Design, fabrication, and evaluation of 3-D-printed cystotomy spoons as a retrieval method in dogs.

OBJECTIVE: Current cystotomy methods often implement the use of off-label devices, resulting in urocystolith extraction difficulty and potentially leading to postoperative complications and discomfort for the patient. The objective of this study was to create 3 novel 3-D printed cystotomy spoons that offer a dedicated solution for removing urocystoliths from a patient's urinary bladder. ANIMALS: Clinical use of the 3 novel 3-D printed cystotomy spoons were ultimately evaluated in 4 dogs and 1 cat that presented for urocystotlith removal at 3 different veterinary hospitals in northwest Arkansas. METHODS: The novel cystotomy spoons were designed using SolidWorks, 3-D printed with a Dental Surgical Guide resin, and underwent prototype testing that included chlorhexidine soaking, autoclave sterilization, 3-point bend testing, and Finite Element Analysis. The efficiency of the spoons was then evaluated through a limited proof-of-concept study utilizing a postoperative questionnaire for the participating clinicians. RESULTS: Practitioner feedback indicated positive experiences using 1 or more of the novel 3-D printed cystotomy spoons while performing a cystotomy surgery. However, successful use of the spoons was ultimately limited to dogs in the 23 to 34 kg weight range. CLINICAL RELEVANCE: Novel 3-D printed cystotomy spoons have the potential to mediate urocystolith extraction difficulty and reduce postoperative complications. Additionally, this research demonstrates how veterinarians might develop custom 3-D models and prints to meet patient-specific needs. As such, further development could impact the standard of healthcare and the veterinary industry by promoting the use of additive manufacturing in veterinary medicine.

Comparison of percutaneous cystolithotomy and open cystotomy for removal of urethral and bladder uroliths in dogs: Retrospective study of 81 cases (2014-2018).

OBJECTIVE: Compare percutaneous cystolithotomy (PCCL) and open cystotomy (OC) for removal of bladder and urethral uroliths. DESIGN: Retrospective study. ANIMALS: Client-owned dogs and cats that underwent PCCL (n = 41) or OC (n = 40) between January 1, 2014 and February 28, 2018 at a referral center. METHODS: Medical records of dogs and cats that underwent a PCCL or an OC were reviewed. History, signalment, physical examination, diagnostic tests, length of the procedure and anesthesia, complications, and duration of hospitalization were recorded. RESULTS: A total 17 cats (PCCL = 10; OC = 7) and 64 dogs (PCCL = 31; OC = 33) were included. There was no significant difference, regardless of species, in the mean surgical time (45 min [24-160 min] and 48.5 min [15-122 min] with P = .54 in dogs, P = .65 in cats) nor mean duration of anesthesia (90 min [50-120 min] and 98 min [54-223 min] with P = .87 in dogs, P = .08 in cats) in the PCCL and OC groups respectively. Number of uroliths did not affect duration of surgery in either group. Complete urolith removal was achieved in 98% of dogs and cats in both groups. The median hospitalization time was significantly shorter in the PCCL group for dogs (11.3 hours [range 4 to 51.3] in the PCCL vs 56.6 hours [range 7.3 to 96] in the OC group; P < .001) but did not differ for cats (24.5 hours [range 8.3 to 30] in the PCCL vs 56.6 hours [range 10.1 to 193.2] in the OC group; P = .08). CONCLUSION AND CLINICAL RELEVANCE: Bladder urolith removal by PCCL procedure is no longer than OC. Further studies are needed to compare the pain related to procedure between PCCL and OC.

Retrospective comparison of open vs minimally invasive cystotomy in 28 cats using a composite outcome score.

