Total of 10 bullocks aged 7 to 10 years were received at Referral Veterinary Polyclinic IVRI, Izatnagar and were divided into two groups, five animals each. On clinical examination, bullocks with complete urine retention and ruptured urinary bladder were allotted to group I and were subjected to cystorraphy with ischeorectal tube cystostomy. The bullocks showing urine dribbling through urethral orifice with intact urinary bladder were allotted to group II and were subjected to postscrotal urethrotomy along with ischeorectal tube cystostomy. Group II animals showed a good and satisfied recovery with no postoperative deaths as compared to group I animals. It was concluded from the study that early presentation and timely surgical intervention of obstructive urolithiasis in bullocks can improve the recovery rate without any major complications.
One of the important economic constraint affecting cattle raising population in India is incidence of urolithiasis in working bullocks. In India an overall incidence of 5.04 percent has been reported with cattle taking a share of 32.87 percent (Amarpal et al., 2004). The higher incidence in male cattle is attributed to extremely tortuous course of urethra leading to every chance of blockade (Gibson, 1984). Urethral obstruction is the major consequence of urolithiasis ultimately leading to rupture of urinary bladder or urethra. The treatment options for obstructive urolithiasis vary widely depending upon the duration of obstruction and clinical status of the animal (Larson, 1996; Van MD, 2004). The different surgical interventions like repair of ruptured urinary bladder (cystorraphy), tube cystostomy, urethrotomy performed singly or in combination are aimed either at urolith removal so as to maintain normal flow of urine or for urine diversion to allow the time for the damaged or blocked urinary tract to restore patency.
Materials and Methods
The study was conducted in 10 adult bullocks aged 7 to 10 years referred to Refferal Veterinary Polyclinic IVRI, Izatnagar. After proper clinical examination, 5 bullocks with complete urine retention and ruptured urinary bladder were allotted to group I and 5 bullocks showing urine dribbling through urethral orifice with intact urinary bladder were allotted to group II. The status of urinary bladder was confirmed through per-rectal examination and clinical signs exhibited by the animals. Animals with ruptured bladder showed potbellied appearance with fluid thrill on abdominal palpation and drainage of straw coloured peritoneal fluid on was appreciated on abdominal puncture. Isceorectal tube cystostomy was performed in both the groups along with cystorraphy in group I and postscrotal uretrotomy in group II animals.
Bullocks in Group I were stabilized by needle drainage of abdominal fluid followed by adequate fluid therapy before subjected to laparotomy. The procedure was done in standing position with left caudal flank incision site anesthetized by line infiltration (1.5 ml/cm) of 2% lignocaine hydrochloride solution. Laparotomy was performed in all the bullocks of the group. Excess fluid if any was drained by suction drainage so as to reduce interference in locating urinary bladder. The bladder was repaired with continuous cushing suture pattern using vicryl no. 1-0. Peritoneum and abdominal muscles were sutured with vicryl no.2 in simple continuous pattern.
Bullocks in Group II were restrained in right lateral recumbency and post-scrotal midline skin incision was given followed by dissection of deeper tissues. Penile sheath was incised carefully and the penis was exposed. Urethral blockade was located either by direct palpation with fingers or by passing a sterile dripset tube. In the former case a nick incision was put directly over the blockade site with a BP blade and urolith was removed. However, in the later case one end of catheter was passed through a small urethral incision to locate the site of blockade and the urolith was removed as in former case. Urethral catheterization with a sterile dripset tube was done so as to maintain patency (Fig. 1).
Fig. 1: Urethra catheterized with simple dripset tube
The urethral incision was closed using vicryl no. 2-0 in simple continuous pattern. The penile fascia was opposed using vicryl no.1-0. Muscles and subcutaneous fascia were sutured using vicryl no. 2 in simple interrupted pattern. The skin incision was closed with polyamide in horizontal mattress pattern. The tip of the catheter was secured to the prepucial skin and mucosa firmly with silk suture (Fig. 2).
Fig. 2: Urethral catheter fixed to prepuce and sutured postscrotal incision site
Ischeorectal Tube Cystostomy
The incision site in the ischeorectal fossa was anesthetized by injecting 10 ml of 2% lignocaine hydrochloride solution. A nick incision was put in ischio-rectal fossa at the left side of anal sphincter using BP blade no.11. A sterile stylet with beveled edge was passed into the eye of Foley’s catheter (Fig. 3).
