Radical Cystectomy and Cutaneous Ureterostomy in 4 Dogs with Trigonal Transitional Cell Carcinoma: Description of Technique and Case Series

Received: 15 July 2015 | Accepted: 18 June 2016 DOI 10.1111/vsu.12583

ORIGINAL ARTICLE

1 Department of Veterinary Clinic and Abstract Surgery, Faculdade Uninga, Maringa, Brazil Objective: To describe radical cystectomy followed by cutaneous ureterostomy as a 2 Department of Veterinary Clinic and treatment of invasive bladder neoplasia in dogs. Surgery, Franca University Study Design: Retrospective study. (UNIFRAN), Franca, Brazil Animals: Client-owned dogs with transitional cell carcinoma of the bladder trigone 3 Department of Veterinary Clinic and (n54). Surgery, S~ao Paulo State University, Jaboticabal, Brazil Methods: Perioperative complications and long-term outcomes of dogs that under- 4 went cutaneous ureterostomy following radical cystectomy and lymphadenectomy Veterinary College, Universidade Unimontes, Santos, Brazil for transitional cell carcinoma of the urinary bladder trigone were reviewed. Both ureters were transected and anastomosed to the ventral abdominal skin. Polyvinyl 5 Veterinary College, Pontifícia chloride catheters were placed in the ureteral stomas and maintained for 5 days. After Universidade Catolica do Parana, catheter removal, dogs were managed with an absorbent diaper over the stomas. Curitiba, Brazil Long-term outcome and survival were documented by follow-up visits or phone 6 Department of Clinical Sciences, contact. College of Veterinary Medicine, North Carolina State University, Results: Median age at the time of surgery was 10.3 years (range, 8–12). Average Raleigh, North Carolina procedural time was 4.7 hours (range, 3.8–6.1). Minor complications occurred in ﬁ – Correspondence all dogs, including bleeding and edema of the ureterostomy site during the rst 2 3 Leandro Z. Crivellenti, Avenida days after surgery. One dog developed urine scald that resolved with improved stoma – Doutor Armando, care and hygiene. Median survival time after surgery was 278.6 days (range, 47 de Sales Oliveira, 201 Parque 498). Distant metastases were documented in 2 dogs at 47 days (bone) and 369 days Universitario CEP 14404-600 (lung) after surgery. Franca, SP, Brazil. Conclusion: Radical cystectomy with cutaneous ureterostomy is a viable salvage Email: [email protected] procedure for urinary diversion after cystectomy in dogs with invasive bladder neoplasia. Postoperative management and quality of life were considered acceptable by most owners. Future studies are warranted to evaluate survival time in a larger number of animals.

1 | INTRODUCTION node dissection is considered the gold standard for surgical management of muscle-invasive bladder cancer.2,3 Urine Several therapeutic techniques have been introduced in drainage is re-established through 1 of 3 techniques: (1) recent years to improve the management of bladder cancer in incontinent diversion using an ileal conduit to abdominal people.1 Radical cystectomy with bilateral pelvic lymph skin; (2) continent cutaneous diversion using an intestinal

Veterinary Surgery 2016; 1-9 wileyonlinelibrary.com/journal/vsu VC 2016 The American College of Veterinary Surgeons | 1 2 |

TABLE 1 Summary of 4 dogs undergoing radical cystectomy and cutaneous ureterostomy

Surgery Presenting Perioperative time Outcome owner † Case signs Hydronephrosis TNM stage* Procedures complications (hours) satisfaction 1 Hyporexia, Bilateral T2N0M0 Prostatectomy Mild edema, 4.8 Hit by car and died dysuria, hematuria, hemorrhage (2 days) (498 days); very sa- episodic vomiting tisﬁed

2 Dysuria, hematuria Bilateral T2N0M0 Prostatectomy Edema left hind leg, 6.1 Euthanasia due to ag- hemorrhage from gression toward own- ureteral stomas er (193 days); (3 days). Urine scald very satisﬁed (30 days)

3 Dysuria, hematuria Bilateral T1N1M0 None Peristomal edema, 4.0 Euthanasia. Probable (left > right) hemorrhage (2 days) lung metastasis (369 days); very satisﬁed

