clinical, laboratory, radiographic ultrasonographic

*AlkanKAMİLOĞLUKafkasUniversity,FacultyofVeterinaryMedicine,DepartmentofSurgery,Kars,TURKEY.e-mail:[email protected]*ThisresearchismadefromthesameheadlineMasterThesis.

AtatürkÜniversitesiVet.Bil.Derg.2017;12(1):14-21

ResearchArticle/AraştırmaMakalesiDOI:10.17094/ataunivbd.309766

Clinical,Laboratory,Radiographic,UltrasonographicDiagnosisandSurgicalTreatmentofFelineLowerUrinaryTractUrolithiasis:StudyCarriedOutof

TenCats*

AlkanKAMİLOĞLU¹*,DeryaKILIÇOĞLU3

1.KafkasUniversity,FacultyofVeterinaryMedicine,DepartmentofSurgery,Kars,TURKEY.

Absract:Inthisstudy,itwasaimedtopresenttheresultsofdiagnosisandtreatmentofurinarytracturolithiasisin10catsbroughttoourclinic.Tencatswithurinarytractcomplaintusedforthestudy.Urolithiasisdiagnosiswasmadethroughurineanalysis,directandindirectradiographyandultrasonographicfindings.Eightcaseswereappliedoperativeprocedureandtwocaseswereadministeredmedical treatment.Accomplishmentwasgainedwithchalcolithicdietand infectioncontrolalongwithoperativeprocedureintwooffourcatswithstruviteurolith.Urethrotomy,cystotomyandurohydropropulsionwereperformedtoremovecalciumoxalate,calciumcarbonate,calciumphosphateandammoniumurateurolith.Petswerepostoperativelycontrolledonthe30thdayinordertocheckwhetherurolithswerereappeared.Inthisstudy,itwasfoundthat frequency of uroliths in descending order may be sorted as struvite, calcium oxalate, ammonium urate, calciumcarbonate and calcium phosphate. Consequently for the diagnosis of urolithiasis, it is required to evaluate urine pH,crystalluria,hematuria,urineleukocytevaluesandstoneanalysisalongwiththeresultsobtainedfromdirectpositivecontrastradiography andultrasonography.Operative approach is indicated for urolith cases andpost-operative special diets andmedicaltreatmentaccordingtourolithtypepreventrelapse.

Keywords:Cat,Cystotomy,Urethrotomy,Urocystolithiasis,Urolithiasis.

KedilerdeAltÜrinerSistemÜrolitiyazisininKlinik,Laboratuvar,Radyografik,UltrasonografikTanısıveCerrahiSağaltım:ÇalışmaOnKediÜzerindeYapıldı

Öz: Bu çalışmada; kliniğimize getirilen 10 kedide alt üriner sistemurolithiasis teşhisi ve sağaltımı sonuçlarının sunulmasıamaçlanmıştır. Çalışmada üriner sistem şikayeti olan 10 kedi kullanıldı. Ürolitiazis tanısı, idrar analizi, direkt ve indirektradyografi ve ultrasonografik bulgular ile konuldu. Sekiz olguda operatif işlem, iki olgudamedikal tedavi gerçekleştirildi.Strüvitürolitlidörtkedidenikisindeoperatifuygulamayanındakalkulolitikdiyetveenfeksiyonkontrolüilebaşarıyaulaşıldı.Kalsiyumoksalat,kalsiyumkarbonat,kalsiyumfosfatveamonyumuratürolitleriüretrotomi,urohydropropulsion,sistotomi,üretro- sistotomi yöntemleri ile uzaklaştırıldı. Hayvanlar postoperatif 30. günde kontrol edilerek ürolitlerin tekrar oluşupoluşmadığı kontrol edildi. Bu çalışmada alt üriner sistem ürolitlerinin striuvit, kalsiyum okzalat, amonyumürat, kalsiyumkarbonat ve kalsiyum fosfat sıklık sırasına göre olduğu saptandı. Sonuç olarak; ürolitiazisin tanısını koymada; idrar pH’sı,kristalüri,hematüri,idrarlökositdeğerlerivetaşkimyasalanalizi,direktvepozitifkontrastradyografiileultrasonografininbirliktedeğerlendirilmesi gerekmektedir.Ürolitolgularındaoperatif yaklaşımınendikeolduğuveoperasyon sonrasıürolittipinegöreözeldiyetvemedikaltedavininnüksleriengellediği,kanısınavarıldı.

AnahtarKelimeler:Kedi,Sistotomi,Üretrotomi,Üretrolitiyazis,Ürolitiazis.

