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Topics in Companion An Med 33 (2018) 77�82
Review Article
Feline Perineal Urethrostomy: A Review of Past and Present Literature
D32X XAlicia K. Nye, D33X XDVM, D34X XJill K. Luther, D35X XDVM, MS, DACVS*
Keywords:
Abbreviations: FLUTD, Feline lower urinary tract disea
signs; FIC, Feline idiopathic cystitis
https://doi.org/10.1053/j.tcam.2018.07.002
1938-9736 � 2018 Topics in Companion Animal Medicin
Urethral obstruction is a potentially fatal condition and in cases of recurrent obstruction or an identified
cause that is refractory to medical management, a urethrostomy may be performed for definitive treatment.
Perineal urethrostomy is the surgical creation of a permanent stoma in the wider pelvic urethra via anasto-
mosis to the perineal skin. Diagnosis of the underlying cause of obstruction, proper perioperative treatment,
and an understanding of the anatomy and surgical technique, are imperative to the success of this procedure.
This review intends to highlight these aspects, as well as the common complications and expected prognosis
to aid decision making in the management of these cases.
© 2018 Elsevier Inc. All rights reserved.
perineal X XX X
urethrostomy X XX X
feline X XX X
urinary X X
FLUTD X XX X
urethra
Small Animal Medicine and Surgery, Veterinary
Health Center, University of Missouri, Columbia,
MO, USA
*Address reprint requests to: Jill K. Luther,
Veterinary Health Center, University of Mis-
souri, 900 E Campus Dr, Columbia, MO 65211,
USA.
E-mail: lutherjk@missouri.edu (J.K. Luther)
se; LUTS, Lower urinary tract
e. Published by Elsevier Inc.
Introduction
Feline lower urinary tract disease (FLUTD) refers to the con-
stellation of clinical signs related to disorders of the urinary blad-
der or urethra. Alternative terms include feline lower urinary
tract signs (LUTS) and feline urologic syndrome. It may be classi-
fied as non D4 5X Xobstructive or obstructive, with obstruction occurring
in 18%-58% of male cats with FLUTD.1-3 Urethral obstruction is a
potentially fatal condition due to intra D 4 6X Xluminal abnormalities such
as urethral plugs, urethroliths, and sloughed tissue, or may be
due to mural or extra-mural pathologies such as strictures,
inflammatory swelling, neoplasms, anomalies, reflex dyssnergia,
and muscular spasm.4 Feline idiopathic cystitis (FIC) is a term
used to describe LUTS in the absence of an alternate diagnosis.
While its pathophysiology is not fully understood, it is believed
to result from complex interactions between the urinary bladder,
nervous, and endocrine systems, husbandry practices, and the
environment in which the cat lives. FIC is the most common
cause of LUTS in cats under 10 years of age, affecting up to 2/3 of
this population.1, D 47 X X2, D 48 X X5, D 49 X X6 Proper management of urethral obstruction
includes correcting systemic disturbances and restoring urethral
patency or providing urinary diversion. Reobstruction has an
overall reported incidence of approximately 36%, and is most
commonly due to urethral plugs (43%), idiopathic obstruction
(36%), and urolithiasis (30%).2, D 50 X X7 A urethrostomy may be performed
for definitive treatment in patients with recurrent obstruction as
in the case of FIC, or those with an identified cause that cannot
be resolved with medical management such as stricture, neopla-
sia, or distal urolithiasis. Perineal urethrostomy is the surgical
creation of a permanent stoma in the wider pelvic urethra via
anastomosis to the perineal skin and involves amputation of the
narrow penile urethra. The purpose of this article is to provide a
thorough review of the historical and clinical aspects of the peri-
neal urethrostomy procedure.
History
Multiple surgical methods have been described to address the
problem of obstruction in the feline urethra. These techniques
include cystocolostomy, ureterocolostomy, urethrocolostomy, and
multiple urethrostomy techniques including prepubic, transpelvic,
subpubic, and the most widely used, perineal.8, D 5 1X X9 Techniques for
perineal urethrostomy were first published in 1963; Wilson and
Harrison did not describe the current method used until 1971.
