TECHNIQUE

Cystotomy in Rabbits (Disease Investigation & Management - Treatment and Care)

Summary Information
Type of technique Health & Management / Disease Investigation & Management / Techniques:
Synonyms and Keywords --
Description Perioperative care: Give intravenous fluids for diuresis, as well as analgesia and systemic antibiotics. (B602.18.w18) See: Treatment and Care
Preparation
  • Anaesthetise the rabbit. See: Treatment and Care - Anaesthesia and Chemical Restraint - Lagomorph Anaesthesia
  • Place the rabbit in dorsal recumbency. 
  • Prepare the skin. (J513.6.w1)
    • See also: Laparotomy in Rabbits
    • Note: if retrograde catheterisation and flushing may be needed to return calculi from the urethra to the bladder, clip and scrub the external genitalia as well as the abdomen. (B601.17.w17)
  • If calculi are in the urethra, they should be pushed back into the bladder for removal. (B600.14.w14)
    • Use reverse urohydropropulsion to push calculi back to the bladder. (B601.9.w9)
Initial surgery
  • Make a midline incision between a point a few centimetres caudal to the umbilicus and the pubis (over the bladder).
    • Incise the skin.
    • Dissect through the subcutaneous tissues to the linea alba.
    • Incise the linea alba with a scalpel, taking care not to cut through into the bladder. (J513.6.w1)
      • Or use Metzenbaum scissors and forceps to cut through the linea alba. (B534.43.w43f)
    • The incision can be from the umbilicus to the pubis; or longer if additional exploration of the abdomen is required. (B601.17.w17)
    • See also: Laparotomy in Rabbits

Cystotomy and urolith removal

  • Identify and isolate the bladder. (B601.17.w17)
  • Exteriorise the bladder.
    • Use gentle traction on the apex. (B601.17.w17)
      • Use atraumatic forceps (e.g. Babcock forceps) to grasp the apex. B534.43.w43f)
    • If necessary, cut the median ligament of the bladder to allow exteriorisation. (B601.17.w17)
    • Reflect cranially.
      • Or reflect caudally. (B534.43.w43f)
    • Exteriorising the bladder enables good visualisation and incision in an avascular plane. (B615.8.w8)
  • Place moistened laparotomy sponges or moistened gauze squares to isolate the bladder from the abdominal cavity. (B601.17.w17)
  • Place stay sutures to hold the bladder in place outside the abdomen while removing the uroliths.
    • Either place at the cranial and caudal ends of the intended incision site. (B534.43.w43f, B601.17.w17)
    • Or place one stay suture on either side of the intended incision site, parallel to the line of the incision. (B601.17.w17)
  • Empty the bladder of urine. 
    • Either: Using a 25 G needle and syringe, empty the bladder by cystocentesis. (B534.43.w43f, B600.14.w14, J513.6.w1)
      • This is preferred to manual expression, which may lead to rupture of the bladder. (B600.14.w14)
    • Or: Make a stab incision with a No. 10 or No. 15 blade in the ventral region of the bladder, half way from the apex to the bladder neck, and use suction to drain the bladder. (B601.17.w17)
  • Incise the bladder longitudinally through the serosa, muscular layer and mucosa (likely to be thickened).
    • Take care that the ureters are not damaged by the incision. (B615.8.w8)
    • Enter through the ventral wall of the bladder. (B601.17.w17)
      • The incision may be made in any avascular region of the dorsal, ventral or apical surface. (B615.8.w8)
    • Extend the stab incision used for draining the bladder by suction, or make an initial stab incision taking care not to penetrate through to the dorsal bladder wall. (B601.17.w17)
    • Insert one blade of tissue scissors through the stab incision and cut cranially and caudally, to make an opening as long as required between the bladder neck and apex. (B534.43.w43f, B601.17.w17, J513.6.w1)
  • Remove the uroliths.
    • Use forceps to grasp and remove any large urolith, taking care not to damage the mucosa, which may become partially everted during this procedure. (B534.43.w43f, J513.6.w1)
    • Use a surgical spoon/bladder spoon to remove smaller stones and sludge. (B601.17.w17, B602.18.w18)
    • Flush with sterile saline and use gentle suction to remove fine granular material and blood clots. (B534.43.w43f, B601.17.w17, B602.18.w18, B615.8.w8, J513.6.w1)
  • Check the urethra is patent.
    • Pass a 3.5 French urinary catheter, normograde, to flush out the urethra and check this is patent. (B601.17.w17)
    • It the ureter is blocked, have an assistant pass a urinary catheter retrograde to flush debris back from the urethra into the bladder. (B601.17.w17)
      • Note: Avoid forcing stones from the urethra back into the bladder as they may become lodged in the urethra or the bladder neck. (B602.18.w18)
  • Take samples for testing. See: Clinical Pathology of Lagomorphs
    • Swab the bladder wall for bacterial culture.
      • OR take a full-thickness bladder wall biopsy for bacterial culture and sensitivity, and (if neoplasia is suspected) for histopathology, (B601.17.w17)
    • Submit calculi for chemical analysis. (B601.17.w17, B602.18.w18)
  • Repair the bladder wall.
    • Suture material
      • Use an absorbable suture material. (B601.17.w17, B615.8.w8)
      • 4-0 (1.5 metric) or 5-0 (1 metric) Monocryl or PDS. (J513.6.w1)
      • Use a fine, absorbable suture material with low reactivity (e.g. 4/0 (1.5 metric) Poliglecaprone (Monocryl). Polygalactin (Vicryl) can also be used (B600.14.w14)
      • 3-0 (2 metric) polyglactin 910 or polydioxanone on a taper needle. (B534.43.w43f)
    • Suture pattern
      • Repair the bladder in a single layer using simple interrupted sutures of absorbable monofilament suture material. (B601.17.w17)
      • A continuous inverting pattern can be used, with 4.0 or 5.0 (1.5 or 1 metric) PDS or Monocryl, in a single layer. (B615.8.w8, J513.6.w1)
        • If the mucosa is very thickened and oedematous, suture the mucosa then the other layers. (J513.6.w1)
      • A simple continuous pattern can be used. (B615.8.w8)
      • A two-layer closure can be used, first a Cushing pattern then a Halstead pattern. (B534.43.w43f)
    • Do not penetrate to the bladder lumen with the sutures. (B534.43.w43f)
      • Full-thickness sutures may be required if it is not possible to identify the submucosa (holding layer). (B601.17.w17)
    • Ensure that the sutures oppose the bladder wall edges, including the submucosa, so a water-tight seal is formed and rapid healing is promoted.
    • Inject saline into the bladder then compress gently, to test the seal formed by the sutures. (J513.6.w1)
  • Replace the bladder in the abdomen and cover with fat. (B615.8.w8, J513.6.w1)
Closing the abdomen
  • Close the abdominal wall with 3-0 or 2-0 absorbable suture material in a simple interrupted pattern. (J513.6.w1)
  • Close the skin with 3-0 non-absorbable sutures in a simple interrupted pattern. (J513.6.w1)
  • Or see: Laparotomy in Rabbits
Post-operative care
  • See: Treatment and Care - Surgery - Post-operative care
  • Provide analgesia. (B601.17.w17)
  • Give intravenous fluids. (B601.17.w17)
  • Give gastro-intestinal motility stimulants. (B601.17.w17)
  • If infection is suspected, start antibiotic treatment intravenously during the procedure, as soon as samples have been taken for culture. (B601.17.w17)
  • Consider modifying the diet to provide adequate but not excessive levels of calcium. (B601.17.w17)