GelişTarihi/Received22.05.2016

KabulTarihi/Accepted14.12.2016

YayınTarihi/Published30.04.2017

Clinical,Laboratory,Ra... KamiloğluandKılıçoğlu

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INTRODUCTION

rolithiasisisacommonnamegiventolithiasisin any part of the urinary system and its

results. If itoccurs inurinarybladder, it iscalledasurocystolithiasis;ifitoccursinurethra,itiscalledasureterolithiasis (1,2). Abnormal microscopicprecipitates in urine are called crystal, crystals inurine are known as crystalluria and macroscopicconcentrationsofcrystalsarecalledasurolith(1-6).Riskaffecting the formationofurolith includerace,age, sex, anatomical and functional anomalies ofurinarysystem,metabolicanomalies,urinarysysteminfections,dietandurinepH(3,4,7).

Lowurinarytracturolithsarecommoninbothmale and female cats. However, urethralobstructions are more common in male cats sincetheirurethrasarelongandnarrower(6,8-10).Also,itwas reported that urethral obstruction is localizedbehindospenis(11).

Struvite (magnesium-ammonium-phosphate)andcalciumoxalateare themostcommonbladderstones in cats.However, urate, calciumphosphate,silicate,cystine,xanthineandmixedstonesare lesscommon bladder stones in cats (1,7,12). Whilestruvite stones are commonly seen in female cats(especially in cross-breed female cats), calciumoxalte stones are commonly seen in male cats.Besides, silicate,urateandcysteine stonesarealsocommonlyseeninmalecats(6,9).

The course of urolithiasis is different in catscompared to other animals. It is generally namedFeline Urological Syndrome (FUS). Urethral plugsseeninFUSpatientsincludetypicallystruvite.UrinepH is 6-8 in healthy cats. There is no significantdifferenceinurinepHvaluesofhealthcatsandcatswithFUS.However,struviteis less likelytodissolvein basicmedium. Therefore, alkaline urine is a riskfactor for struvite stones. Struvite crystals arecommonlyseenespecially inurinewithapHabove6.8.Also, formationofstruvitestones iseasier inaurinarytractwithbacterialinfection.ThesebacteriaincreasethepHofurineandreducethesolubilityof

struvite. Inthecaseofacidicurine,calciumoxalatecrystals form (3,13). Calcium oxalate stonescommonly form in cats with hypercalcaemia andhypercalciuria. If the pH of urine decreases, theformation of calcium oxalate crystals accelerates(6,10). However, the risk of formation of calciumoxalate is higher in cats fed with canned pet foodwith a high amount of carbohydrates. It wasobservedthatcalciumoxalatestonesarelesslikelytoform in thecats fedwithdrypet foodswithahighamountofprotein, calcium,phosphor,magnesium,sodium,potassiumandchloride(14).

Itwasreportedthatradiopaquestonescanbedetermined and information on their shapes andnumbersof thesestonescanbeobtainedbydirectradiography (8,11). However, some researchersreported that incorrect results are obtained sinceuro-cystoliths in urinary tract usually cannot bedetermined radiographically (9,15,16). Someresearchers (17,18) reports that uroliths whichcannotbedeterminedbydirectradiographycanbedeterminedbycontrastradiography.Inliteratures,itwas reported that uroliths are observed ashyperechoic lesions in ultrasonographicexaminations,theycreatestrongechowithacousticshadowintheirdistalsand,urolithsinbladderfallinthe side down which the patient lies during theultrasonographicexamination(15,18-20).

Itwas reported that the diseasemay recur insome caseswhich the final diagnosis of urolithiasiswasestablishedandtreatedaccordingly(3,20). InastudyOsborneetal. (4),casesof recurrentstruviteurolithiasiswerereportedincats.

Inthisstudy,itwasaimedtopresenttheresultsof diagnosis and treatment of urinary tracturolithiasisin10catsbroughttoourclinic.

MATERIALSandMETHODS

Working material consists of 10 cats withdifferent race,ageandgenderwhichwerebroughtwith the complaints of urinary tract and found to

U


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havefindingssuchasdifficultyurinating,haematuria,thamuria and urine incontinence as a result ofmedicalhistorytakenandclinicalexaminationmade(Table1).Distributionbybreed,age,sexanddietof

totally10caseswith lowerurinarytracturolithiasiswhichconstitutethestudymaterialofthisstudywasrecorded.

Table1.Distributionofcasesaccordingtobreed,age,sexanddiet.Tablo1.Olgularıntür,yaş,cinsiyetvebeslenmeşeklinegöredağılımı.

