Minimally invasive removal of obstructive ureteral stones by intracorporeal lithotripsy in horses: 3 patients.

Three client-owned horses diagnosed with obstructive ureteral stones were referred and treated in a minimally invasive manner by retrograde ureteroscopy in conjunction with electrohydraulic lithotripsy (EHL) or laser Holmium:YAG lithotripsy (HYL). For all 3 horses, additional tests revealed variable degrees of azotemia and ureteral obstruction. Ultrasound examination (2 horses) revealed a loss of cortico-medullary distinction consistent with a chronic nephropathy. Ultrasound-guided biopsy of the right kidney in 1 horse revealed moderate glomerulosclerosis and lymphoplasmacytic nephritis. A standing anesthesia with a coccygeal epidural was done for each horse. A perineal urethrotomy was performed in 2 horses before the urethrocystoscopy. One horse was treated with Holmium:YAG laser lithotripsy and 2 others were treated using a electrohydraulic lithotripsy probe. Each procedure was successful. The ureteroscopy was successfully performed and visualization was excellent. Fragmentation of stones seemed easier with the electrohydraulic lithotripsy probe. No complications, pain, or signs of discomfort after the procedure were noticed. All 3 horses were discharged from the hospital. Key clinical message: Obstructive ureteral stones in horses can be successfully treated in a minimally invasive manner by retrograde ureteroscopy accompanied by lithotripsy. This technique is safe, not painful and did not require general anesthesia. Electrohydraulic lithotripsy appeared superior for stone fragmentation.

Exérèse minimalement invasive de calculs urétéraux obstructifs par lithotritie intracorporelle chez le cheval : trois patients. Trois chevaux appartenant à des clients diagnostiqués avec des calculs urétéraux obstructifs ont été référés et traités de manière peu invasive par urétéroscopie rétrograde en conjonction avec une lithotripsie électrohydraulique (EHL) ou une lithotripsie au laser Holmium:YAG (HYL). Pour les trois chevaux, des tests supplémentaires ont révélé des degrés variables d'azotémie et d'obstruction urétérale. L'échographie (deux chevaux) a révélé une perte de distinction cortico-médullaire compatible avec une néphropathie chronique. La biopsie échoguidée du rein droit chez un cheval a révélé une glomérulosclérose modérée et une néphrite lymphoplasmocytaire. Une anesthésie debout avec une péridurale coccygienne était effectuée pour chaque cheval. Une urétrotomie périnéale a été réalisée chez deux chevaux avant l'urétrocystoscopie. Un cheval a été traité par lithotripsie au laser Holmium:YAG et deux autres ont été traités à l'aide d'une sonde de lithotripsie électrohydraulique. Chaque procédure a réussi. L'urétéroscopie a été réalisée avec succès et la visualisation était excellente. La fragmentation des calculs semblait plus facile avec la sonde de lithotripsie électrohydraulique. Aucune complication, douleur ou signe d'inconfort après la procédure n'a été remarqué. Les trois chevaux ont obtenu leur congé de l'hôpital.Message clinique clé :Les calculs urétéraux obstructifs chez les chevaux peuvent être traités avec succès de manière peu invasive par urétéroscopie rétrograde accompagnée de lithotripsie. Cette technique est sûre, non douloureuse et ne nécessite pas d'anesthésie générale. La lithotritie électrohydraulique est apparue supérieure pour la fragmentation des calculs.(Traduit par Dr Serge Messier).

Endoscopic-guided laser lithotripsy for removal of an encrusted ureteral stent in a dog.

CASE DESCRIPTION: An 8-year-old spayed female Dalmatian was evaluated because of recurrent urinary tract infections following ureteral stent placement 3 years earlier. CLINICAL FINDINGS: Polyuria, pollakiuria, and hematuria were reported by the owner. Abdominal radiography revealed well-defined, faintly mineralized material superimposed over the distal portion of the previously placed ureteral stent. Abdominal ultrasonography revealed thickening of the bladder wall, right hydroureter, and right pyelectasia; the ureteral stent appeared to extend into a region containing cystic calculi. Cystoscopy revealed small uroliths and mineralized encrustation of the distal portion of the ureteral stent. TREATMENT AND OUTCOME: A holmium:yttrium-aluminum-garnet laser was used to fragment mineralized material from the distal end of the stent and allow endoscopic transurethral removal. Stone analysis revealed ammonium urate as the major component of the mineralized material. The owner was instructed to feed the dog a diet formulated to decrease the likelihood of urate stone recurrence and to administer marbofloxacin for 6 weeks because of suspected pyelonephritis. Follow-up bacterial culture of a urine sample and abdominal ultrasonography revealed resolution of urinary tract infection, pyelectasia, hydroureter, and associated clinical signs. CLINICAL RELEVANCE: Results suggested that endoscopic-guided laser lithotripsy can be used as a minimally invasive alternative to surgery for removal of severely encrusted ureteral stents in dogs.

