed ventral sutures are concerns in a ventral cystotomy. These concerns have been alleviated by studies comparing these risks in dogs that underwent ventral or dorsal cystotomy, 1,2 Desch et al I compared the prevalence of abdominal wall adhesions in 36 dogs that underwent dorsal cystotomy (n = 12), ventral cystotomy (n = 20), or abdominal incision and aspiration of the

From the Department of Small Animal Medicine, College of Veterinary Medicine, Universityof Georgia,Athens, GA. Address repnnt requests to Karen K. Cornell, DVM, PhD, DACVS, Assistant Professor of Small Animal Medicine, College of Veterinary Medicine, Universityof Georgia,Athens, GA 30677. E-mall: kcornell@calc.vet.uga.edu Copynght 2000 by W.B. Saunders Company 1096-2867/00/1501-0003510.00/0 doi:l 0.1053/svms.2000 7300

Chnical Techniques in SmallAnimal Pracbce, Vol 15, No 1 (February), 2000: pp 11-16

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Sacralnerves Pelvicnerve Internalpudendalartery

. .~ ~ o , Umbilical artery

,,,

""

Pudendalne Vaginal:
ore hra,

~ -

Hypogastricnerve Caudalvesicalartery Cranialvesicalartery

Fig 1. Neurovascular anatomy of the canine bladder is shown,

Ureteral

branch

All,son U G A 2 0 0 0
urmary bladder was closed using a two-layer inverting pattern. The incidence of adhesion to the body wall may be higher in bladders closed using a single layer appositional suture pattern where more suture material is exposed.

urinary bladder (n = 4) and found none of the dogs developed adhesion of the bladder to the ventral body wall. Crowe 2 found similar results in 75 dogs that underwent dorsal (n = 35) or ventral (n = 40) cystotomy performed by third-year veterinary students. In additmn, Crowe noted that visual inspection of the trigone region was significantly improved in dogs undergoing a ventral cystotomy. Interestingly, Crowe noted 4 of the 35 cytotomies performed on the dorsal surface impinged on the ureteral openings. It should be noted that, in both studies, the

Suture Type
Suture type for closure of the urinary bladder has been debated. When deciding on the suture type, consider the presence or absence of infection, urine pH, and the presence of other factors that may delay wound healmg or accelerate degradation of suture material. The presence of neoplasia or traumatic mjury may significantly delay bladder healing. In the normal bladder, mucosal defects heal within 5 days of wounding and wall strength returns to normal in 14 to 21 daysP 4 The majority of absorbable suture materials retain more than 50% of thmr original tensile strength for more than 14 days. Therefore, there is no need to use nonabsorbable suture materials in urinary bladder surgery. In fact, when nonabsorbable suture materials penetrate the mucosa, they provide a indus for urinary calculi formation. Absorbable sutures vary in the rate of reduction of tensile strength in infected urine or alkaline urine. 5 Schiller et aP found that polydiaxanone and chromic gut retained the greatest percentage of original tensile strength in sterile urine and in Escherichia coli inoculated urine when compared with polyglycolic acid, polyglactin 910, and polyglyconate. However, the exceptional performance of chromic gut must be examined in context, because this was an in vitro experiment lacking the normal cellular constituents necessary for degradation of chromic gut by phagocytosis. In the same study, loss of tensile strength was significantly accelerated in alkaline urine regardless of whether the alkaline pH was due to chemmal modification or inoculation with Proteus rmrabilis. One reason to hesitate using polydiaxanone is that, if the suture penetrates the mucosa, it may be present long enough to provide a nidus for stone formation. Julian and Rawtch 6 reported on the use of stainless steel staples (Auto Suture TA 55; United States Surgical Corp, Norwalk, CT) for bladder closure in dogs with noninfected, acutely infected, and chronically infected urinary bladders. Fifty-two bladders were stapled using stainless steel staples; at the ume of necropsy, only 6 staples were found to have penetrated the mucosa.
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Fig 2. Isolate the urinary bladder before cystotomy. Use saline-moistened laparotomy sponges and stay sutures to prevent urine contamination of the abdomen and facilitate visualization within the bladder.

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Minute crystal formation was found associated with one exposed staple. The longest follow-up in this study was 4 months; therefore, it is difficult to extrapolate the long-term outcome of an exposed staple. Stapling of the urinary bladder is not commonly performed in clinical practice. In the clinical setting, the use of any type of absorbable suture is appropriate if the suture does not penetrate the urinary bladder mucosa and all knots are tied securely.