4 Dysuria, hematuria, Bilateral T2N1M0 None Peristomal edema 4.7 Euthanasia. Bone abdominal pain (3 days) metastasis (47 days); very satisﬁed aTNM stage20,21 5 tumor (T), lymph node (N), metastasis (M). T0: no evidence of a primary tumor; T1: superﬁcial papillary tumor; T2: tumor invading the bladder wall, with induration; T3: tumor invading neighboring organs (prostate, uterus, vagina, and pelvic canal). N0: no regional lymph node involvement; N1: regional lymph node involved; N2: regional lymph node and juxtaregional lymph node involved. M0: no evidence of metastasis; M1: distant metastasis present. bIn addition to cystectomy and cutaneous ureterostomy. HUPPES TAL ET . HUPPES ET AL. | 3

FIGURE 1 Illustration of radical cystectomy followed by cutaneous ureterostomy in dogs. (A) Exploratory laparotomy was performed and the urinary bladder and ureters were identified. (B) Bladder, membranous urethra, and prostate were resected en bloc, the ureter was implanted into the skin over the ventral abdomen after creating a 3–4 cm tunnel, parallel to the linea alba. (C) The ureters were sutured to the skin pouch; or (3) creation of an orthotopic bladder that is anasto- female dogs with invasive transitional cell carcinoma of the mosed to the remaining urethra.3 In general, continent diver- urinary bladder. sion techniques with formation of a neobladder are used in stable patients, while simpler ileal conduits are favored in elderly or compromised patients that are considered unfit for 2 | CLINICAL REPORT more extensive procedures. Cutaneous ureterostomy has been reported as an alternative to ileal conduit in debilitated Medical records of client-owned dogs diagnosed with transi- persons, reducing surgical trauma and risk of complications.4 tional cell carcinoma of the bladder trigone presented to the Cutaneous ureterostomy avoids surgical and metabolic com- Veterinary Teaching Hospital at UNESP, Brazil (3 dogs) and plications such as small bowel obstruction, paralytic ileum, the Ribeir~ao Preto Hospital, Brazil (1 dog) between 2012 delirium, and delayed ambulation that can be seen after ure- and 2014 were reviewed. Initial diagnosis of a trigonal mass teroenteric anastomoses.4 of the urinary bladder was made by ultrasound (cases 1, 3, In veterinary medicine, historical use of ureterocolonic and 4) or by positive contrast retrograde urethrocystogram anastomosis for urinary diversion has been largely aban- (case 2), and carcinoma was diagnosed by histopathology in doned due to severe hyperammonemia, metabolic alkalosis, all cases by open bladder biopsy 7–10 days before definitive diarrhea, vomiting, and neurologic complications resulting surgery was performed. Staging included abdominal ultra- from absorption of uremic toxins across the colonic mucosa.5 sound examination and 3-view thoracic radiographs to evalu- Intestinal or gastric pouch reservoirs have also been ate for metastasis (Table 1). Complete blood cell count, attempted for bladder replacement in dogs, but led to similar biochemistry panel, and urinalysis were obtained in all dogs. complications of hypochloremic metabolic alkalosis and fre- Because all dogs were referred with a recent history of anti- quent pyelonephritis from ascending infections.5–11 More biotic use, no cultures were performed. Piroxicam (0.5 mg/ recent case reports described reimplantation of the ureters in kg orally every 24 hours) was administered for 30 days in all the cranial aspect of the vagina12,13 and prepuce.13 Although dogs in an attempt to reduce tumor volume. All 4 dogs this procedure avoided the previously described metabolic showed progressive disease during this period, with the complications associated with intestinal pouch reservoirs, its development of progressive bilateral hydroureter and hydro- use must be restricted to cases in which the uninvolved ureter nephrosis. One dog (case 4) had moderate azotemia (creati- is long enough to be reimplanted and would be contraindi- nine 2.5 mg/dL and blood urea nitrogen 75 mg/dL). In each cated in animals with neoplastic extension into the distal ure- case, indications for radical cystectomy included the detec- thra or vagina. The purpose of this report was to describe the tion of an invasive tumor in the bladder trigone, causing ure- use of complete cystectomy and cutaneous ureterostomy as teral obstruction without evidence of distant metastasis. an alternative method for urinary diversion in male and Descriptive statistics for age, survival, and surgical time 4 | HUPPES ET AL.