Technological Advances in Endoscopic Equipment in Exotic Pet Medicine.

The aim of this article is to review some of the technological advances in endoscopy and endosurgery. The article focuses on a few key areas relevant to exotic pets, including advances in urolith management, visualization, and laparoscopic surgery.

[Management of urethral stones in dogs using pneumatic and laser lithotripsy]. / Management von Urethralsteinen beim Hund mittels pneumatischer und laserenergetischer Lithotripsie.

OBJECTIVE: Description of clinical experience with two different lithotripsy modalities for treatment of urethral stones in dogs. MATERIAL AND METHODS: Retrospective analysis (October 2016 - November 2017) of medical records from dogs with urinary stones that underwent transurethral pneumatic or laser lithotripsy. RESULTS: In 28 male and 5 female dogs, either pneumatic lithotripsy (39 %) or laser lithotripsy (61 %) was performed. In the urethra, stone free rates of 100 % in females and over 85 % in males could be achieved using either fragmentation modality. In 3 of 28 (11 %) male dogs, after fragmentation of urethral stones, urethral patency was impaired because of endoscopically suspected polypoid urethritis requiring urethrostomy. In 8 out of 28 (29 %) male dogs and in 1 of 5 (20 %) female dogs, an additional lithocystotomy was necessary to achieve stone-free status in the lower urinary tract. CONCLUSION AND CLINICAL RELEVANCE: Transurethral pneumatic or laser lithotripsy of urinary stones is a successful procedure in dogs. Major pathological conditions of the urethral mucosa may require further surgical or interventional methods for the restoration of a functional urethra.

[Therapeutic options of obstructive urolithiasis in small ruminants]. / Therapeutische Möglichkeiten bei obstruktiver Urolithiasis des kleinen Wiederkäuers.

The diagnosis of obstructive urolithiasis in small ruminants frequently results in a multitude of decisions that have to be made by the consulted practitioner. Factors that influence the decision for therapy (or euthanasia) are the type of the animal's use, economic aspects and specific options of the veterinarian practice as well as emotional aspects depending on the owners of small ruminants kept as companion animals. The present article aims to present the currently available methods of therapy to facilitate a decision by the practicing veterinarian based on the present state of the science. Naturally, the individual method of choice may differ from the scientific point of view depending on the practitioner's evaluation.

Retained laser fiber in the nidus of a recurrent cystine urolith in an intact male English bulldog.

A lithotripsy and percutaneous cystolithotomy (PCCL) were performed on a 5-year-old intact male English bulldog. The composition of the uroliths was 100% cystine. When a second PCCL was performed 2 months later, the nidus of the largest urolith was a segment of an optical fiber broken off during laser lithotripsy.

Fibre laser formant le nidus d'une urolithiase à cystine récurrente chez un Bulldog Anglais mâle entier. Une lithotripsie et une cystolithotomie percutanée (PCCL) ont été réalisées sur un Bulldog Anglais mâle entier de 5 ans. L'urolithe était constitué à 100 % de cystine. Lors d'une seconde PCCL réalisée 2 mois plus tard, le nidus du plus grand calcul de cystine se révéla être un fragment de fibre optique brisée durant la lithotripsie au laser.(Traduit par Dre Emmanuelle Butty).

Minimally Invasive Management of Uroliths in Cats and Dogs.