This procedure allowed first intention healing of pelvic urethral
mucosa to perineal skin, attempting to shorten recovery time and
reduce the occurrence of stricture and urine scald compared to
the other techniques introduced by Carbone, Blake, and Christen-
sen.8 In the Carbone method, a circumferential stoma was created
between the pelvic urethra and perineal skin without a drain
board.10 The Blake, or lateral-flap technique, created two lateral
flaps of the longitudinally incised urethra and was allowed to
heal by second intention.11 Christensen’s method, or preputial
urethrostomy, maintained the prepuce for anastomosis with the
pelvic urethra.12 In a study comparing the techniques, Smith and
Schiller found all D 5 2X X3 techniques had a higher risk for the develop-
ment of urinary tract infections and urethral strictures than the
Wilson and Harrison procedure.9
Indications for Perineal Urethrostomy
Indications for perineal urethrostomies have shifted over the
years from a first-line treatment to being considered a salvage proce-
dure. A study of the frequency of perineal urethrostomies performed
in North America found a 70% decline between the early 1980s and
years 1985-1999.13 This decline is also believed to be due to appropri-
ate medical management and a resultant decline in the number of
urethral obstructions.5,D53X X13,D54X X14 The most common causes of obstruction
are idiopathic and matrix-crystalline urethral plugs, often composed
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78 A.K. Nye, J.K. Luther / Topics in Companion An Med 33 (2018) 77�82
of struvite.15 Idiopathic obstructions have been diagnosed in 29%-53%
of cats, and urethral plugs have a reported incidence of 17%-59%. Uro-
lithiasis causes obstruction in 5%-29% of cats, and stricture has been
determined to be the cause in up to 11% of cases.1,D55X X16,D56X X17
Male cats are overrepresented, as the long and narrow penile ure-
thra is the most common site of obstruction. The current standard is
that perineal urethrostomies are reserved for cases of recurrent or
persistent urethral obstruction despite appropriate management for
FLUTD, obstructions refractory to catheterization, urethral trauma,
stricture, or neoplasia.16,D57X X18
The goal of the perineal urethrostomy procedure is to reduce the
risk of urethral obstruction recurrence;D58X Xhowever, adjunctive manage-
ment including dietary changes and/or multimodal environmental
modification may be indicated for prevention of clinical signs in the
case of FIC, urethral plugs, and urolithiasis.18-20
Demographics and Clinical Signs
The average age of cats presenting for perineal urethrostomy is 3-
7 years, with a range of 1-15 years. Average weight is 5.1 kg with a
range of 2.5-9.3 kg. Preoperative clinical signs include dysuria, ure-
thral obstruction, hematuria, pollakiuria, and stranguria.16,D59X X20-22
Diagnostics
Due to the systemic complications that may occur from long-term
obstruction, a urinalysis and biochemical profile should be obtained
prior to anesthesia to evaluate renal, metabolic, and electrolyte
parameters. Urinalysis may reveal hematuria, crystalluria, pyuria, and
improperly concentrated urine may indicate an underlying polyuric
disorder, such as renal insufficiency. A bacterial culture of urine
should be performed to identify a current urinary tract infection prior
to administration of antibiotics. Serum biochemistry will disclose any
azotemia, metabolic acidosis, hyperkalemia, and other electrolyte
abnormalities including hyperphosphatemia and hypocalcemia.23
ECG monitoring may reveal changes consistent with hyperkalemia
(i.e. lack of P waves) if potassium concentration is not immediatelyavailable.
Imaging may be indicated when attempts to pass a catheter or
flush the urethra are unsuccessful, or if multiple sites or mural/extra-
mural causes are suspected.24 Various modalities may be utilized to
define the specific cause and location of obstruction, or identify
causes not amenable to the perineal urethrostomy procedure. Radi-
ography should be performed in every case of urethral obstruction
and can determine the anatomic location and morphology of the
bladder, presence of radiopaque uroliths, or extramural abnormalities
that may cause obstructions. The addition of contrast is beneficial for
illuminating areas of stricture, trauma, or neoplasia. Additional imag-
ing modalities including ultrasound, computed tomography, and
magnetic resonance imaging may be helpful if a neoplasm is sus-
pected or findings on a contrast cystourethrogram are unusual. The
diameter of the male urethra makes routine urethroscopy problem-
atic prior to the performance of urethrostomy.