(B534.43.w43f, B600.14.w14, B601.17.w17, B602.18.w18, B615.8.w8, J513.6.w1)

Appropriate Use (?)
  • Removal of uroliths from the bladder and proximal urethra. (B601.17.w17, B602.18.w18, B615.8.w8, J34.24.w3, J513.6.w1)
Notes
  • Healing of the bladder wall is rapid in rabbits (three days to epithelialization of the suture line). (B600.14.w14)
Complications/ Limitations / Risk
  • Take care that the ureters are not damaged by the incision in the bladder wall. (B615.8.w8)
  • If performing the initial stab incision of the bladder in a flaccid bladder (after emptying the bladder by cystocentesis), there is a risk that the scalpel blade will penetrate through the dorsal as well as the ventral wall of the bladder. (B601.17.w17)
  • Calculi may form along suture material within the lumen of the bladder; their persistence depends on the longevity of the suture material. (B600.14.w14)
    • Ideally, do not penetrate to the bladder lumen with the sutures.
    • Full-thickness sutures may be required if it is not possible to identify the submucosa (holding layer). (B601.17.w17)
Equipment / Chemicals required and Suppliers
  • Anaesthetic drugs and equipment.

  • Surgical equipment.

  • Suture materials.

Expertise level / Ease of Use
  • This procedure should only be carried out by an individual with appropriate clinical training and practical experience.
Cost/ Availability

The costs of a surgical operation include those associated with: (J15.30.w1)

  • Pre-operative diagnostics (e.g. radiography, ultrasonography, blood tests)
  • Anaesthesia.
  • Perioperative medication (e.g. analgesics, antibiotics, fluids).
  • Surgical preparation (of the operating theatre and the patient, including staff time).
  • Consumables and equipment.
  • Time of the surgeon and assistant(s).
  • Post-operative hospitalisation.
Legal and Ethical Considerations In some countries there may be legislation restricting the use of this type of technique to licensed veterinarians. For example in the UK: "The Veterinary Surgeons Act 1966 (Section 19) provides, subject to a number of exceptions, that only registered members of the Royal College of Veterinary Surgeons may practice veterinary surgery." (See: LCofC1 - RCVS Guide to Professional Conduct 2000 - Treatment of Animals by Non-Veterinary Surgeons).
Author Debra Bourne MA VetMB PhD MRCVS (V.w5)
Referee Aidan Raftery MVB CertZooMed CBiol MIBiol MRCVS (V.w122)
References B534.43.w43f, B600.14.w14, B601.17.w17, B602.18.w18, B615.8.w8, J15.30.w1, J34.24.w3, J513.6.w1

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