OBJECTIVES: The aim of this study was to compare the outcomes of cats undergoing open cystotomy with those undergoing minimally invasive surgery (MIS) for removal of cystic calculi by use of a composite outcome score. METHODS: Twenty-eight cats were retrospectively enrolled and divided into two groups: open cystotomy (n = 14) and MIS (n = 14). The primary outcome measure was a composite outcome score, including three variables: pain scores ⩾2 at either 6 or 12 h postoperatively; failure to remove all stones as determined by postoperative radiographs; and postoperative complications requiring a visit to the hospital separate from the planned suture removal appointment. Other data collected included signalment, history, other procedures performed during anesthesia, willingness to eat the day after surgery and the financial cost of the procedures. RESULTS: There was no significant difference in age, weight, sex or breed between the two groups. The risk of experiencing the composite outcome was 3/14 (21.4%) in the MIS group and 10/14 (71%) in the open procedure group (P = 0.02). The cats in the open surgery group had 8.3 times greater odds of developing the composite outcome than cats in the MIS group (odds ratio 8.3, 95% confidence interval 1.3-74.4; P = 0.02). In the MIS group, 10/14 cats were eating the day after surgery vs 3/14 in the open procedure group (P = 0.02). The procedural cost was higher in the MIS group, with a median cost of US$945 (interquartile range [IQR] US$872-1021) vs US$623 (IQR US$595-679) in the open group (P <0.01). CONCLUSIONS AND RELEVANCE: In this study the composite outcome score provided evidence to support the use of MIS techniques in cats with cystic calculi. The composite outcome score should be considered in future veterinary studies as a promising method of assessing clinically relevant outcomes.

NEOURETEROCYSTOSTOMY AND URETHRAL STENT PLACEMENT IN A BLACK-HANDED SPIDER MONKEY (ATELES GEOFFROYI).

A 27-y-old female black-handed spider monkey (Ateles geoffroyi) was evaluated 13 d after an ovariohysterectomy because of abdominal distension, anorexia, and absent urination. The animal was diagnosed with a uroabdomen and urethral obstruction from computed tomographic findings and fluid creatinine levels. During exploratory laparotomy, a defect in the right ureter was confirmed as the source of the uroabdomen. Utilizing intraoperative fluoroscopy, a urethral obstruction with an irregular luminal filling defect was evident. A self-expanding nitinol urethral stent was placed, and a ureteral transposition was performed. Two months after the procedure, the animal developed dysuria, a urinary tract infection, recurrent bladder distension and a partial urethral obstruction. Treatment with prazosin 1 mg/kg PO q12h improved urination. Reobstruction of the urethra occurred 17 mo postsurgery, and the animal was euthanatized. On postmortem examination, the animal had ingrowth into the stent with proliferative granulation tissue, detrusor muscle degeneration, pelvic adhesions, cystitis, pyelonephritis, and hydronephrosis.

Cystotomy with or without fibrinogen clot removal for refractory cystoid macular edema secondary to branch retinal vein occlusion.

To demonstrate the long-term effect of cystotomy with or without fibrinogen clot removal for treatment-resistant cystoid macular edema (CME) secondary to branch retinal vein occlusion (BRVO). Retrospective clinical study. We retrospectively analyzed medical records of 22 eyes of 22 patients with treatment-resistant CME secondary to BRVO with 12 months observation after cystotomy with or without fibrinogen clot removal. Patients included 11 women and 11 men. The mean ± SD age was 72.7 ± 10.2 years. LogMAR-converted best corrected visual acuity (BCVA) was statistically better at 12 months after surgery (0.30 ± 0.30) than preoperative BCVA (0.39 ± 0.27) (p = 0.01). The central sensitivity of microperimetry (dB) was maintained during follow-up (preoperative sensitivity: 25.4 ± 4.1, postoperative sensitivity at 12 months after the surgery: 25.9 ± 4.2, p = 0.69). Twelve months after surgery, there was a significant improvement in the central retinal thickness (CRT) on optical coherence tomography (OCT) (303.7 ± 80.1) (µm) compared with the preoperative CRT (524.2 ± 114.8) (p < 0.01). In 12 months, CME recurred in 3 of 22 eyes. The preoperative reflectivity in cystoid cavity on OCT was significantly higher in patients with fibrinogen clot removal (n = 5) than in patients without fibrinogen clot removal (n = 17) (p < 0.01). For treatment-resistant CME secondary to BRVO, Cystotomy with or without fibrinogen clot removal may be one of the treatment options.