FIGURE 2 Postsurgical evaluation of dogs following radical cystectomy and cutaneous ureterostomy. (A) Immediately after surgery showing catheterized ureters prior to securing to them to the skin. (B) Surgical wound and stoma 2 days after surgery; note the attachment of the temporary catheter to the skin and zinc oxide-lanolin cream applied around the stoma to prevent dermatitis. (C) At the time of suture removal 14 days after surgery. (D) Appearance of wounds 90 days after surgery. Note the presence of urine coming out of the ureter after removing the diaper (arrow) were calculated using a statistical software program (Graph- line approach and the urinary bladder and ureters were iden- Pad Software Inc, San Diego, CA). tified (Fig 1). The ureters were dissected distally using tweezers to the level of the bladder, but were transected 5 cm from the trigone to allow a wide margin around the trigonal 2.1 | Surgical technique mass at both ureteral margins and to remove redundant ure- Protocols for general anesthesia were determined by the teral length before performing cutaneous ureterostomy. The supervising clinician and varied between cases. Each dog abdominal wall was incised lateral to the rectus abdominal received an epidural prior to surgery (2% lidocaine 0.22 mg/ muscle using a scalpel, creating a short (3–4 cm) and oblique kg). Exploratory laparotomy was performed by ventral mid- tunnel parallel to the linea alba (Fig 1). The ureter was HUPPES ET AL. | 5 spatulated by making a 2–3 mm longitudinal incision in the counts, serum biochemistry panels and ultrasonographic cut end and the ureter was anastomosed to the ventrolateral examination of the urinary tract. Due to the retrospective abdominal skin using a simple interrupted pattern (Fig 1). nature of the study, follow-up appointments after suture Full thickness suture bites were placed between the ureter removal were performed at varying frequency as documented and skin, 1–2 mm from the incision edges and 2 mm apart in the following case reports. However, all dogs were fol- with 5-0 polyglecaprone 25 (cases 1, 2, 3) or 5-0 nylon lowed until death. Owners were contacted at the time of writ- (case 4). ing this report and were asked to estimate quality of life of After urinary diversion was completed, definitive resec- their dog after surgery (poor, fair, good, excellent), their sat- tion of the transitional cell carcinoma was performed. The isfaction with the procedure (unsatisfied, somewhat satisfied, urinary bladder was decompressed using a urinary catheter very satisfied), and whether they would do the surgery again and radical cystectomy was performed,13 including resection in another pet (yes or no). of the distal 5 cm of the ureters bilaterally. The proximal urethra was similarly resected to include a margin of at least 2.3 | Case 1 3 cm from the bladder trigone and was ligated using polygle- An 8-year-old 3.2 kg male mixed breed dog was presented caprone 25 in the pelvic portion of the urethra before transec- to the Veterinary Teaching Hospital at UNESP, Brazil, with tion. In male dogs (cases 1 and 2), complete prostatectomy a history of hyporexia, dysuria, hematuria, and episodic was performed in coordination with cystectomy.14 Bilateral vomiting. Complete blood count and biochemical profile sublumbar lymph node resection was performed in all dogs were within reference intervals (creatinine 1.1 mg/dL [refer- and the sublumbar lymph nodes and surgical margin at both ence, 0.5–1.4] and urea 50 mg/dL [reference, 15–65]). Uri- ureters and at the urethra were examined for neoplastic inva- nalysis was performed