Preoperative Management
A complete assessment of patients prior to surgery is necessary, as
obstructions can have systemic consequences. Stability of the patient
must be assessed prior to anesthesia; this includes determining
hemodynamic status and metabolic derangements including hyper-
kalemia and metabolic acidosis, with severe (>8.0) hyperkalemia
being the most life-threatening abnormality.
Hyperkalemia is caused by exchange of potassium and hydrogen
ions between the intra- and extra-D60X Xcellular space, retention due to
decreased GFR, and reabsorption of potassium from the damaged
bladder mucosa. Hyperkalemia results in reduced cardiac
contractility and conduction disturbances. If rapid measuring of
potassium cannot be achieved in the unstable patient, bradycardia
(less than 120 bpm) and hypothermia (less than 96.6 ° D61X XF) are the best
predictors of severe hyperkalemia, with a specificity of 98%-100%.25
Treatment of hyperkalemia includes intravenous (IV) crystalloid flu-
ids and urinary diversion. For severe hyperkalemia (>8.0) calcium
gluconate can be administered with concurrent ECG monitoring, as
well as regular insulin followed by dextrose, dextrose alone, terbuta-
line, or sodium bicarbonate. Sodium bicarbonate should only be
administered with caution if the aforementioned treatments are
unsuccessful and pH is less than 7.2 or total CO2 is less than
12 mmol/L.
Metabolic acidosis results from decreased urinary excretion of
hydrogen ions and possibly impaired renal production of ammonia.
Hypocalcemia may result from the retention of phosphorus or due to
the kidneys’ impaired response to parathyroid hormone and synthe-
sis of vitamin D. Metabolic acidosis along with low ionized calcium
may exacerbate the cardiotoxic effects of hyperkalemia, impair car-
diac contractility, and enhance venoconstriction that may lead to
fluid overload.26
An D62X XIV D63X Xcatheter should be placed and IV fluid therapy is adminis-
tered prior to induction; ideally fluid therapy should continue until
electrolyte abnormalities and dehydration are corrected. Lactated
Ringer’s D64X Xsolution or other balanced electrolyte solutions may be more
efficient in correcting metabolic derangements when compared to
physiologic saline (0.9% NaCl), but any resuscitative fluid may be
administered as the amount of potassium in the fluid is negligible
even in the hyperkalemic patient.27,D65X X28
Urinary diversion and bladder decompression should be achieved
via catheterization, intermittent cystocentesis, or cystostomy tube
placement in order to prevent resorption of electrolytes and waste
products. Restoration of urine flow and appropriate fluid therapy typ-
ically resolves the hyperkalemia, metabolic acidosis, and postrenal
azotemia seen in obstructed patients.26 Table 1 illustrates preopera-
tive considerations and treatment recommendations.
Anatomy
The urethra of male cats measures approximately 8.5-10.5 cm in
length and is divided into preprostatic, prostatic, postprostatic, bul-
bourethral, and penile segments; these segments measure up to
2.1 mm, 2.5 mm, 1.6 mm, 1.3 mm, and 0.7 mm in diameter, respecti-
vely.29,D66X X30 Innervation of the urethra is similar to other domestic spe-
cies; smooth muscle is innervated by the pelvic and hypogastric
nerves, and the short, striated urethralis muscle is innervated by ure-
thral branches of the pudendal nerve.31
Surgical Technique
Several resources have covered the procedure in detail and pro-
vided step-by-step illustrations or photographs. For the approach in
sternal recumbency, the practitioner may refer to small animal
surgery textbooks including Johnston and Tobias, and Fossum.32,33
Visual aids for the dorsal recumbency approach can be found in
articles by Tobias, Goh, and Kagan.34-36
Perioperative antibiotics, most commonly a first generation ceph-
alosporin, should be administered to prevent infection that can pro-
long healing. The patient should be intubated for general anesthesia
and maintained with an inhalant anesthetic to achieve maximum
muscle relaxation and allow for proper ventilation throughout the
procedure. The perineum is clipped and aseptically prepared, and a
purse-string suture is placed in the anus. The cat is placed in sternal
recumbency with the hindquarters elevated off the edge of the oper-
ating table, or alternatively, in dorsal recumbency. The tail is secured
out of the surgical field prior to the final sterile preparation. A sterile
urethral catheter may be placed to aid in identification of the urethra.
