Things That Make Me Cringe

I don’t really keep track of how many surgeries I do, though sometimes I think maybe I should start – just for the fun of it. If I had to guess I would say the non-elective surgery I do the most is a cystotomy. Either that or exploratories.

Cystotomy is literally cutting into the bladder. Cysto = bladder; tomy = surgical incision. There’s really only one reason I do this: to remove bladder stones.

Even just typing the term “bladder stones” makes my urinary tract cringe. The things I have felt and seen. . . *shudder*

Usually it goes like this: a dog or cat is having urinary issues, and when I have a look at the urine I see crystals. I recommend a radiograph to check for stones to go along with those crystals. Sometimes the crystals have not yet partied hard enough to form stones. Sometimes I wonder how the animal didn’t have problems before now.  If there are stones, I have a chat with the owner about the risks of leaving the stones in there and recommend surgery to remove them. Sometimes I can use a diet to dissolve them, but even still there are risks in the waiting.

Sometimes, an animal presents because it CAN’T urinate, thanks to a rogue stone making a go for the outside world and getting caught up in the urethra. (cringing again. . . ). In these cases, I will pass a catheter to relieve the immediate obstruction, and strongly recommend surgery as soon as possible to prevent reoccurrence.

Most cringe worthy case I’ve had? Cat came in blocked, which is actually not very often because of stones, and I passed a catheter to relieve the obstruction and empty the bladder. Before I passed the catheter, when I palpated his abdomen I felt a ginormous, very firm, melon that was his bladder. After getting a decent amount of urine out, I had my hand on his belly over his bladder, only now instead of being a firm melon, it was a giant sack of marbles. (I just experienced a bladder cramp thinking back on that.) That cat had surgery, it was the most stones I have ever removed from a cat, and he’s doing fine now.  . . but I will never forget that moment. *shudder*

When we go to surgery, it’s pretty easy to find our target: the bladder is usually all kinds of angry. Instead of being a thin walled little balloon I encounter during a spay surgery, I am greeted by a thick, red, ugly, thing. I try to find a spot in the bladder wall to make a hole – being sure to be far away from ureters (the tubes that bring urine from kidneys to bladder. They’re kind of important, don’t want to cut those). You don’t want too big of a hole, but you need to be able to get your bladder spoon in there and scoop out your stones. Yeah, bladder spoon. It’s a surgical tool that’s a bit of a scoop, with a scraping edge of it, so you can scrape the bladder walls for grit. Using it makes all of the sphincters in my urinary tract spasm.

Cystotomies come in wide variety : lots of little stones, lots of big stones, a few big stones with lots of little tiny gritty stones, one giant stone, smooth stones, crazy spiked jaggedy stones that make your bladder cry in sympathy for the bladder you removed them from. You always have a ‘before’ radiograph so you have an idea what you’re going in for. And you ALWAYS should take an ‘after’ radiograph to make sure you didn’t leave behind anything. The last thing you want, after the clients pay $ 1000+, is for the animal to come back next week with the same problem because you left one errant stone behind.

Random factoid about cystotomies: If you read an old surgery textbook, it will advise you to take the bladder up out of the abdominal cavity and flip it over to you make your incision on the dorsal (top) side of the bladder. The idea being that when the animal is standing, this side will be at a lower risk for urine leakage because gravity brings the urine to the bottom of the bladder. If you read current surgery textbooks, this idea has been abandoned and we make the incision on the ventral (bottom) side of the bladder. Why? Because the bladder is a balloon. It’s only as big as the volume of urine in it requires. There’s no air bubble. The pressure of urine against the ‘top’ it the same as the ‘bottom’. Silly old school surgical ideas. . .

When you’re confident you removed all your stones and grit, and you close up that bladder, you leak test it. Even if you buy into the old school dorsal side idea, you fill the bladder with sterile saline, give a squeeze, and make sure nothing bubbles out your incision. Then you place the bladder back down inside the abdomen, close the animal up, and take that post-op radiograph (making sure nobody touches your surgical instruments so they remain sterile just in case you have to go back in. If you don’t keep your instruments sterile, I guarantee your post-op rad will tell you to go back in.)

Bladders are pretty awesome about healing up. Once, when I was a student, I assisted on a cystotomy on a dog who had had a cystotomy 2 days prior, but still had stones left. . . and we could only barely figure out where the original incision was.

For all my complaints of cringing, I kind of enjoy cystotomies. They have a certain satisfaction to them – I enjoy surgeries that have before and after pictures where you can see that you fixed the problem. Maybe that’s why I like castrations so much? You can’t tell by looking that I’ve removed the uterus, but an empty scrotal sack is pretty telling.

Or maybe I just enjoy ripping out testicles. Just because.