Caseno Breed Age Sex Diet

1 Persian 6 ♂ Homemadefood

2 Tuxedo 2.5 ♂ Food

3 OrangeTabby 2 ♀ Food

4 Bombay 3 ♂ Food

5 VanCat 2.5 ♂ Homemadefood


7 Calico 5 ♂ Food

8 VanCat 4 ♂ Homemadefood


10 VanCat 3 ♂ Food

Physical, chemical and biochemical analysesthatcarriedoutonpre-operativeTable2andonthe30thdayofthepost-operativeperiodurinesamplesof the cases showed in Table 3. It was found thaturine color and appearance turned to normal, andpH, protein, leukocyte and urine density revertedbacktonormallimits.

According to the results obtained from thechemical analysis of uroliths of the cases, urolithtypesweredeterminedasstruvite,calciumoxalate,ammonium urate, calcium carbonate and calciumphosphate(Table4).

Radiographic and ultrasonographic imagingmethodswereemployed.Directandindirectimagesof the cases were taken. 6-12 ml/kg sodiumamidotrizoate(Urografin76%;Schering)dilutedwith%0.9 NaCl solution that given into the bladder viaurinary catheter. Urination was stimulated by

applying external pressure on the bladder. WhenurinaryappearintheexternalurethralorificiumL/Lradiographs were taken and evaluated.Ultrasonographic examination was made with fullbladder. Imaging process was carried out bycomparinglongitudinallyandtransversally.

Urine sample was collected by sterile catcatheter, through massaging bladder or duringurination. The collected urine samples weresubjectedtophysicalandchemicalanalysessuchascolor, turbidity, pH, blood, hemoglobin, proteinanalyses. Also, after the urine samples werecentrifugedat3000rpmfor3minutes,microscopicexaminations were made on the remainingprecipitate. Thus, the samples were evaluated intermsoferythrocyte, leucocyte,epithelial cellsandcrystals.


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Besides these analyses, uroliths obtained bysurgicaloperationsonlowerurinarytractsofsevencases were analyzed biochemically. Analysis ofUrolithswasmadebyDepartmentofBiochemistry,FacultyofVeterinaryMedicine inKafkasUniversity.Diet and medical treatment to be applied to thepatients were determined based on the results ofsuchanalyses.

All surgical operations were carried out withgeneralanesthesia.Thepatientswereadministered0.08mg/kgofmedetomidin(Tomidin,10ml,Provet)and 5-7.5mg/kg of ketamine (Ketasol 10%, 10ml-Richter Pharma ag) intramuscularly. Movableuroliths in urethra were removed byurohydropropulsion method in one case, byurethrotomyintwocases,bybothurethrotomyandcystotomy in two cases and by only cystotomy inthreecases.

Foodswhichcontainlowamountofmagnesiumandphosphorbuthighamountofsaltthereforewillincreasetheacidityofurinewererecommendedforfourcasesdiagnosedwithstruviteurolithbasedontheurolithanalysis.Foodscontaininglowproteinand

purine concentration were recommended for onecasediagnosedwithurateurolithswhilefoodswithreduced protein and Na concentration wererecommended for three cases diagnosed withcalciumoxalate urolith. The samedietwas appliedfor the cases diagnosed with calcium carbonateurolith. Nitrofurantoin (piyeloseptyl 25mg/100ml)or5-15mg/kgcefazolinsodium(cefozin1g IM, IV)were administered to the patients in order toeliminatebacterial infectionandthetreatmentwascontinued with amino-acid supplement, oralmethionineorprescriptiondiet(purinau/r)inordertoincreasetheacidityofurine.

RESULTS

Whilecomplaintssuchasdifficultyinurination,hematuriaandurine incontinencewerereportedinmedical histories obtained from patient owners, inclinicalexaminations,hematuriaandpollakiuriaweredetermined in five cases; hematuria and dysuria infourcases;andurineincontinenceandurinarytractsymptoms such as hematuria and polyuria weredeterminedinonecase.

Table2.Resultsofpreoperativebiochemicalurineanalysis.Tablo2.Preoperatifidrarbiyokimyasalanalizsonuçları.No Hematuria Appearance pH Protein Leukocyte Density