Table 1
Preoperative Considerations D1X X
Diagnostic Abnormality Treatment
Point of care tests:
Hematocrit/Total D2X Xprotein Dehydration Crystalloids; D3X Xattempt rehydration over 4-6 hours
Blood D4X Xpressure Hypotension, signs of shock Crystalloids, D5X Xboluses as needed
Serum D6X Xbiochemistry with
acid-base status
Azotemia Crystalloids, D7X Xurinary diversion
Metabolic acidosis Crystalloids, D8X Xurinary diversion
Bicarbonate 0.5-1.0 mEq/kg IV over 10-15 min
Hyperkalemia Crystalloids, D9X Xurinary diversion
- If D10X Xsevere (>8.0) Calcium D11X Xgluconate 10% 0.5 ml/kg IV over 5-15 min with ECG monitoring
-Insulin 1 U/cat followed by 0.5-1 ml/kg 50% dextrose IV(dilute 1:4 with saline)
-50% Dextrose 0.5-1 ml/kg IV (dilute 1:4 with saline)
-Terbutaline 0.01 mg/kg IM or IV slowly
-Bicarbonate 0.5-1.0 mEq/kg IV over 5-15 min
Hypocalcemia Calcium D12X Xgluconate 10% 0.5 ml/kg IV over 5-15 min with ECG monitoring
ECG Hyperkalemia:
- 5.5-6.5 -Increase in T wave amplitude
- 5.6-7.0 -Decrease in R wave amplitude, prolonged QRS and P-R Interval, S-T segment depression
- 7.1-8.5 -Decrease in P wave amplitude, increase in P wave duration, prolonged Q-T interval
- 8.6-10.0 -Lack of P waves and sinoventricular pattern
- >10.1 -Widening of QRS complex and eventual development of ventricular flutter/fibrillation/asystole
Additional D13X Xdiagnostics:
Complete D14X Xblood D15X Xcount Typically normal
Urinalysis Bacteriuria or pyuria indicating UTI Empirical therapy while awaiting culture and sensitivity results.
Culture may be of urine, bladder mucosa, or urolith.
Concentrated (USG >1.035) Crystalloids; D16X Xattempt rehydration over 4-6 hours
Abdominal D17X Xradiograph+/-
D18X Xcontrast study
Urolithiasis Cystotomy with stone analysis
Stricture, D19X Xneoplasia, or D20X Xrupture May indicate need for a more proximal urethrostomy location or additional imaging modality
A.K. Nye, J.K. Luther / Topics in Companion An Med 33 (2018) 77�82 79
An elliptical incision is made in the perineum ventral to the anus
incorporating the scrotum and prepuce. Castration is performed in
intact cats. The penile urethra is freed ventrally from its pelvic attach-
ments using sharp and blunt dissection, along with transection of the
ventral penile ligament. Dorsal dissection is minimized to preserve
innervation. The paired ischiocavernosus muscles are transected at
their attachments to the ischium. The retractor penis muscle, located
on the dorsal aspect of the penis, is locatedand transected. Dissection
is continued proximally until the paired bulbourethral glands are
identified.
The urethra is incised using sharp, delicate scissors or a #15 blade
over a tomcat catheter beginning distally on its dorsal midline and
extending to the level of the bulbourethral glands. The diameter of
the urethra at this level may be assessed as adequate if a pair of Kelly
hemostatic forceps may be inserted to its box locks, or by insertion of
an 8-Fr to 10-Fr red rubber catheter.