Fig. 3: Stylet loaded with Foley’s catheter
The sharp beveled tip of the loaded stylet was pushed into the skin incision with the help of an assistant surgeon. It may be noted here that in group I animals the main surgeon guided the tip of the stylet into the lumen of urinary bladder through laparotomy incision put for cystorraphy, whereas in group II animals the loaded stylet was guided into the bladder per-rectally. The catheter was fixed at place by distending the balloon with 20 ml normal saline through one of the ports.
Ammonium chloride was administered orally (100g/250 kg b.wt./day) for 30 days after surgery in both the groups. Enrofloxacin (5 mg/kg b.wt) for 7 days and meloxicam (0.2 mg/kg b.wt.) for 3 days, were administered intramuscularly. Daily dressing of surgical wound was done with providence iodine liquid followed by application of fly repellent ointment up to 12 days. Sutures were removed on the 12th day. After 5th day postoperatively, Foley’s catheter was occluded periodically by putting a rubber band around one of the ports for more than 1 hr to build up pressure so as to allow urination through prepuce. The rubber band was removed if the bullocks showed signs like kicking at belly, looking at abdomen etc. With the cystostomy catheter occluded, when the bullocks passed urine normally with full speed through the preputial opening, catheter was removed. The urethral catheters were also removed after 10th day.
Results and Discussion
All the bullocks in group I were anorectic on presentation because of uremic changes. Two bullocks died 24 hours after surgery which may be attributed to systemic changes like uremia owing to late presentation of the cases. Uroliths were present in the urinary bladder of 4 animals which were thoroughly flushed out by normal saline. Postoperatively periodic occlusion of the tube cystostomy catheter helped in creating pressure and flow of urine through the normal route within 12 days postoperatively in this group. Further the concretions in the urethra if any were dissolved by creating acidic pH of urine due to administration of oral acidifiers. Amarpal et al. (2010) reported urine dribbling through the urethral orifice after 4-5 days of tube cystostomy in goats. Tamilmahan et al. (2014) observed normal urination through urethra on 12-18 days in 35 male calves and 23 goats postoperatively. Kalim et al. (2015) reported a successful recovery of bullock after 15 days of tube cystostomy.
Bullocks in group II with dribbling and intact bladder were subjected to postscrotal urethrotomy keeping in view the possibility of blockade at the sigmoid flexure. After exteriorization of sigmoid flexure through post-scrotal incision, the urethra was located and palpated for lodgment of uroliths. Urethra at the distal curve of sigmoid flexure (close to insertion of retractor peni muscles) was the site of blockade in 3 bullocks. Whereas, in other two bullocks blockade site above the proximal curve of sigmoid flexure was located by passing a dripset catheter proximally. The uroliths were retrieved by putting a small nick incision at the site with a BP blade. A single and round urolith was retrieved from each of the 3 animals with blockade at the second curve of sigmoid flexure. Whereas, several multifaceted concretions were retrieved from the other two bullocks (Fig. 4).
Fig. 4: Uroliths removed from urethra
Free flow of urine through catheter placed in the urethra was noticed in all the animals of group II immediately after urethrotomy. However, during the subsequent days drop by drop urination was observed which may be attributed to the painful stimuli due to acidification of urine caused by oral acidifiers (Kane et al., 1989). It may be noted here that ischeorectal tube cystostomy was performed in this group so as to aid in urination along with urethral catheter. The tube cystostomy catheter was flushed regularly with normal saline twice a day so as to avoid any blockade. The animals in this group recovered normally with an average period of 10 days.
In the present study group II animals showed a good and satisfied response as compared to group I animals which can be attributed to uremia and peritonitis in group I animals owing to their late presentation thus reaffirming the need of early presentation for successful outcome. Further, the use of diuretics by unqualified quacks in obstructive urolithiasis poses a great challenge in field conditions. In this study 8 animals had the history of parentral administration of diuretics like Lasix injection by local paraveterinarians. The use of diuretics may lead to rupture of urethra or bladder resulting in subcutaneous periurethral urine scalding & cellulitis, and peritonitis respectively. To avoid these untoward incidences awareness to cattle owners is important. The other constraint remains faulty flushing of the Foley’s catheter by owners thus leading to rupture of balloon and consequent dislodgement of catheter from urinary bladder. However, the same can be prevented by proper demonstration and explanation of postoperative care to the owner.
The early presentation with intact bladder in ruminants with obstructive urolithiasis has good prognosis and early recovery than ruptured bladder with uroperitoneum. The timely surgical intervention of such cases with sound postoperative management and owner knowledge remains the cornerstone of treatment in urolithiasis patients at field level.