and cytology was suggestive of sion using histopathology. The abdominal cavity was lav- transitional cell carcinoma, with atypical cells and a high aged with saline solution and the linea alba was closed using nuclear/cytoplasmic ratio. Ultrasound imaging revealed a tri- polyglecaprone 25 in a simple interrupted pattern. The sub- gonal mass (4.65 3 3.87 cm), bilateral hydroureter, and mild cutaneous tissue was closed in a simple continuous pattern hydronephrosis. Thoracic radiographs showed no evidence and the skin was closed with simple interrupted sutures using of lung metastasis. Open bladder biopsy through a caudal nylon. Sutures were removed from the cutaneous ureteros- midline laparotomy confirmed a diagnosis of transitional cell tomy sites and skin incision 14 days after surgery. Median carcinoma. procedure time was 4.7 hours (range, 3.8–6.1). An 8 (cases Thirty days after piroxicam therapy was initiated, addi- 1, 3, and 4) or 12 Fr (case 2) polyvinyl chloride catheter tional tumor growth was noted, but the size of the renal pel- (Embramed Ind. E Com. LTDA, S~ao Paulo, Brazil) was vis and ureter were unchanged. No evidence of prostatic or placed into each ureteral stoma and sutured in place using 2 lymph node invasion were detected. Cutaneous ureteros- simple interrupted sutures placed through adhesive tape tomy, radical cystectomy, and concurrent prostatectomy affixed to the catheter (Fig 2). Ureteral catheters were con- were performed. The prostatic artery was ligated near its ori- nected to a closed aseptic collecting system (P. Simon, S.A, gin from the internal pudendal artery and the prostatic veins S~ao Paulo, Brazil) and maintained for 5 days after surgery were ligated at their insertion into the common iliac vessels. (Fig 2). The urethra was ligated and divided 2 cm caudal to the prostate. The vas deferens was ligated and divided bilaterally. 2.2 | Postoperative care and follow-up Then, the bladder, membranous urethra, and prostate were An Elizabethan collar was maintained for 15 days after sur- resected en bloc, along with surrounding peritoneal and ret- gery. All ureters were patent after catheter removal (Fig 2C). roperitoneal fat. Ureteral and urethral margins were free of Disposable absorbent diapers were applied to cover the cuta- neoplastic tissue, confirming complete resection of the transi- neous ureterostomy sites and were replaced every 8–12 tional cell carcinoma. No evidence of metastasis was found hours. Before replacing the diaper, saline solution was used in the sublumbar lymph nodes. to clean the stoma and zinc oxide-lanolin cream (Hipoglos® During the immediate postoperative period, analgesia cream, Procter & Gamble, S~ao Paulo, Brazil) was applied was provided with morphine (0.3 mg/kg IM, as needed). around the stoma to prevent dermatitis (Fig 2B). Diaper Cephalexin (30 mg/kg orally every 12 hours) and metronida- changes and hygiene protocol were continued in this manner zole (10 mg/kg orally every 12 hours) were prescribed for 15 for the entire life of the dogs following surgery. Due to the days. Anti-inflammatory and analgesic therapy was pre- perceived risk of introducing bacteria into the ureter by cath- scribed for 4 days after discharge (meloxicam 0.1 mg/kg eterization of the cutaneous ureterostomy stoma, urinalyses orally every 24 hours and tramadol 2 mg/kg orally every 12 or urine cultures were not obtained in any of the dogs after hours). Mild edema and hemorrhage were noted from the surgery. Instead, dogs were monitored using complete blood catheterized ureterostomy sites for 2 days after surgery. 6 | HUPPES ET AL.