The urethral mucosa is apposed to the skin of the perineum dor-
sally with a simple interrupted or simple continuous pattern of 4-0 or
5-0 monofilament suture material. The author prefers a rapidly
absorbable monofilament such as poliglecaprone 25 (Monocryl; Ethi-
con, Inc.) to avoid the need for suture removal, which may necessitate
sedation. The suture at the apex of the stoma is placed first. It is
important to ensure that the urethral mucosa is engaged and secured
directly to the skin, without engaging the penile and subcutaneous
tissues. Two additional apical sutures on either side of the initial
interrupted suture are placed to begin two separate continuous
suture lines around the stoma and the drainboard. Prior to amputa-
tion of the distal penis, a suture may be placed around the corpus cav-
ernosum penis to decrease intra D67X Xoperative and post D68X Xoperative
bleeding.
Several modifications to the original technique have been made
since its introduction. An investigation of closure with nonD69X Xabsorbable
and absorbable suture material, and the use of simple interrupted
versus two simple continuous patterns, found no significant differ-
ence in postoperative complications. The use of absorbable suture
material negates the need for suture removal, and reported
advantages to a simple continuous pattern include rapid closure,
improved hemostasis, and decreased number of suture knots.37 Sur-
gical positioning in dorsal recumbency was first described by Kagan
and negates the need for repositioning and preparation if a cystotomy
is to be performed. Surgeons who prefer dorsal positioning claim it is
more ergonomic, minimizes pressure on the diaphragm by abdominal
viscera during the surgical procedure, and avoids cranial movement
of the urinary bladder that could make adequate exposure of the pel-
vic urethra difficult.35,D70X X36
Postoperative D71X XManagement
Those cats with systemic derangements may require IV fluid ther-
apy for several days after the procedure. Up to 46% of cats experience
postD72X Xobstructive diuresis within 6 hours of resolution of obstruction
and it may continue up to 84 hours post D73X Xobstruction. Diuresis is
defined as urine production of more than 2 ml/kg/hr. Acidemia is sig-
nificantly associated with the development of diuresis and 40% of
obstructed cats present with a blood pH below 7.3; this demonstrates
the need for ongoing monitoring of electrolytes, acid-base status, and
urine output.23,D74X X38 Urine output may be monitored by at least twice-
daily monitoring of patient weight and weighing of pee pads, as the
use of indwelling urinary catheters postD75X Xsurgery is not recommended
due to risk of irritation and ascending infection. The patient should
be monitored for normal urination through the stoma for 24-48 hours
prior to discharge from the hospital.
Analgesics are recommended for 3-5 days in the postoperative
period and typically consist of an opioid. NonD76X Xsteroidal anti-inflamma-
tories should be avoided in patients that were azotemic due to any
acute injury the kidneys may have sustained during obstruction and/
or anesthesia, but may be considered in nonD77X Xazotemic patients to help
with inflammation. An Elizabethan collar to prevent licking at the
incision and paper litter should be used for 1D78X X-3 weeks to minimize
the risk of stricture. Antibiotics should be continued for 4-6 weeks
with confirmed urinary tract infection, as most urinary tract infec-
tions in cats are considered complicated. Suggested first-line
Table 2
Postoperative Considerations D21X X
Consideration Timeline Monitoring or D22X XTreatment
Analgesia As needed for pain, typically
several days after surgery
Buprenorphine 0.01-0.02 mg/kg q8-12h
Fentanyl 2-6 mcg/kg/h
Oxy- or D23X Xhydro-morphone 0.1 mg/kg q3-4h
If not azotemic may use an NSAID:
Robenacoxib 2 mg/kg qd SC or 1-2 tabs/cat qd (depending on weight)
Fluid D24X Xtherapy While hospitalized Monitor urine output. Post-obstructive diuresis may continue up to
84 hours after relief of obstruction. Fluid rate should match urine out-
put. Taper fluids once azotemia and dehydration resolve.
Weigh patient at least twice daily for prevention of dehydration and alter-
natively, fluid overload. Estimate patient normal weight based on esti-
mated level of dehydration.
Monitor electrolytes and supplement as needed.