LONG-TERM EFFECT OF CYSTOTOMY WITH OR WITHOUT THE FIBRINOGEN CLOT REMOVAL FOR REFRACTORY CYSTOID MACULAR EDEMA SECONDARY TO DIABETIC RETINOPATHY.

PURPOSE: To show the long-term effect of cystotomy with or without fibrinogen clot removal for refractory cystoid macular edema secondary to diabetic retinopathy. METHODS: Retrospective analyses of the medical records of 30 eyes of 30 patients with refractory cystoid macular edema secondary to diabetic retinopathy who had followed up for 12 months after the surgery were performed. RESULTS: There were 15 men and 15 women. The mean ± SD age was 68.4 ± 7.9 years. The best-corrected visual acuity (logarithm of the minimal angle of resolution) at 12 months after the surgery (0.33 ± 0.25, Snellen equivalent, 20/42) was statistically better than the preoperative best-corrected visual acuity (0.45 ± 0.33, Snellen equivalent, 20/56) (P < 0.01). The central sensitivity on microperimetry (dB) was not statistically changed between preoperatively (24.0 ± 4.9) and 12 months after the surgery (24.1 ± 4.0) (P = 0.75). The central retinal thickness on optical coherence tomography (µm) at 12 months after the surgery (300.3 ± 99.0) was statistically improved compared with the preoperative central retinal thickness (565.6 ± 198.7) (P < 0.01). During the follow-up period, cystoid macular edema relapsed in seven of 30 eyes. The preoperative cystoid cavity reflectivity on optical coherence tomography in patients with fibrinogen clot removal (n = 16) was significantly higher than that in patients without fibrinogen clot removal (n = 14) (P < 0.04). CONCLUSION: The cystotomy with or without fibrinogen clot removal may be a promising treatment option for refractory cystoid macular edema secondary to diabetic retinopathy.

A New Approach to the Hostile Bladder in Transplantation.

The intravesical and extravesical techniques for ureteral reimplantation, traditionally described, cannot be applied to a very small, contracted bladder, especially in the morbidly obese patient. An alternative approach using a pull-through technique of ureterocystostomy is described in 6 patients with excellent 2-year follow-up.

Removal of lower urinary tract stones by percutaneous cystolithotomy: 68 cases (2012-2017).

OBJECTIVE: To describe the use and outcome of percutaneous cystolithotomy (PCCL) for removal of urethral and bladder stones in dogs and cats. STUDY DESIGN: Retrospective case series. ANIMALS: Sixty-eight client-owned dogs and cats. METHODS: Records were reviewed and analyzed for dogs and cats that underwent PCCL between January 2012 and December 2017. Signalment, clinical presentation, laboratory and imaging data, procedure time, use of lithotripsy, biopsy, perioperative and immediate postoperative complications, hospitalization times, stone composition, and urine culture results were recorded. Owners were contacted by phone or email 3 weeks after the procedure. Follow-up communications with the owner and referring veterinarian were also recorded. RESULTS: Seventy percutaneous cystolithotomies were performed in 59 dogs and nine cats. The median duration of the procedure was 95 minutes (45-420), and lithotripsy was required in 3% (2/70) of PCCL. Complications during the procedure were reported in one case. In eighty-three percent of procedures (58/70), animals were discharged within 24 hours postoperative. Twenty-four percent (16/68) of animals had minor complications (lower urinary tract signs), and one dog had a major complication (surgical wound dehiscence) during the 3 weeks after the operation. Long-term follow-up revealed stone recurrence in 21% of cases followed more than a year after the procedure (7/33). CONCLUSION: Percutaneous cystolithotomy allowed removal of bladder and urethral stones with rapid postoperative recovery and few major perioperative or short-term postoperative complications. CLINICAL SIGNIFICANCE: Percutaneous cystolithotomy provides an attractive minimally invasive surgical alternative for removal of lower urinary tract stones in small animals.

Comparison of initial leak pressures after single- and double-layer cystotomy closure with barbed and nonbarbed monofilament suture material in an ex vivo ovine model.