These resolved with local wound care consisting of frequent re-instituting diaper changes every 8–12 hours, the dermatitis diaper changes (every 6–8 hours), saline cleansing, and resolved within 5 days. Complete blood count and biochemi- application of zinc oxide-lanolin cream. cal parameters were within reference ranges at 1 month after Postoperative chemotherapy was declined by the client surgery. Adjuvant chemotherapy was declined by the owner and the dog was re-evaluated at 3 and 6 months after sur- after surgery and follow-up was limited to phone contact gery. Complete blood count and biochemical profile were after this time. Euthanasia was performed 6 months (193 within reference ranges at both re-evaluations. Abdominal days) after surgery due to aggression towards the owner and ultrasound showed no evidence of hydronephrosis. One year inability to perform nursing care. No necropsy was per- and 4 months (498 days) after surgery the dog was hit by a formed. On phone follow-up the owner was very satisfied car and died. No necropsy was performed. On phone follow- with the surgical procedure and the lack of complications up, the owner was very satisfied with the surgery and would and said that quality of life was difficult to assess for this perform the same surgery in another pet, if necessary. The dog due to a larger behavioral problem. The owner noted quality of life for the dog was considered excellent. that nursing care was difficult because the dog was very aggressive. Despite the difficulties described, this owner 2.4 | Case 2 expressed that they would perform the same surgery in another pet, if necessary. An 11-year-old 59 kg intact male Fila Brasileiro dog was presented to the Veterinary Teaching Hospital at UNESP, 2.5 | Case 3 Brazil, with a history of dysuria and hematuria. Complete blood count and biochemical profile were within reference A 10-year-old 4 kg spayed female Maltese dog was pre- intervals. A mass was noted in the bladder trigone (7.3 3 sented to the Veterinary Teaching Hospital at UNESP, Bra- 4.0 cm) on ultrasound examination. There was no evidence zil, with a history of dysuria and hematuria. Complete blood of prostatic or lymph node invasion. Mild bilateral hydrour- count and biochemical profile were within reference intervals eter and hydronephrosis were present, but creatinine (1.1 mg/ (creatinine 1.3 mg/dL and urea 65 mg/dL; 15–65 mg/dL dL) and urea (50 mg/dL) were within the reference ranges. were in the upper end of the reference ranges). On ultrasound Thoracic radiographs showed no evidence of lung metastasis. examination, bilateral hydronephrosis (left > right) and mild Exploratory laparotomy and open bladder biopsy confirmed increase in echogenicity were noted. Both ureters were a diagnosis of transitional cell carcinoma. Urinalysis showed dilated. Tumor size was 0.6 3 0.5 cm (trigonal area) at initial mildly increased cellularity and no bacterial growth was examination and increased despite 30 days of piroxicam ther- obtained on urine culture from a cystocentesis sample apy. No lymphadenopathy was detected. Thoracic radio- obtained during the surgical procedure. graphs were normal. Radical cystectomy, lymphadenectomy, Cutaneous ureterostomy and radical cystectomy with and cutaneous ureterostomy were performed without intraop- prostatectomy and lymphadenectomy were performed as erative complications. During the postoperative period anal- described. During the immediate perioperative period, analgesia was provided with morphine (0.3 mg/kg IM as gesia was provided with morphine (0.3 mg/kg IM, as needed). Cephalexin (30 mg/kg orally every 12 hours for 14 needed). Amoxicillin clavulanate (25 mg/kg orally every 12 days) and tramadol (3 mg/kg orally every 12 hours for 5 hours for 14 days) and tramadol (4 mg/kg orally every 12 days) were prescribed. Histopathology showed that ureteral hours for 5 days) were prescribed. Firocoxib (2.2 mg/kg and urethral margins were clean, but metastasis to the orally once daily) was administered daily during the first resected sublumbar lymph nodes was identified, despite nor- month, then every 48 hours for 3 months. Ureteral and ure- mal appearance on previous ultrasound examination. thral margins were free of neoplastic tissue, confirming com- Peristomal edema and mild hemorrhage occurred during plete resection of the transitional cell carcinoma. No the first 2 days after surgery, but resolved with standard evidence of metastasis was found in the sublumbar lymph stoma care and hygiene. Firocoxib (2.2 mg/kg orally once nodes. daily) was used continuously during the first month after sur- After surgery, pitting edema was observed in left hind gery and every 48 hours for the next 3 months. Adjuvant limb, which was resolved in 3 days after treatment with mas- chemotherapy was begun at the time of suture removal using sage and warm compresses. Hemorrhage from the ureteral doxorubicin (30 mg/m2) and carboplatin (250 mg/m2) every stomas and catheter site were reported during