Elizabethan D25X Xcollar
and D26X Xpaper D27X Xlitter
Minimum 2-3 weeks and
until complete healing of incision is confirmed.
Necessary for prevention of self-trauma or irritation that may result in
prolonged healing, excess granulation tissue, stricture, or infection
Antibiotic D28X Xtherapy If confirmed UTI, treat until resolution of infection Empirical therapy for Gram + cocci or Gram - rods
-Amoxicillin 50 mg per cat q24h
-Cephalexin 12-25 mg/kg q12h
-Trimethoprim D29X Xsulfamethoxazole 15 mg/kg q12h
Preferably, therapy based on culture and sensitivity testing of urine or
bladder mucosa.
At-home D30X Xmedical
D31X Xmanagement
Indefinitely for LUTS secondary to FIC, urolithiasis,
crystalluria, or urethral plugs
Increased water intake
-Moist food, multiple meals per day-Water fountains-Ice cubes or broth in
water
Urinary diet specific to symptoms of FLUTD
Environmental enrichment and stress-reduction
-Increased interaction with owners
-Minimize conflict
-Gradual changes
-Feline facial pheromone diffusers
80 A.K. Nye, J.K. Luther / Topics in Companion An Med 33 (2018) 77�82
antimicrobials for urinary tract infections include amoxicillin, cepha-
lexin, or trimethoprim-sulfamethoxazole, while awaiting culture and
sensitivity results from urine or urinary bladder wall mucosal biopsy.
Depending on the reason for perineal urethrostomy, medical man-
agement including multimodal environmental modification and/or
nutritional management is likely indicated for at-home management
of FIC, urolithiasis, crystalluria, and urethral plugs.18-20 Table 2 pro-
vides a summary of postoperative considerations.
Complications
Reported complications include urethral strictures, recurrent bac-
terial urinary tract infection, urolithiasis, and rarely, wound dehis-
cence, extravasation of urine, urinary or fecal incontinence,
hemorrhage, rectal prolapse, perineal hernia, and rectourethral fistu-
la.9, D79X X22,D80X X39-42 Bass et al D81X Xfound that early and late complications of peri-
neal urethrostomy will occur in 25% and 28% of cats, respectively,
with early complications occurring less than 4 weeks postoperatively
and late complications defined as more than D82X X4 months after the
procedure.16
Urethral Strictures
Urethral stricture is a commonly reported postoperative compli-
cation, reported in up to 17% of cases.9D83X XReports of time from proce-
dure to stricture formation vary; Bass et alD84X X found a 12% incidence
within the first 4 weeks postoperatively and 5% after 16 weeks, Smith
Phillips et alD85X Xfound a range of less than D86X X1 week to over 4.5 years.43
Urethral strictures have been associated with indwelling urinary
catheters, trauma, improper surgical technique, and lack of surgeon
experience. The mucocutaneous junction is the most common site of
stricture.9,D87X X39,D88X X43,D89X X44 Inflammation due to irritation from catheters, sur-
gery, or trauma (either self-inflicted or external), may lead to excess
granulation tissue formation. Inadequate dissection of the urethra
cranial to the bulbourethral glands due to failure to transect the
ischiocavernosus muscles or insufficient ventral dissection, leadsto
incomplete mobilization of the urethra and excess tension on sutures.
Poor apposition of mucosa and skin can be due to improper surgical
technique or edematous urethral tissue. A study of 11 cats requiring
surgical revision of a strictured perineal urethrostomy found that in 8
of D90X X11 (73%) cats, dissection did not involve the urethra to the level of
the bulbourethral glands. In the remaining D91X X3 cats (27%), stricture was
presumed to be due to poor mucosa-to-skin apposition indicated by
urine extravasation postoperatively. Time between the initial peri-
neal urethrostomy and development of stricture ranged from D92X X4 to
1623 days. Eight of D93X X9 cats included in follow-D94X Xup had no reported com-
plications following the surgical revision. One cat developed inappro-
priate urination and licking at the stoma site.43
Revision surgery should be performed in the case of stricture and
consists of adequate dissection and mobilization of the urethra to just
cranial to the bulbourethral glands. If dissection of the urethra does
not allow tension-free closure, alternative techniques may be consid-
ered including the prepubic, subpubic, or transpelvic urethrostomy.