Urolithiasis commonly affects cats and dogs. The American College of Veterinary Internal Medicine established guidelines for the treatment of uroliths that reflect modern techniques prioritizing minimally invasive procedures with an emphasis on prevention strategies to limit morbidity and mortality. Extracorporeal shockwave lithotripsy and endoscopic nephrolithotomy constitute some of the minimally invasive treatment modalities available for upper urinary tract uroliths. Cystoscopic-guided basket retrieval, cystoscopic-guided laser lithotripsy, and percutaneous cystolithotomy are minimally invasive options for the management of lower urinary tract uroliths. Following stone removal, prevention strategies are essential to help reduce morbidity and mortality associated with stone recurrence.

Treatment of ureteral calculus obstruction with laser lithotripsy in an Atlantic bottlenose dolphin (Tursiops truncatus).

An adult female bottlenose dolphin (Tursiops truncatus) presented with acute anorexia secondary to progressive azotemia (blood urea nitrogen = 213 mg/dl, creatinine [Cr] = 9.5 mg/dl) and electrolyte abnormalities (K = 7.4 mEq/L). It was later diagnosed with postrenal obstruction secondary to bilaterally obstructing ureteral calculi seen on ultrasound. Treatment of the obstruction required two endoscopic procedures, cystoscopy for ureteral stent placement and ureteroscopy to perform intracorporeal lithotripsy on the obstructing calculi. Before the first procedure, the dolphin's azotemia was stabilized with aggressive fluid therapy, peritoneal dialysis, and treatment for acidosis. Diuresis subsequent to the fluid therapy enabled passage of the right obstructing urolith. For both endoscopic procedures, the dolphin was placed in left lateral recumbency due to the peritoneal dialysis catheter in the right retroperitoneal region. For the first procedure, a 12-French (Fr) flexible cystoscope was inserted retrograde into the bladder via the urethra, whereupon a calculus was seen obstructing the left ureteral orifice. A 4.8-Fr, 26-cm double-pigtail ureteral stent was placed up the left ureter to relieve the postrenal obstruction. Inadvertent proximal migration of the left ureteral stent occurred during the procedure. However, renal parameters (serum Cr = 5.8, K = 5.4) improved significantly by the next day. For the second procedure, 28 hr later, ureteroscopy was performed to treat the calculus and replace the existing stent with a longer stent. The left ureteral calculus was pulverized into tiny fragments by using a holmium:yttrium-aluminum-garnet laser inserted through a 6.9-Fr semirigid ureteroscope. The migrated stent was visualized in the distal left ureter and replaced with a 90-cm single-pigtail ureteral stent that was sutured exterior to the urogenital slit and removed 3 days later. Renal function normalized over the next several days, and the dolphin recovered over the next 2 mo.

Methods of urolith removal.

Multiple techniques exist to remove uroliths from each section of the urinary tract. Minimally invasive methods for removing lower urinary tract stones include voiding urohydropropulsion, retrograde urohydropropulsion followed by dissolution or removal, catheter retrieval, cystoscopic removal, and cystoscopy-assisted laser lithotripsy and surgery. Laparoscopic cystotomy is less invasive than surgical cystotomy. Extracorporeal shock wave lithotripsy can be used for nephroliths and ureteroliths. Nephrotomy, pyelotomy, or urethrotomy may be recommended in certain situations. This article discusses each technique and gives guidance for selecting the most appropriate technique for an individual patient.

Efficacy and safety of laser lithotripsy in fragmentation of urocystoliths and urethroliths for removal in dogs.

OBJECTIVE: To characterize the efficacy and safety of laser lithotripsy in the fragmentation of urocystoliths and urethroliths for removal in dogs. DESIGN: Prospective case series. ANIMALS: 100 dogs with naturally occurring urocystoliths and urethroliths. PROCEDURES: Via cystoscopy, laser lithotripsy was performed to fragment uroliths. Basket retrieval and voiding urohydropropulsion were used to remove fragments. Postprocedural contrast cystography was performed to assess efficacy and safety. In 40 dogs, midstream urine samples were collected just prior to laser lithotripsy (day 0) and on days 1, 3, and 11 after laser lithotripsy to assess inflammation. RESULTS: Urolith removal was complete in 82% of dogs (52/66 with only urocystoliths, 17/17 with only urethroliths, and 13/17 with urocystoliths and urethroliths). Urolith removal was incomplete in 18 dogs; of these dogs, 9, 6, and 3 had urolith fragments >or= 3 mm, 1 to < 3 mm, and < 1 mm in diameter, respectively. Sex (female) was the most significant predictor for success. Median procedure time was 72 minutes. Two dogs developed urinary tract obstruction following laser lithotripsy. Hematuria was detected in 53% of dogs on day 0 and in 84%, 13%, and 3% of dogs on days 1, 3, and 11, respectively. Leukocyturia was detected in 13% of dogs on day 0 and in 47%, 0%, and 3% of dogs on days 1, 3, and 11, respectively. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggested that use of laser lithotripsy was a safe and effective alternative to surgical removal of urocystoliths and urethroliths in dogs.