OBJECTIVE: To compare initial leakage pressure after double-layer inverting and single-layer appositional closures with unidirectional barbed suture or an analogous monofilament absorbable suture in an ex vivo ovine model. STUDY DESIGN: Experimental study. SAMPLE POPULATION: Ovine cadaveric bladders (n = 48). METHODS: A 4-cm ventral cystotomy was performed in each bladder. Bladders were randomly divided into 4 groups (n = 12 each group) and sutured in an open setting with a single-layer appositional or a double-layer inverting pattern of unidirectional 2-0 barbed or an analogous monofilament suture. Intraluminal pressure at initial leakage and leakage location were recorded. Analysis of variance was used to compare initial leak pressure between the 4 groups (P < .05). RESULTS: Ovine urinary bladders closed with double-layer inverting closures leaked at intraluminal pressures about twofold greater than bladders closed with single-layer appositional closures (P < .0001) whether barbed or nonbarbed suture was used (P ≥ .987). Bladders most commonly leaked at the suture hole after single-layer closure. Bladders that had been repaired with a double-layer closure leaked at the knot in nonbarbed closures or at the preconstructed end loop in barbed closures. CONCLUSION: Double-layer closure increased leakage pressures compared with single-layer closures, irrespective of the suture type used. CLINICAL SIGNIFICANCE: This study provides evidence to support double-layer rather than single-layer closure of cystotomies in clinical cases. The use of barbed suture may be suitable for cystorrhaphy in sheep.

Laparoscopic approach for intravesical surgery using pneumovesicum in the management of anterior colporrhaphy mesh erosion and stones around the bladder neck.

INTRODUCTION AND OBJECTIVE: Perforation of the bladder or urethra and erosion of the mesh after cystocele repair surgery are not uncommon and have potentially serious complications. Traditionally, surgical management of such complications has involved excision of the mesh using either a transurethral approach or open surgery. In this video, we present our experience of laparoscopic transvesical surgery for exposed mesh and stone. MATERIALS AND METHODS: Patient was placed in the lithotomy position under general anesthesia and a 30° operating cystoscope was inserted under direct vision. After filling the bladder with 300 mL normal saline, a 5 - mm VersaStep™ bladeless trocar was placed 2 cm above the pubic symphysis. Two more 5 mm trocars were placed bilaterally at 3 cm intervals from the initial trocar site. The pneumovesicum state was maintained at 8 - 12 mmHg and a 5 mm telescope was introduced. Using a curved dissector and curved Mayo scissors, the exposed mesh was mobilized and removed. Interrupted 4 - 0 Vicryl sutures were used to close the defect. To localize the ureteral orifice, intravenous Indigo Carmine was used. The bladder stones were removed through the urethra using a stone basket, guided using a ureteral stent pusher. RESULTS: Total operation time was 55 min and the Foley catheter was removed at post - operative day 5 after postoperative cystography. CONCLUSIONS: Excellent visualization of mesh exposure and ureteral orifice was possible under aparoscopic transvesical surgery, and reconstruction including the mucosa and muscle layer was able to be achieved. This method is useful and feasible, with minimal invasiveness and an early post - operative recovery.

Robot-assisted vesicovaginal fistula repair via a transvesical approach.

OBJECTIVE: The objective of this video is to demonstrate a technique for robot-assisted vesicovaginal fistula (VVF) repair utilizing a mini cystotomy with a transvesical approach. METHODS: A 53-year-old female developed a VVF after she underwent an abdominal hysterectomy for uterine fibroids at an outside facility. She was referred to us following two failed VVF repairs (one vaginal, one abdominal with bladder bivalving and omental flap). After discussing options, she underwent a robotic VVF repair via a transvesical approach. Following port placement, the space of Retzius was mobilized. An intentional cystotomy was made and the camera and working arms advanced into the bladder. The fistula was identified and circumferentially mobilized. The fistula was closed in three layers using absorbable sutures, and care was taken to avoid the ureters. RESULTS: The patient's postoperative recovery was uncomplicated. Follow-up imaging was performed via cystogram at 4 weeks and showed resolution of the fistula. CONCLUSIONS: A robot-assisted transvesical approach using a mini cystotomy to VVF repair is a useful technique especially when previous surgical planes have been used in prior repairs and failed. It maintains a minimally invasive approach and may avoid complications associated with an open abdominal approach.