Suture Pattern
Desirable characteristics of a suture pattern are a watertight closure, ease of application, minimization of lncisional tension, maximization of bladder lumen diameter, anatomic realignment of tissues, and no penetration of the mucosa. Comparison of circular bursting wall tension in bladders closed with either a singledayer, simple interrupted, appositional closure or a two-layer continuous inverting closure revealed no difference in strength in the first 24 hours. 7 Therefore, for chronic infection, urolithiasis, and neoplasia in which thickening of the bladder wall is common, use a single-layer, appositional closure to minimize reduction of the lumen diameter. A two-layer inverting pattern, such as a Cushing pattern, oversewn by a Lembert pattern may be used in a bladder of normal thickness. Sutures placed within the wall of the urinary bladder must incorporate the submucosal holding layer but should not penetrate the mucosa. Inject sahne into the bladder lumen to distend the bladder and evaluate the incision for leakage. Lavage the abdominal cavity with warm sterile saline and close routinely.

instances, close the remaining bladder over a small (5 mL) Foley catheter bulb. Reports of materials to augment bladder repair In humans and in dogs are abundant. A recent study of bladder augmentation in dogs reported replacement of 35% to 45% of the bladder surface with grafts of porcine small intestinal submucosa (SIS). n Kropp et al reported no evidence of graft rejection, bladder infection, calculi formation, or urinary incontinence. Four to six months after surgery, bladder capacity of dogs augmented with SIS was not significantly different than preoperative capacity. In contrast, dogs that underwent partial cystectomy of 35% to 45% of bladder surface and primary closure without augmentation had a significantly decreased bladder capacity when compared with presurgical values. Both groups returned to normal bladder capacity by 8 to 12 months after surgery. All dogs had less than 8 mL of residual urine volume when catheterized after voiding.

Indications
Neoplasia. Transitional cell carcinoma (TCC) is the most common bladder tumor in dogs and cats. 1>14 In dogs, TCC is diagnosed most commonly in females, typically involves the trigone region, and is highly invasive. Because of the anatomic location and aggressive biological behavior of TCC, attempts at complete surgical resection are not recommended. Total cystectomy with urinary diversion or creation of a reservoir has been performed for treatment of bladder tumors in dogs, but reported postoperative morbidity associated with these procedures makes them unacceptable to most pet owners. 1~-18 In cats, TCC is more often located in the apex of the bladder; therefore, surgical resection may have a more beneficial role in treatment. In the majority of patients with TCC, histopathologic confirmation of tumor type can be accomplished by submitting tissue obtained by traumatic catheterization. When diagnosis cannot be obtained via catheterization, perform a biopsy. When taking a surgical biopsy specimen from a bladder with suspected neoplasia, make the incision in close proximity to the tumor mass but not within the mass. Partial resection may be attempted with the idea of closing normal bladder tissue without incorporating neoplastic tissue. When attempting complete resection of a bladder mass, remove at least a 2-cm margin of healthy tissue. After resection, change instruments, gloves, and drapes before closure to prevent surgically induced tumor seeding. Tumor seeding of urinary carcinoma to the skin with subsequent tumor growth has been reported in veterinary medicine.19 Patent urachus and urachal diverticula. Patent urachus is the persistence of a patent urachal tube from the urinary bladder to the umbilicus. This condition is uncommon in dogs and cats and is corrected by complete excision of the tube with partial cystectomy and excision of the opening at the umbilicus. Urachal diverticula are thought to be potential cause of recurrent urinary tract infections in dogs. Patients with these diverticula are treated with partial cystectomy. In cats with idiopathic lower urinary tract disease, diverticula of the bladder usually resolve spontaneously. Trauma. Traumatic injury of the bladder is most commonly associated with blunt vehicular trauma, penetrating trauma, or entrapment of the urinary bladder within a hernia. Vehicular trauma victims with pelvic fractures frequently have concurrent urinary tract trauma. 2 The patient's ability to urinate or the retrieval of urine after bladder catheterization

Indications
Urinary Calculi. When performing a cystotomy to remove urinary calculi, make an incision long enough to remove the calculi and provide adequate visualization of the trigone and neck region of the bladder. Remove calculi using forceps or a bladder spoon. After calculi removal, pass a urinary catheter into the distal urethra and flush sterile saline retrograde into the bladder to force any remaining stones from the urethra. After retrograde flushing, pass a urinary catheter normograde from the bladder while flushing with sterile saline to assure that no urinary calculi remain. Before closure of the bladder, obtain a sample of the mucosa for bacteriologic culture, s Calculi must be submitted for quantitative analysis to make recommendations regarding possible dietary prevention. Obtain a lateral radiograph immediately after surgery to assure all calculi have been removed. This recommendation is based on data from a study performed at the University of Minnesota that documented 14% of dogs and 20% of cats that underwent cystotomy for urinary calculi removal had radiographic evidence of remaining calculi after surgery. 9

Partial C y s t e c t o m y When performing a partial cystectomy, approach and isolate the bladder as described for a cystotomy. After isolation, evaluate the bladder for viability by assessment of color, wall thickness, and blood supply. Excise all tissue of questionable viability. It has been reported that up to 75% of the bladder can be resected with return to near normal function during a period of weeks if the trigone region is preserved. 1 In these
CYSTOTOMY, PARTIALCYSTECTOMY,AND TUBE CYSTOSTOMY

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~.