Comparison of laser lithotripsy and cystotomy for the management of dogs with urolithiasis.

OBJECTIVE: To compare efficacy, required resources, and perioperative complications between laser lithotripsy and cystotomy for urolith (ie, urocystoliths and urethroliths) removal in dogs. DESIGN: Retrospective case-control study. ANIMALS: 66 dogs with urolithiasis treated by laser lithotripsy (case dogs) and 66 dogs with urolithiasis treated by cystotomy (control dogs). PROCEDURES: Medical records were reviewed. Complete urolith removal rate, resources (ie, duration of hospitalization, procedure time, anesthesia time, procedure cost, and anesthesia cost), and complications (ie, hypotension, hypothermia, incomplete urolith removal, and requirement of an ancillary procedure) were compared between cystotomy group dogs and lithotripsy group dogs. RESULTS: Duration of hospitalization was significantly shorter for lithotripsy group dogs, compared with cystotomy group dogs. Procedure time was significantly shorter for cystotomy group dogs, compared with lithotripsy group dogs. Cost of anesthesia was significantly less for cystotomy group dogs, compared with lithotripsy group dogs. No significant differences were found between cystotomy group dogs and lithotripsy group dogs with regard to urolith removal rate, procedure cost, anesthesia time, or any of the evaluated complications. CONCLUSIONS AND CLINICAL RELEVANCE: Laser lithotripsy is a minimally invasive procedure that has been shown to be safe and effective in the removal of urocystoliths and urethroliths in dogs. No significant differences were found in the required resources or complications associated with laser lithotripsy, compared with cystotomy, for removal of uroliths from the lower portions of the urinary tract of dogs. Laser lithotripsy is a suitable, minimally invasive alternative to surgical removal of urethroliths and urocystoliths in dogs.

Changing paradigms in the treatment of uroliths by lithotripsy.

Surgery remains a common procedure for removal of uroliths from the lower urinary tract of dogs. Incorporation of intracorporeal laser lithotripsy and extracorporeal shock wave lithotripsy has provided impetus for a paradigm shift in the way veterinarians manage urinary stones, however. These minimally invasive techniques provide a successful alternative to surgical urolith extraction.

Use of laser lithotripsy for fragmentation of uroliths in dogs: 73 cases (2005-2006).

OBJECTIVE: To describe use of transurethral cystoscope-guided laser lithotripsy for fragmentation of cystic and urethral uroliths and determine procedure duration and short-term and long-term outcome in dogs. DESIGN: Retrospective case series. ANIMALS: 73 dogs with naturally occurring uroliths in the urinary bladder, urethra, or both. PROCEDURES: Transurethral cystoscope-guided laser lithotripsy was performed in all dogs, and medical records were reviewed for short-term and long-term outcome and complications. RESULTS: Laser lithotripsy resulted in complete fragmentation of all uroliths in all 28 female dogs and a majority of male dogs (39/45 [86.7%]). Dogs with urethroliths had shorter median laser time than dogs with cystic uroliths. Basket extraction and voiding urohydro-propulsion were successful for removal of the urolith fragments following laser lithotripsy. Complications related to cystoscope-guided laser lithotripsy occurred in 5 of 28 (17.9%) female dogs and 6 of 45 (13.3%) male dogs. CONCLUSIONS AND CLINICAL RELEVANCE: Transurethral cystoscope-guided laser lithotripsy was successful in female dogs and most male dogs for fragmentation of cystic and urethral uroliths. Short-term complications were most commonly related to urethral swelling and resolved with placement of an indwelling urinary catheter. There were no long-term complications.

Laser lithotripsy for treatment of canine uroliths.