Simulated management of urinary tract injury during robotic pelvic surgery utilizing the porcine model.

Urologic injury is an infrequent but serious complication of pelvic surgery. Training in the assessment and management of this injury might be enhanced through animated simulation. Our objective was to assess the intraoperative management of urologic injury with robotic pelvic surgery using a simulated injury animal model. We used a female domestic pig to create three types of urologic injury, which we then managed with robotically assisted surgery. An edited video of the model was assessed by 14 senior learners and 10 attending faculty. The assessments included key competencies and domains of fidelity. A scale of poor, fair, or good was utilized. The defects and repairs simulated those seen in humans, both anatomically and surgically, although deficiencies were noted. Related to fidelity of the anatomy of the ureter and bladder, lower ratings were given for some of the key competencies (determining the relationship to the trigone, ureteral mobilization, repair of all 3 injuries). The porcine model for simulation of urologic injury during robotically assisted pelvic surgery may be useful for training purposes.

Retrospective Validation of an Algorithmic Treatment Pathway for Necrotizing Pancreatitis.

The role of surgical intervention for necrotizing pancreatitis has evolved; however, no widely accepted algorithm has been established to guide timing and optimal modality in the minimally invasive era. This study aimed to retrospectively validate an established institutional timing- and physiologic-based algorithm constructed from evidence-based guidelines in a high-volume hepatopancreatobiliary center. Patients with necrotizing pancreatitis requiring early (≤six weeks from symptom onset) or delayed (>six weeks) surgical intervention were reviewed over a four-year period (n = 100). Early intervention was provided through laparoscopic drain-guided retroperitoneal debridement (n = 15) after failed percutaneous drainage unless they required an emergent laparotomy (due to abdominal compartment syndrome, bowel necrosis/perforation, or hemorrhage) after which conservative, sequential open necrosectomy was performed (n = 47). Robot-assisted (n = 16) versus laparoscopic (n = 22) transgastric cystgastrostomy for the delayed management of walled-off pancreatic necrosis was compared, including patient factors, operative characteristics, and 90-day clinical outcomes. Major complications after early debridement were similarly high (open 25% and drain-guided 27%), yet 90-day mortality was low (open 8.5% and drain-guided 7.1%). Patient and operative characteristics and 90-day outcomes were statistically similar for robotic versus laparoscopic transgastric cystogastrostomy. Our evidence-based algorithm provides a stepwise approach for the management of necrotizing pancreatitis, emphasizing minimally invasive early and late interventions when feasible with low morbidity and mortality. Robot-assisted transgastric cystogastrostomy is an acceptable alternative to a laparoscopic approach for the delayed treatment of walled-off pancreatic necrosis.

[TUEB (TRANSURETHRAL ENUCLEATION WITH BIPOLAR) COMBINED WITH CYSTOTOMY OF THE GIANT PROSTATIC HYPERTROPHY: A CASE REPORT].

A 75-year-old man with urinary retention was referred to our hospital. Pelvic magnetic resonance imaging showed that his prostate was remarkably enlarged, with an estimated prostate weight of 509 g. He underwent TUEB (transurethral enucleation with bipolar) combined with cystotomy. The surgical specimen weighed 349 g. He did well postoperatively, and his urinary function was improved at 3 months after the operation. Although transurethral methods are effective for resection of adenoma and control of bleeding, effective performance of the procedure with a resectoscope and resection of an adenoma in cases of giant prostatic hypertrophy need to be considered on a case-by-case basis.

[Giant bladder stone]. / Lithiase vésicale géante.

A 67 years old patient has consulted for hypogastric pain, associated with a pollakiuria running for more than 12 months. The medical story reported genital prolapse, some episodes of haematuria and dysuria. Pelvic ultrasound showed a voluminous image of lithiasic appearance with irregular borders. A cystotomy was performed under perimedullary anesthesia allowing the extraction of a giant bladder stone measuring 7.2 cm as major axis and 5.5 cm for small axis.