the first 3 days 21 days for a total of 4 cycles. After the end of the fourth after surgery. Urine scald (redness, swelling, and inflamma- chemotherapy cycle the dog was noted to have a normal tion) occurred on the ventral abdominal skin 5 days after sur- appetite and activity level. Euthanasia was performed 1 year gery. Further questioning revealed that the client was (369 days) after surgery due to development of respiratory experiencing difficulty in changing the diapers as recom- signs and detection of lung metastasis on thoracic radio- mended, due to the aggressive temperament of the dog. After graphs. No necropsy was permitted. On follow-up phone HUPPES ET AL. | 7 call, the owner was very satisfied, rated the dog’s quality of to the local lymph nodes and that survival time would likely life to be good, and stated that he would perform the same be shorter, they remained very satisfied with the procedure surgery in another pet, if necessary. and said that they would perform the same surgery in another pet, if necessary. 2.6 | Case 4 3 | DISCUSSION A 12-year-old 6 kg spayed female Maltese dog was presented to the Ribeir~ao Preto Hospital, Brazil, with a history This small retrospective case series supports that cutaneous of dysuria, hematuria, and abdominal pain. A trigonal mass ureterostomy is a viable technique for urinary diversion after (4.1 3 2.6 cm) affected more than 50% of bladder and failed complete cystectomy in dogs. Aside from 1 dog that showed to respond to piroxicam therapy. No lymph node enlarge- aggressiveness towards the owner, maintenance of dogs after ment was detected on preoperative ultrasound exams. Hydro- surgery was surprisingly simple and clients perceived their ureter and mild hydronephrosis was noted, along with dog’s quality of life to be good. While radical cystectomy moderate azotemia (creatinine 2.5 mg/dL and urea 75 mg/ and lymphadenectomy may be expected to increase survival dL). Thoracic radiographs showed no evidence of lung metastasis. Urinary bladder biopsy was performed at an ini- times, the small number of cases in this report, the retrospec- tial surgery and incidental cystoliths were removed at that tive design, and the lack of consistent use of adjunctive time. Ten days after the initial surgery, radical cystectomy, chemotherapy prevents us from making any strong conclu- fi cutaneous ureterostomy, and lymphadenectomy were per- sions regarding the potential survival bene ts for this proce- formed. Biopsy results confirmed the presence of transitional dure when compared to other methods of treatment. cell carcinoma. Although indications for radical cystectomy have been 2,3 Definitive resection and ureterocutaneous anastomoses proposed for transitional cell carcinoma in people, there is were performed as previously described. Histopathology of no consensus on how to determine which patients are candi- 2 the terminal ureters and proximal urethra showed no evi- dates for cystectomy. Some authors propose that muscle dence of neoplasia at the surgical margin. After surgery, invasion on histopathology is an indication of aggressive bio- enrofloxacin (5 mg/kg orally every 12 hours) and tramadol logical behavior and therefore to pursue radical resection in – (2 mg/kg orally every 8 hours) were prescribed for 10 days. people with transitional cell carcinoma; however, 10 30% of Anti-inflammatory drugs were prescribed for 4 days (meloxi- initially non-muscle invasive cancer will progress to muscle- 15 cam 0.1 mg/kg orally every 24 hours). Histopathology of the invasive disease. Factors currently used to determine the submitted tissues showed that clean margins were obtained suitability of human patients for surgery are age, functional for both ureters and the urethral resection. Metastatic transi- status, nutritional status, cognitive status, and medical co- 2 tional cell carcinoma was identified in the resected sublum- morbidities. In our canine study, the decision to pursue radi- bar lymph nodes. Although metastasis was diagnosed, cal cystectomy was based on tumor location (trigonal) and adjuvant chemotherapy was declined by the owner after progressive dysuria and hydronephrosis despite medical surgery. management with piroxicam. It should be noted that radia- Peristomal edema was reported for 3 days after surgery, tion therapy and interventional procedures such as ureteral but resolved with wound management (cleaning with saline stenting are not widely available in Brazil and there were no solution and more frequent diaper changes). Abdominal pain other practical options for pursuing care of these dogs aside and incoordination of the hind limbs were noted 47 days from urinary bypass surgery. Dogs with the most difficult to after surgery. Complete blood count and biochemistry panel manage tumors were selected for this study. However, the revealed anemia (hematocrit 35.5%, reference 37–55), throm- fact that we selected dogs with documented hydroureter may bocytosis (878,000/mL, reference, 