1 + Turbid Straw Color ++ - 1035

2 + Turbid Reddish 6.2 +++ 1-2pcs 1040

3 - Clear Straw 7.5 + - 1025

4 + Turbid Reddish 6.4 +++ 1-2pcs 1040

5 - Clear Straw 7.4 ++ - 1035

6 + Turbid Reddish 6.1 +++ - 1045

7 + Clear Straw 7.3 + - 1038

8 + Turbid Reddish 7.5 ++ 1-2pcs 1038

9 + Turbid Pink 6.5 ++ - 1035

10 - Clear Straw 7.5 ++ - 1042


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Table3.Resultsofbiochemicalurineanalysisonpost-operative30thday.Tablo3.Postoperatif30.gündeidrarbiyokimyasalanalizsonuçları.No Hematuria Appearance Color pH Protein Leukocyte Density1 - Clear Straw 6.8 - - 10252 - Clear Straw 6.6 + 1-2pcs 10303 - Clear Straw 7.0 - - 10304 - Clear Straw 6.7 + - 10355 - Clear Straw 6.7 - - 10256 Dead 7 - Clear Straw 6.8 - - 10308 - Clear Straw 6.9 - 1-2pcs 10259 - Clear Straw 6.8 - - 103010 - Clear Straw 6.9 - - 1025

Table4.Resultsofurolithanalysis.Tablo4.Ürolitanalizsonuçları.Caseno UrolithType1 Ammoniumurate2 Calciumoxalate3 Struvite4 Calciumoxalate5 Struvite6 Calciumoxalate7 Struvite8 Calciumcarbonate9 Calciumphosphate10 Struvite

While uroliths were determined in urinary

bladders of the cases in ultrasonographic

examination (Case no: 5, Fig. 1a), urinary bladderthickeningwasalsoobserved.

Whilenourolithfindingswerefoundinsixcases(Caseno:1,2,4,6,8,9,)duringdirectradiography,urolithswerefoundinthesamecasesduringcontrastradiography.However,urolithfindingswerefoundintheremainingfourcases(Caseno:3,5,7,10)duringdirectradiography(Caseno:3,Fig.1b).Urethrotomywas applied for two cases (Cases no: 4, 8) withurethral obstruction while ureterocystotomy wasapplied for other two cases (Cases no: 2, 5).Moveable uroliths in urethra were removed byUrohydropropulsionmethod (retrograde) (Case no:1)andbycystotomymethodinthreecases(Caseno:3,6,9,Fig.2)(Table5).

Table5.Operationresults.Tablo5.Operasyonsonuçları.Caseno Technique 30thdayaftertheoperation1 Urohydropropulsion Returnedtonormal2 Ureterocystotomy nocrystal,1-2leucocytes3 Cystotomy Returnedtonormal4 Urethrotomy nocrystal,1-2leucocytes5 Ureterocystotomy Returnedtonormal6 Cystotomy Notevaluated7 DietandMedicalTreatment Returnedtonormal8 Urethrotomy Returnedtonormal9 Cystotomy Returnedtonormal10 DietandMedicalTreatment Returnedtonormal


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Figure1.a.Ultrasonographicviewofcaseno.5(a:struviteuroliths)b.DirectL/L;radiologicalviewofcaseno.5.Şekil1.a.Olgu5’inultrasonografikgörünümü(a:struvitürolitleri)b.DirektL/L;Olgu5’inradiyolojikgörünümü.

In the period following the operation,hematuriawasdeterminedintwocases(Caseno:4,8), urethral stricture in one case (Case no: 2). Nocomplications developed in four cases after thesurgicaloperations (Caseno:1,3,5,9).Oneof thecases died (Case no: 6). Wound complicationsdeveloped in one case (Case no: 2). It wasdetermined that urethral catheter did not passbehind os penis during the urethral catheterinsertion in one case (Case no: 9) and frequentgettinginpositiontourinateandfrequenturinationwas determined in one case (Case no: 6). It wasdetermined that one case have been previouslyundergone cystotomy due to calcium phosphateurolith. Recurrence was observed in this case andurolithswereremovedbycystotomy(Caseno:9).

Figure 2. Uroliths removed by surgical operationfromcaseno.5.Şekil2.Olgu5’tenoperasyonlauzaklaştırılanürolitler.

While seven cases administeredwithdiet andmedicaltreatmentinthepost-operativeperiod(Caseno:1,2,3,4,5,8,9)andtwocasesadministeredwithdiet and medical treatment without a surgicaloperation (Caseno:7,10) returned tonormal,onecasediedduetoinsufficientpost-operativecareanddiet(Caseno:6).

DISCUSSIONandCONCLUSION

Lowerurinarytracturolithsarecommonlyseenin both female and male cats. However, urethralobstructions are more common in male cats sincetheirurethrasarelongerandnarrowerthanthoseoffemale cats (1,6,8-10). Also, it was reported thaturethralobstructionisgenerallylocalizedbehindospenis (11).Weweredeterminedthat lowerurinarytracturolithiasiswhichsituatedbehindtheospenisarecommonlyseeninmalecats.