Urinary Tract Infections
Recurrent urinary tract infection is the most commonly reported
late postoperative complication. The reported rate ranges from 10%
when combined with a calculolytic diet to 33%.9,D95X X16,D96X X20,D97X X45,D98X X46 Urinary tract
infections may be subclinical or clinical and may be self-limiting.
Proposed contributing factors to urinary tract infections include
an underlying uropathy, trauma secondary to inadequate or recurrent
catheterization, and alterations of the urinary tract’s intrinsic
defenses against infection.9,D99X X16,D100X X22,D101X X45,D102X X47 Perineal urethrostomy per-
formed in healthy cats versus those with FLUTD found recurrent uri-
nary tract infections in 22% of those with FLUTD, and no incidence in
the healthy group. This suggests that perineal urethrostomy may
A.K. Nye, J.K. Luther / Topics in Companion An Med 33 (2018) 77�82 81
predispose cats with an underlying uropathy to infections, but the
procedure alone does not.48
Widening and shortening of the urethra, neuropraxia, or trauma
to the striated muscle urethral sphincter leading to decreased intra-
urethral pressure, may all facilitate ascending bacterial contamina-
tion.38,D103X X39 Gregory and Vasseur found a decrease in electromyographic
activity of the urethralis muscle and urethral pressures postopera-
tively; this persisted in only 39% of the cats at long-term follow up.
The authors concluded from this study that decreased urethral
sphincter function alone could not explain the increased prevalence
of infections postoperatively.46,D104X X49 A later study investigating sharp
versus blunt dissection during perineal urethrostomy found no signif-
icant difference between the preoperative and postoperative urody-
namic status of patients in either group; it was suggested that
avoiding dissection dorsal to the urethra may be more important in
maintaining lower urinary tract function than minimal or extensive
dissection.50 To investigate other potential causes of neuropraxia, the
diameter of the lumbococcygeal vertebral canal was determined in
dorsal versus ventral recumbency. This study found a significant
reduction of diameter in both positionsD105X X; however, a larger degree of
reduction was seen in the sacrococcygeal vertebral segments of cats
placed in ventral recumbency. The authors determined that this could
be a potential cause of iatrogenic nerve injury leading to anal sphinc-
ter or urinary bladder dysfunction and therefore dorsal recumbency
may be the superior method.51
Due to the risks for bacterial urinary tract infection, proper surgi-
cal technique and correct identification of anatomy can help prevent
iatrogenic trauma, and indwelling catheters in the postoperative
period are not recommended. Urinalysis and bacterial culture have
been recommended at 1, 3, 6, and 12 months postD106X Xoperatively due to
the potential for urinary tract infection.34,D107X X45
Urolithiasis
Struvite and calcium oxalate urolithiasis has been reported in cats
after perineal urethrostomy. Of 59 cats that underwent perineal ure-
throstomy, Bass et al D108X X found 13% developed urolithiasis postopera-
tively.16 Proper treatment and prevention depends on the type of
stone, therefore stones removed from the urinary tract should be
sent for analysis to determine the composition. Struvite stones may
or may not be infection-induced, and often resolve with a calculolytic
diet and antibiotics if indicated. Calcium oxalate stones must be
removed surgically or by urohydropulsion and those affected should
be placed on a prescription diet for prevention of stone recurrence.
Since the regular use of calculolytic diets was instituted, stone analy-
sis has shown a vast decrease in the proportion of struvite urolithiasis
and subsequent increase in calcium oxalate. In addition to reducing
the proportion of struvite urolithiasis, these acidifying diets have
been proposed as a risk factor for the formation of calcium oxalate
stones.18,D109X X52 Regardless of stone composition, increased water con-
sumption is encouraged for prevention in order to decrease minerals
associated with urolith formation.