180,00–480,000), and have actually decreased the technical difficulty associated mildly increased alkaline phosphatase (190 U/L, reference, with the procedure, because the dilated ureteral lumen was 20–150). Radiographs of the lumbar spine showed periosteal easier to suture and may have been less likely to obstruct. new bone formation at lumbar vertebrae 5–7 and S1 sugges- In people, a similar method of cutaneous ureterostomy tive of bone metastasis. Euthanasia was recommended and and radical cystectomy has been described.4 In that study, a necropsy confirmed the presence of metastatic carcinoma in double-J ureteral stent was placed in all patients, with the lumbar spine. No lung metastasis was detected. Mild planned replacement every 6 months. Antibiotic prophylaxis hydroureter and hydronephrosis were noted bilaterally, was maintained for life.4 In our series of dogs, ureteral pat- though there was no evidence of pyelonephritis. On a ency was maintained without the need to maintain a perma- follow-up phone call, the owner classified the dog’s quality nent ureteral stent, significantly simplifying postoperative of life as fair during the postoperative period. While the care and avoiding the need for follow-up procedures. It is owner stated that they knew that the disease had metastasized important to note that incontinence is an expected outcome 8 | HUPPES ET AL. of cutaneous ureterostomy and this must be explained to the Completeness of local resection and presence of lymph pet owner prior to surgery. In addition, owners should be node metastasis are major prognostic indicators in transi- counseled that this procedure may be contraindicated in dogs tional cell carcinoma.3,15 While we were fortunate to obtain intolerant to direct owner handling to maintain hygiene as clean margins in all dogs in this series using ultrasound find- described in the postoperative care section. Use of disposable ings and surgical palpation, uroendoscopy would be a pre- diapers and diaper rash ointment allowed a low cost and sim- ferred method to plan the areas of surgical resection. Ideally, ple method to maintain hygiene after discharge from the hos- a systematic endoscopic survey of the urethra and bladder pital, and probably helped avoid self-injury. Interestingly, no should be performed in all dogs with transitional cell carci- clinical or biochemical signs of urinary tract infection were noma.20 Localized or diffuse erythematous areas should raise detected in these dogs after surgery, although standard assess- a suspicion of carcinoma15 and may affect planned margins ment of urinalyses or culture were not considered practical of surgical excision. due to the potential risk of percutaneous catheterization of the In conclusion, based on our limited case series, radical ureteral stomas. Instead, dogs were monitored by noninvasive cystectomy and cutaneous ureterostomy can be successfully ultrasound of the urinary tract, complete blood count, and performed in dogs with naturally occurring transitional cell serum biochemistry panels at each follow-up visit. While it is carcinoma in the bladder trigone. Postoperative management recognized that this is not an ideal method to detect subclini- and quality of life were considered acceptable by most own- cal urinary tract infection, the clinicians involved in the care ers, but docility and easy handling should be potential crite- of these animals felt that the risks of ureteral stoma catheteri- ria for pursuing this surgery due to the need for life-long zation outweighed the benefits when dogs were not showing hygiene control using diapers and creams applied to the sto- clinical or biochemical evidence of pyelonephritis. mas. Long-term effects of radical cystectomy and cutaneous Radical cystectomy in people is associated with ureterostomy on survival and local recurrence will need to be recurrence-free survival rates of 68 and 66% at 5 and 10 evaluated in a larger prospective study. years, respectively.2 While ureterocolic anastomosis and intestinal reservoir surgeries in dogs led to important adverse effects such as severe vomiting and neurologic signs, more ACKNOWLEDGMENT clinically acceptable outcome was described after total cys- We thank Professor Daniel K. Honsho for the illustrations. tectomy and ureteral transplantation to the prepuce13 or vagina.12,13 The majority of protocols used in veterinary patients focus on palliation using standard chemotherapy and DISCLOSURE piroxicam,16 intravesical chemotherapy,17 metronomic ther- The authors declare no conflicts of interest related to this apy,18 or radiation therapy,5,19 although no studies have report. documented improved outcomes compared to piroxicam and chemotherapy alone.19 REFERENCES Median survival time in our case series (276.8 days) was [1] Cheung G, Sahai A, Billia M, et al: Recent advances in similar to chemotherapy with vinblastine (299 days),16 or to the diagnosis and treatment of bladder cancer. 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