While struvite (magnesium ammoniumphosphate) and calcium oxalate stones were themostcommonbladderstonesincats,urate,calciumphosphate, silicate, cysteine, xanthine and mixedstoneshavebeenfoundlessinresearch(1,7,12).Inthis study as previous research the most commontypeofbladderstonewasstruvite(40%).However,other types of bladder stones included calciumoxalate (30%), ammonium urate (10%), calciumcarbonate(10%)andcalciumphosphate(10%)havebeendetected.

a


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Itwassuggestedthatradiopaquestonescanbedetermined and information on their shapes andnumbers can be obtained by direct radiography(4,15,20).However,someresearchersreportedthatincorrectresultsareobtainedsinceuro-cystolithsinurinary tract usually cannot be determinedradiographically(9,16).SomeresearchersAlkan(17),KealyandMcallister(18)reportsthaturolithscanbedeterminedbycontrastradiographywhichcannotbedetermined by direct radiography. In this study,radiopaque uroliths with various shapes, size andnumbers were found by direct radiographicexamination in six cases diagnosed with clinicalstrangury, pollakiuria or hematuri. However thepresence of uroliths was determined by contrastradiography and ultrasonographic examination infour cases that urolith findings were not seen bydirectradiography.Itwasconcludedthatdirectandcontrast radiography should be evaluated togetherwith ultrasonographic data for diagnosis of lowerurinarytracturolithiasisincats.

It was reported Kealy and Mcallister (18),Johann (19) that uroliths are observed ashyperechoic lesions in ultrasonographic findings,theycreatestrongechowithacousticshadowintheirdistalsanduroliths inbladder fall in the sidedownwhich the patient lies during the ultrasonographicexamination. In our study, uroliths which havevarioussizeandnumbers,hyperechoicappearance,acoustic shadow in their distal and displace as thepatient moves were found by ultrasonographicexaminations.

ReasarchersOsborneandFinco(3)showedthatthediseasemayrecurinsomecaseswhichthefinaldiagnosisofurolithiasiswasestablishedandtreatedaccordingly. In another study Osborne et al. (4), itwas reported that there are cases of recurrentstruvite urolithiasis in cats. In this study, it wasdetermined that recurredone case diagnosedwithstruvite urolithiasis and have been previouslyoperated in order to remove uroliths. Also, it wasconcludedthatcrystalluriashouldbemonitoredthatcritical forthesuccessoftreatmentandrecurrenceofthedisease.

Itwasdeterminedinourresearchthatstruvitecrystalswerecommonlyseeninthecaseswithahighurine pH. Altought struvite crystals are commonlyseen especially in urine with a pH above 6.8, nosignificant difference reported by researchers inurinepHvaluesofhealthycatsandcatswithfelineurological syndrome (FUS) (4,13). It is known thaturethral plugs seen in patients with FUS includetypically struvite. On the other hand, bacterialinfectionintheurinarytractfacilitatestheformationof struvite stones by increase the urine pH anddecrease the solubility of struvite (1,3,13).Conversely, when the pH of urine decreases, theformation of calcium oxalate crystals accelerates(6,10).Moreover,calciumoxalatestonescommonlyformincatswithhypercalcaemiaandhypercalciuria.Also,theriskofformationofcalciumoxalateishigherincatsfedwithcannedpetfoodwithahighamountof carbohydrates. On the contrary, it was showedthat Lekcharoensuk et al. (14), Albasan et al. (7),calciumoxalatestonesare less likelytoforminthecats fedwith dry pet foodswith a high amount ofprotein, calcium, phosphor, magnesium, sodium,potassiumandchloride.ItwasreportedthatHoustonet al. (12), Osborne and Finco (3), the aim of thetreatmentshouldbepreventthechangingonpHthatformedtheseuroliths.Becauseofstruviteislikelytoform in basicmedium and, calcium oxalate, urate,cysteine,calciumphosphateandsilicateurolithsarelikely form in acidic medium. In this study, it wasdetermined that the patients responded to thetreatmentbasedontheurineanalysismadeonthe30thdaysaftertheoperation.Itwasalsoconcludedthat the treatment accomplished by the diet andmedicaltreatmentapplieddependingontheurolithtypetodisruptthenecessarypHofthemediumfortherecurrenceofuroliths.

Consequently;themostcommonurolithtypeisstruviteandothercommontypesofurolithsincludecalcium oxalate, ammonium urate, calciumcarbonate and calcium phosphate respectively.Clinical, laboratory, radiological andultrasonographic findings should be evaluated tomakethediagnosisofurolithiasis.Dietandmedical


21

treatment to be appliedwith orwithout a surgicaloperation is critical to prevent recurrence of thedisease.

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