C
Mucosa ~ Submucosa Muscle Serosa Muscle Submucosa Lumen of Bladder Mucosa

Lumen of Jejunum

i
(
2~ ga

Fig 3. Use a serosal patch to reinforce bladder closure. (A) Isolate the traumatized bladder using laparotomy sponges and stay sutures. (B) Resect devitalized bladder tissue and perform primary closure when possible. (C) Suture the antimesenteric border of the jejunum over the site of bladder closure. The continuous suture line should originate at least 5 mm from the primary closure to assure incorporation of viable tissue. (D) Sutures incorporate the submucosal layer but do not penetrate the bladder lumen. (E, F) A second continuous suture line completes the 360 patch over the primary closure.

does not preclude bladder rupture. Positive contrast cystography is the best method for evaluating integrity of the bladder. The majority of bladder ruptures occurs at the apex of the bladder and can be treated by debridement of nonviable tissue and closure of remaining healthy tissue. When a large amount of bladder wall is resected and compromise of lumen diameter is a concern, use a single-layer appositional closure. When lumen diameter is adequate, an inverting pattern may be used. When the viability of bladder tissue at the suture line is questionable, use a serosal patch to reinforce the suture line (Fig 3). 21 A serosal patch involves placing the antimesenteric border of a loop of small intestine over a suture line or defect and securing it with sutures. Place sutures approximately 5 m m from the incision hne or edge of the defect and 3 to 5 m m apart in either an interrupted or a continuous pattern. Sutures must incorporate the submucosa of both the small intestine
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and the urinary bladder but should not penetrate the lumen of either organ. Tube C y s t o s t o m y Cystostomy tube placement can be performed through a caudal ventral midline celiotomy. After adequate exteriorization of the bladder, place a purse-string suture m the ventral surface of the bladder using a nonabsorbable monofilament suture matertal and make a stab incision m the center of the purse-string. Make a paramedian incision through the body wall approximately 2 cm from the ventral midline recision. Pass a mushroom-tip urinary catheter (Bard Urological Dive> sion, CR Bard Inc, Covington, GA) through the paramedian incision and into the bladder lumen through the stab incision (Fig 4). Tighten and tie the purse-string suture. Tack the
CORNELL

Fig 4. Cystostomy tube placement is shown. (A) After isolation of the bladder, place a purse-string suture into the submucosa of the ventral wall and make a stab incision. (B) Pass the mushroom-tip catheter through a paramedian abdominal incision and introduce into the bladder. (C) Tie the purse-string suture and pull the bladder to the paramedian incision using the urinary catheter. (D) Secure the bladder to the internal ventral body wall around the tube exit site with tacking sutures. Anchor the cystostomy tube to the external body.

i n o l s ~ n
Purse-string closed

[ [

/ /

\Paramedian mcmlon

Tacking suture to body wall

bladder to the ventral abdominal wall using interrupted nonabsorbable sutures. Close the ventral midline incision routinely and anchor the urinary catheter to the skin using a nonabsorbable suture material.

Indications
Tube cystostomy is indicated for temporary or permanent urine diversion. Indications for temporary urine diversion include acute bladder or urethral trauma, surgical repair of the urethra, and urinary obstruction. Long-term urine diversion with a cystostomy tube may be indicated m animals with neurogenic bladder atony or transitional cell carcinoma. In many patients with TCC, stranguria due to partial or complete obstruction of the bladder neck or urethra is the most acute life-threatening problem. Permanent placement of a tube

cystostomy has been reported in seven patients with T C C . 22 Although tube placement had no effect on survival times, all owners reported the tube was easily managed at home and stranguria was relieved m six of seven dogs. 22 Tube cystostomy is not indtcated if ureteral obstruction is present; therefore, it is important to evaluate the ureteral openings via excretory urogram or visual inspection at the time of surgery. Long-term tube care is minimal and includes cleaning of the tube-skin interface and maintaining the tube within a bandage or stockinette to prevent trauma to or entrapment of the tube. Presence of a cystostomy tube for long periods of time does mcrease the risk of urinary tract infection. When clinical signs of urinary tract infection are present, perform a urinalysis and urine culture with subsequent administration of appropriate antibiotic therapy.