Giant Urethral Calculus without Acute Urinary Retention.

A 46-year gentleman presented with a left-sided lumbar region pain without fever or dysuria. He denied episodes of acute urinary retention. There was a hard mass at the distal urethra with normal laboratory blood tests. Computed tomography urogram revealed a concurrent left renal staghorn calculus and large distal urethral stone. The urethral stone was fragmented via endourologic technique successfully. We report a case of a non-obstructing large urethral calculus in a gentleman with concurrent left renal staghorn calculus and discuss the literature review.

Murine model for the evaluation of candiduria caused by Candida tropicalis from biofilm.

To evaluate the pathophysiology of catheter-associated candiduria, the bladders of female mice were infected with Candida tropicalis. One group was implanted with a catheter fragment with preformed biofilm by cystotomy technique, while another group received, in separate, a sterile catheter fragment and a correspondent yeast suspension. The bladder tissues were examined by histopathology and the quantity of colony forming units was evaluated. All the animals presented inflammation and the presence of C. tropicalis was observed in the tissue within 72 h of the introduction of biofilm, while 75% of the mice remained infected after 144 h. However, only 50% of animals from the group infected with C. tropicalis in suspension (planktonic yeasts), exhibited such signs of infection over time. The cystotomy technique is therefore viable in mice, and is an effective model for evaluating the pathogenesis of candiduria from catheter biofilms. The model revealed the potential of C. tropicalis infectivity and demonstrated more effective evasion of the host response in biofilm form than the planktonic yeast.

Minimally Invasive Management of Concomitant Vesicovaginal and Ureterovaginal Fistulas After Transabdominal Hysterectomy: Laparoscopic Vesicovaginal Fistula Repair With Ureteroneocystostomy Using a Boari Flap.

STUDY OBJECTIVE: To demonstrate a laparoscopic approach for repair of concomitant vesicovaginal and ureterovaginal fistulas as a troublesome complication of transabdominal hysterectomy (TAH). DESIGN: Video presentation with narration demonstrating a laparoscopic approach for repair of a vesicovaginal fistula and ureter reimplantation using a bladder (Boari) flap (Canadian Task Force Classification III). SETTING: Mothers and Children Hospital, Shiraz University of Medical Sciences. The local Institutional Review Board deemed this video exempt from formal approval. INTERVENTIONS: This 55-year-old woman had a history of continuous urine leakage from the vagina for 10 days after undergoing a complicated TAH. She had sustained an injury to the posterior bladder wall and right ureteral transection during TAH, which had been recognized and managed by ureteroneocystostomy into the posterior bladder wall over a double-J stent and bladder repair. A 4-week course of conservative therapy failed to manage her continuous urine leakage. After cystoscopic evaluation and catheterization of the fistula tract and left ureter, 4-port transperitoneal laparoscopy was performed. The right ureter was identified, divided, and mobilized. The vesicovaginal pouch was entered, the posterior wall of the bladder was opened at the level of the fistula, and the fistula tract was dissected. Once the bladder was separated from the vaginal cuff, both were repaired with absorbable sutures, and an omental flap was interposed between them. The Retzius space was developed, and a 7 × 2-cm bladder (Boari) flap was harvested from the anterior bladder wall to bridge the gap between the bladder and the ureter. After the bladder flap was tabularized, it was anastomosed to the right ureter, and the anterior bladder wall was closed. The total operating time was 250 minutes. Excellent laparoscopic visualization and magnification, along with the presence of a catheter in the fistula tract, allowed for meticulous dissection in the retrovesical space between the bladder and the vaginal cuff, as well as resection of the fistula tract with minimal manipulation of the bladder, without the need for a large cystotomy. The Foley and the ureter catheters were removed at 2 and 4 weeks after the operation, respectively. Intravenous pyelography at 3 months postsurgery showed no hydronephrosis, and the patient remained symptom-free during the follow-up period. CONCLUSION: With adequate laparoscopic experience and patient counseling, complex genitourinary fistulas can be approached with a minimally invasive technique. The laparoscopic approach provides excellent exposure to a poorly exposed area of the retrovesical space while minimizing bladder manipulation.