Extravasation of Urine and Wound Dehiscence
Extravasation of urine into the subcutaneous tissues may occur
with laceration of the urethra during catheterization or surgery, or
insufficient mucosa-skin apposition. Urine leakage into the perineum
may lead to cellulitis, wound dehiscence, or stricture formation. Clini-
cal signs include hind limb and perineal edema, red or yellow bruis-
ing extending from the incision, or sloughing of skin. If urine
extravasation is suspected, diversion of urine via indwelling catheter
or tube cystostomy will prevent inflammation caused by hyperosmo-
lar urine and allow healing.34,D110X X39,D111X X43
Wound dehiscence may occur due to poor apposition, urine
extravasation, or infection. Dehisced incisions should be treated as
open wounds. Infection may be iatrogenic or due to fecal
contamination.16,D112X X39,D113X X43,D114X X44 In the study of 59 cats by Bass et alD115X X, only 1 D116X X
(2%) experienced urine extravasation, wound dehiscence, and celluli-
tis, and Smith and Schiller found a 3% incidence of dehiscence.9, D117X X16
Urinary or Fecal Incontinence
Urinary and fecal incontinence are infrequent complications. Uri-
nary incontinence may result from damage to the pudenal nerve,
sacral spinal cord, pelvic plexus, or over distension secondary to
obstruction.31,D118X X40 Urinary and fecal incontinence are avoided with
careful dissection, avoiding dorsal dissection, and proper surgical
technique. Other rare but potential complications resulting from
aggressive dissection include the development of perineal hernias
and rectourethral fistulas.41,D119X X42
Hemorrhage
Hemorrhage during and after the procedure may occur from the
cavernous tissue and incision of the ischiocavernosus muscles. While
it rarely becomes a serious problem, suture placement around the
corpus cavernosum penis, transection of the ischiocavernosis muscles
at their ischial attachment, and proper skin to mucosa apposition may
all help to reduce the amount of hemorrhage intra- and
postD120X Xoperatively.40
Prognosis
Perineal urethrostomy can provide a good long-term functional
outcome, especially when combined with appropriate medical man-
agement of the underlying cause. Long-term postoperative complica-
tions, most commonly urinary tract infections and strictures, are
often treatable conditions. In a study of 86 cats, Ruda and Heiene
investigated the cause of death and survival times of cats after peri-
neal urethrostomy under the assumption that euthanasia would be
elected shortly after surgery if it resulted in a poor quality of life.
Eighty-seven percent of cats survived at least 6 D121X Xmonths, and 60% of
survivors were asymptomatic after surgery.Of the 13% of cats that
died within the first 6D122X Xmonths postoperatively, causes included re-
obstruction, sepsis, multi-systemic disease, and recurrence of FLUTD.
A good long-term quality of life postoperatively was reported by 88%
of cat owners.21 Similarly, Bass et alD123X X found that 89% of owners
reported their cat had a very good quality of life despite more than
half of the cats requiring veterinary attention for complications or
disease recurrence in the long-term. It is of note that 73% of cats that
died or were euthanized during this retrospective study were due to
reasons unrelated to the urinary tract.16
Conclusions
Perineal urethrostomy is a salvage procedure indicated for cases of
urethral obstruction of the cat refractory to medical management.
The goal of the procedure is to prevent potentially fatal obstructions.
The most frequently reported complications include bacterial urinary
tract infections and urethral stricture, which are often due to an
underlying uropathy or improper surgical technique, respectively.
Cats undergoing perineal urethrostomy can have a good long-term
prognosis with the supplementation of medical management for
FLUTD or other underlying causes of obstruction.
AcknowledgmentD124X X
None.
82 A.K. Nye, J.K. Luther / Topics in Companion An Med 33 (2018) 77�82
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	Feline Perineal Urethrostomy: A Review of Past and Present Literature
	Introduction
	History
	Indications for Perineal Urethrostomy
	Demographics and Clinical Signs
	Diagnostics
	Preoperative Management
	Anatomy
	Surgical Technique
	Postoperative Management
	Complications
	Urethral Strictures
	Urinary Tract Infections
	Urolithiasis
	Extravasation of Urine and Wound Dehiscence
	Urinary or Fecal Incontinence
	Hemorrhage
	Prognosis
	Conclusions
	Acknowledgment
	References