OBJECTIVE: To confirm in vivo optimal laser energy settings previously determined in vitro for lithotripsy, to develop a technique for Ho:YAG laser lithotripsy, and to evaluate acute and chronic tissue effects of laser lithotripsy. STUDY DESIGN: Prospective, randomized preclinical trial. ANIMALS OR SAMPLE POPULATION: Nineteen intact, adult male dogs. METHODS: Via cystotomy, a single urolith was inserted into the urethra to the level of the base of the os penis to simulate obstruction. Uroliths (calcium oxalate, urate, or magnesium ammonium phosphate) were fragmented by Ho:YAG laser, in contact mode through a 320 micro optic fiber, passed through the operating channel of a 2.8 mm flexible endoscope. The time and total energy to fragmentation were recorded. Dogs were euthanatized immediately after lithotripsy (3 dogs) or at 3 days (7 dogs), and urethral lesions and any stone remnants were evaluated. Urethral integrity was also evaluated in 9 other dogs by endoscopy on day 10; these were also monitored clinically for 30 days. RESULTS: The mean time for adequate fragmentation was 166.7 seconds (range, 47-494.5 seconds). The mean+/-SD energy used was 1418+/-851.2 J. In part 1, 2 dogs were obstructed with urolith fragments at necropsy. Eight dogs had minimal (<30 mg) or no urolith material evident within the urethra. Four dogs had gross focal or circumferential erosion, ulceration, or hemorrhage of the urethral mucosa. Lesions were not associated with the site of laser irradiation in 2 dogs. In dogs observed for 30 days, hematuria, pollakiuria, and stranguria that were observed after lithotripsy, resolved in all affected dogs by day 5. No mucosal lesions were observed by endoscopy and none of the dogs became obstructed. CONCLUSION: Laser lithotripsy with the Ho:YAG laser in contact mode successfully fragmented obstructive uroliths in male dogs. CLINICAL RELEVANCE: Laser lithotripsy may be a clinically relevant technique for treatment of urolithiasis in male dogs; clinical studies to evaluate long-term effects on urethral mucosa and the role of repeat treatment for recurrence are indicated.

[Endoscopic lithotripsy of a urinary bladder calculus with the aid of a holmium-YAG-laser in a gelding]. / Endoskopische Lithotripsie eines Harnblasensteines mit Hilfe eines Holmium-YAG-Lasers bei einem Wallach.

A 6 year old Haflinger gelding was presented to the reporting clinics with a history of chronic dysuria. A large cystic calculus (12 x 9 x 9 cm) was diagnosed cystoscopically. Lithotripsy was carried out endoscopically in the standing, sedated patient with a Holmium:YAG surgical laser (2100 nm, 0.5-3.5 J/pulse, 3-60 pulses/sec.). The endoscope was inserted into the bladder via perineal urethrostomy. Fragmentation of the urolith was carried out with a laser fiber (core diameter 600 microns) in contact mode. Healing proceeded uneventfully. On follow up examination 8 weeks post surgery, no signs of recurrence, cystitis or strictures of the urethra were present.

Urethroscopy and laser lithotripsy for the diagnosis and treatment of obstructive urolithiasis in goats and pot-bellied pigs.

OBJECTIVE: To explore the use of urethral endoscopy and laser lithotripsy in the diagnosis and management of urolithiasis in goats and pot-bellied pigs. DESIGN: Prospective clinical study. ANIMALS: 16 male goats and 6 male pot-bellied pigs with dysuria. PROCEDURE: Abdominal ultrasonography and urethral endoscopy were performed on all 22 animals. Endoscopic-guided holmium:yttrium-aluminum-garnet laser lithotripsy was performed in 3 goats and 2 pot-bellied pigs. RESULTS: Urolithiasis was identified in 15 goats and 5 pot-bellied pigs. Primary urinary bladder paralysis and cystitis were identified in the remaining pot-bellied pig and goat. Mean bladder diameters of obstructed small- and large-breed goats were 7 and 9.5 cm, respectively. The mean bladder diameter of obstructed pot-bellied pigs was 9.5 cm. Five of 20 animals with obstructive urolithiasis had severe urethral necrosis or stricture formation at the time of urethroscopy. All of these animals were euthanatized within 6 months because of persistent dysuria. When used, laser lithotripsy successfully fractured the distally located obstructing stones in the 3 goats and 2 pot-bellied pigs. CONCLUSIONS AND CLINICAL RELEVANCE: Urethral endoscopy is useful for evaluating urethral patency in goats and pot-bellied pigs. Examination of the urethral mucosa following relief of urethral obstructions aids in the assessment of the long-term prognosis for urethral stricture. Urethral endoscopy also expands the therapeutic options for management of urolithiasis by providing a route for conducting laser lithotripsy. Laser lithotripsy proved to be safe and effective for clearing distally located calculi refractory to removal by traditional urethral flushing. Lithotripsy application is restricted to calculi lodged in the urethra.