CYSTOTOMY, PARTIAL CYSTECTOMY, AND TUBE CYSTOSTOMY

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Conclusions
There are many in&cations for surgery of the urinary bladder. Before performing any surgical procedure mvolving the bladder, knowledge of bladder anatomy, healing characteristics, and surgical materials is required. In addition, thorough preoperative evaluation and planning in combination with knowledge of the pathophysiology of common bladder disorders are necessary to assure appropriate therapy with minimal morbidity.
9.

10. 11.

12. 13.

References
1. Desch JP, Wagner SD: Urinary bladder incisions in dogs: comparison of ventral and dorsal. Vet Surg 15:153-155, 1986 2. Crowe DT: Ventral versus dorsal cystotomy: an experimental investigation. J Am Anlm Hosp Assoc 22.382-386, 1986 3. Hastings JC, Van Winkle W, Barker E, et al: The effect of suture materials on healing wounds of the bladder. Surg Gynecol Obstet 140:933-937, 1975 4. Rasmussen F: Healing of the urinary bladder wounds: morphologlc and biochemical studies. Proc Soc Exp Biol Med 123 470-475, 1966 5. Schiller TD, Stone EA, Gupta BS: In vitro loss of tensile strength and elasticity of five absorbable suture materials in sterile and infected canine urine. Vet Surg 22:208-212, 1993 6. Julian MD, Ravitch MM. Closure of the urinary bladder with stainless steel and absorbable staples. Ann Surg 204:186-192, 1986 7. Radasch RM Merkley DF, Wilson JW, et al: Cystotomy closure: a comparison of the strength of appositional and inverting suture patterns. Vet Surg 19:283-288, 1990 8. HamaideAJ, Martinez SA, Hauptman J, et al: Prospective comparison of four sampling methods (cystocentesls, bladder mucosal swab, bladder mucosal biopsy, and urohth culture) to identify urinary tract 14. 15. 16. 17. 18.

19. 20. 21. 22.

infections in dogs with urollthiasls. J Am Anim Hosp Assoc 34 423430, 1998 Lullch JP, Osborne CA, Polzln DJ, et al. Incomplete removal of canine and feline u rocystohths by cystotomy Proceedings of the 11th Annual Conference of the American College of Veterinary Internal Medicine, May 28, 1993, p 937 (abstr) Peacock EE: Healing and repair of viscera, in Peacock EE (ed): Wound Repair (ed 3). Philadelphia, PA, Saunders, 1984, pp 477 Kropp BP, Rippy MK, Badylak SF, et al: Regenerative urinary bladder augmentation using small intestinal submucosa: urodynamlc and histopathologlc assessment in long-term canine bladder augmentations J Uro1155:2098-2104, 1996 Phillips BS: Bladder tumors in dogs and cats Compend Cont Educ Pract Vet 21:540-547, 1999 Norris AM, Lalng EJ, Valh VE, et al: Canine bladder and urethral tumors: a retrospective study of 115 cases (1980-1985). J Vet Intern Med 6:145-153, 1992 Schwarz PD, Greene RW, PatnaikAK" Urinary bladder tumors in the cat: a review of 27 cases. J Am An~m Hosp Assoc 21:237-245, 1985 Stone EA, Walter MC, Goldschmldt MH, et al: Ureterocolonlc anastomosis in clinically normal dogs Am J Vet Res 49:1147-1153, 1988 Stone EA, Withrow SJ, Page RL, et al: Ureterocolonic anastomosis in ten dogs with transitional cell carcinoma. Vet Surg 17:147-153, 1988 McCarthy RJ, Lipowltz AJ, O'Brlen TD: Continent jejunal reservoir (Kock pouch) for urinary diversion in dogs. Vet Surg 21:208-215, 1992 McLoughhn MA, Walshaw R, Thomas MW, et al: Gastric conduit urinary diversion in normal dogs. Part I, Upper urinary tract structure, function, and sepsis. Vet Surg 21 25-32, 1992 Gilson SD, Stone EA: Surgically induced tumor seeding in eight dogs and two cats. J Am Vet Med Assoc 196:1811-1815, 1990 Selcer BA: Urinary tract trauma associated with pelvic trauma. J Am Anim Hosp Assoc 18:785-793, 1982 Crowe DT: The serosal patch: clinical use in 12 an,mals. Vet Surg 13:29-38, 1984 Smith JD, Stone EA, G~lson SD Placement of a permanent cystotomy catheter to relieve urine outflow obstruction in dogs with transitional cell carcinoma. J Am Vet Med Assoc 206:496-499, 1995

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