Transendoscopic electrosurgery of an equine pulmonary granular cell tumor.

OBJECTIVE: Description of transendoscopic electrosurgical treatment of a pulmonary granular cell tumor in a horse. STUDY DESIGN: Case report. ANIMALS: A 12-year-old Standardbred mare. METHODS: After endoscopic examination and transendoscopic biopsy, a granular cell tumor nodule was removed transendoscopically from the right principal bronchus of the sedated horse (0.02 mg/kg detomide intravenous) with a monopolar electrosurgical wire snare. Two days later, the surgical area was irradiated transendoscopically using a Nd-YAG laser. RESULTS: After surgery, the horse had no further signs of respiratory disease. Clinical and endoscopic examination and radiography performed 4 times during the following 2 years showed no evidence of recurrence. CONCLUSIONS: Transendoscopic electrosurgical removal of nodular masses located intraluminally in the principal bronchi is possible on the sedated standing horse. CLINICAL RELEVANCE: Granular tumors are rare lung neoplasms that lead to unspecific signs of a low airway disease. Diagnosis requires endoscopic examination of the large bronchi. Early intraluminal stages can be treated transendoscopically.

Endoscopic-assisted disruption of urinary calculi using a holmium:YAG laser in standing horses.

OBJECTIVE: To describe a technique for endoscope-assisted disruption and removal of urinary calculi using a holmium:YAG laser in sedated, standing horses. STUDY DESIGN: Retrospective study. ANIMALS: Six horses with urinary calculi. METHODS: A holmium:YAG laser was used to disrupt naturally occurring urinary calculi in horses (4 geldings, 1 stallion, 1 mare). Ischial urethrotomy was performed in male horses to provide a portal for the endoscope and laser fiber. Calculus fragments were removed by a combination of lavage, transendoscopic basket snare removal, forceps, and digital manipulation. Ischial urethrotomies healed by second intention. Follow-up was obtained by recheck examination and telephone interview of owners. RESULTS: No major operative or postoperative complications occurred. Two calculi (1 stallion and 1 mare) were fragmented by a combination of laser ablation and manual disruption with a lithotrite. Postoperative dysuria occurred in the mare, but resolved after 1 month. Mean (+/- SD) follow-up was 306 +/- 149 days; no other complications were reported. CONCLUSIONS: Calcium carbonate urinary calculi (up to 15 cm in diameter) in horses can be effectively fragmented with a holmium:YAG laser. It is not known if this technique would be completely effective for larger calculi or extremely dense calculi. CLINICAL RELEVANCE: Calculus disruption by an endoscopically assisted holmium:YAG laser offers a minimally invasive method that can be performed in standing horses and that minimizes patient risk.

Failure of holmium:yttrium-aluminum-garnet laser lithotripsy in two horses with calculi in the urinary bladder.

Holmium:yttrium-aluminum-garnet (Ho:YAG) laser lithotripsy was attempted in a mare and a gelding with calculi in the urinary bladder. The procedure was unsuccessful in producing adequate fragmentation of the calculi. In the gelding, pulsed dye laser lithotripsy was subsequently used to fragment the urolith. Manual removal of the urolith via the urethra was performed in the mare.

Laser lithotripsy of a urethral calculus via ischial urethrotomy in a steer.

A steer examined because of obstructive urolithiasis and urethral rupture underwent laser lithotripsy, using a chromium-thulium-holmium:yttrium-aluminum-garnet (Ho:YAG) laser inserted through an ischial urethrotomy. Procedures were performed with caudal epidural anesthesia. Six months after surgery, the urethra was patent with no clinical evidence of urethral stricture or fistula. Ischial urethrotomy provided rapid access to the bladder for catheterization and to the obstructive urolith for lithotripsy. Laser lithotripsy was a rapid and effective means of urolith removal in this steer.