Drainage of cavities and longitudinal prostatic
omentalization under ultrasound control in
dogs (10 cases)
F. COLLARD1*, C. GILSON1, C. CAROZZO2, D. FAU2, S. BUFF3, E. VIGUIER2
Clinique Vétérinaire 24, 994 avenue de la république, 59 700 Marcq en Baroeul, FRANCE.
Service de Chirurgie, Ecole Nationale vétérinaire de Lyon, 1 av Bourgelat, 69 280 Marcy l’Etoile, FRANCE.
Service de Reproduction, Ecole Nationale vétérinaire de Lyon, 1 av Bourgelat, 69 280 Marcy l’Etoile, FRANCE.
1
2
3
*Corresponding author: [email protected]
SUMMARY
This study reports another way to perform prostatic cavities drainage throughout longitudinal prostatic omentalization under ultrasound control in 10
dogs and presents clinical outcome and eventual complications. A castration
and a caudal median celiotomy were performed and after reclining laterally
ventral periprostatic adipose tissue and catheterising urethra for good ultrasonographic visualisation, the prostatic gland was examined with a sectorial
transducer to locate cysts or abscesses. Under ultrasound-guided control, a
needle centesis, an opening of the cavities and a passage of an omentum leaf
through the prostate craniocaudally were performed using forceps. The surgery lasted between 90 and 120 minutes. Thereafter, ultrasonography examinations were performed at least 2 weeks, one and six months postoperatively. No major complication was encountered and the mean hospitalisation
time was 1.9 days. Within 6 hours, hematuria resolved in all dogs. Urinary
retention occurred in one dog within two days and resolved spontaneously.
After 6 months, only 1 dog still had one small cavity without any clinical
sign. Long-term resolution of clinical signs was achieved in all dogs, with
follow-up periods ranging from 10 to 18 months. Prostatic surgery using
longitudinal prostate omentalization with ultrasound assistance provides a
safe and good drainage in dogs presenting marked cavities and also limits
recurrence or sepsis complications and avoids urethral injury.
Keywords: Prostate, dog, prostatic cavity, drainage,
omentalization, complication.
RÉSUMÉ
Vidange et épiploïsation longitudinale de cavités prostatiques sous
contrôle échographique chez le chien : à propos de 10 cas
Le but de cette étude conduite sur 10 chiens est de proposer une nouvelle
procédure de vidange des cavités prostatiques en réalisant une épiploïsation
longitudinale de la prostate sous contrôle échographique et d’en présenter le
suivi postopératoire et les éventuelles complications. Après castration et
laparotomie, la graisse para-prostatique a été réclinée latéralement et une
sonde urinaire a été placée afin de visualiser l’urètre à l’échographie, puis la
prostate a été inspectée par échographie afin de localiser les kystes ou abcès.
Sous contrôle échographique, les cavités ont été vidangées et ouvertes afin
de permettre l’insertion cranio-caudale d’une bande d’épiploon dans la glande.
Cette chirurgie a duré entre 90 et 120 minutes. En post opératoire, au moins
3 contrôles échographiques ont été réalisés (à 2 semaines, 1 mois et 6 mois).
Aucune complication majeure n’est survenue et la durée moyenne d’hospitalisation a été de 1,9 jour. L’hématurie s’est résolue en moins de 6 heures
dans tous les cas. Un seul chien a présenté une situation de rétention urinaire
de 2 jours qui s’est spontanément résorbée. Après 6 mois, seul un chien présentait à nouveau une petite cavité sans manifester de signe clinique.
Aucune récidive n’a été observée durant le suivi sur 10 à 18 mois. Ainsi, la
technique chirurgicale d’épiploïsation longitudinale de la prostate sous
contrôle échographique assure une vidange sûre et efficace des cavités de
type abcès ou kystes, limite les risques de récidive et de complications septiques et permet d’éviter des lésions urétrales.
Mots clés : Prostate, chien, cavité prostatique, drainage,
épiploïsation, complication.
Introduction
Approximately 80% of male dogs above 10 years old are
presenting with prostatic disease [6]. Common pathologies
affecting the prostate gland are benign hyperplasia, abscesses
and cysts. Clinical signs depend on the size of the prostate or
the cavities, the compression of adjacent structures or complications associated with local or systemic bacterial infections [2, 5, 15].
Many procedures have been described in the literature to
drain these cavities. These techniques include marsupialisation,
drainage by suction or Penrose drains, transverse omentalization or ultrasound-guided percutaneous drainage. All techniques but omentalization are associated with a high rate of
complications or recurrence [1, 6-9, 11, 13, 14, 16-18, 20].
On one hand, urethral injuries, recurrence of urinary incontinence,
Revue Méd. Vét., 2010, 161, 5, 239-244
dehiscence, peritonitis secondary to leakage or death are the
most frequently encountered problems postoperatively [1, 7,
11, 14, 16-18, 20]. On the other hand, ultrasound-guided percutaneous drainage is associated with a high rate of recurrence
and risk of peritonitis [6, 7, 13]. To the author’s knowledge,
this is the first report that describes longitudinal omentalization
of the prostate or surgical drainage of cavities with ultrasound assistance.
Our aim was to evaluate the feasibility and the long-term
outcome of an ultrasound-guided drainage of prostatic
abscesses and cysts associated to a longitudinal omentalization of the prostate realised only with a ventral approach. We
hypothesized that this technique would allow treatment of
each cavity without injuring the urethra and would decrease
the rate of recurrence and the postoperative hospitalisation
duration in comparison with other published procedures.
240
Materials and Methods
ANIMALS
Ten dogs diagnosed by ultrasound examination with prostatic retention cysts or abscesses from October 2006 to
October 2007 were included in the present study. On admission,
an ultrasound examination of the prostate was performed.
Dogs showing cavities over 1cm in diameter were included
in the study. When the clinical signs and the animal’s condition
allowed it, a medical treatment (Finasterid, 5 mg/kg per day
per os / Meloxicam, 0.1 mg/kg per day per os / marbofloxacin,
2 mg/kg per day per os) was administered. After a medical
treatment of 4 weeks minimum, a second ultrasound examination was carried out. If the cavity resumption was insufficient
(diameter still greater than 1cm) and/or the dog experienced
abdominal discomfort, we opted for a surgical management.
In emergency cases or perineal hernia, surgery was immediately performed. A complete blood count and a serum biochemical profile were performed in parallel.
COLLARD (F.) AND COLLABORATORS
examination to rule neoplastic process out. Two leaves of
omentum were prepared. The prostatic capsule was incised
with a #11 blade on the caudal aspect of each lobe. Forceps
were passed through the first incision, pushed caudocranially
through the main cavities and exited by a second incision
performed on the cranial aspect of the prostate under ultrasound assistance (figure 2). To facilitate the omentum passage,
the incisions were widened by opening the forceps. The leaf
of omentum was grasped, gently pulled craniocaudally
through the prostatic lobe with forceps and secured at the
caudal exit with mattress sutures of 3-0 polydioxanone.
Omentalization of each lobe was carried out (figure 3). An
abdominal lavage was performed and celiotomy wounds
were closed routinely.
POSTOPERATIVE TREATMENT AND FOLLOW UP
Warm Lactated Ringers solution was infused until complete
recovery, pain relieving management and antibiotics were
ANAESTHESIA
Dogs were premedicated with morphine (0.2 mg/kg IM)
and diazepam (0.25 to 0.5 mg/kg IV) and anaesthesia was
induced with propofol (4 mg/kg IV) or thiopental (10 mg/kg
IV) according to the patient’s health. Anaesthesia was maintained with a mixture of oxygen and isoflurane delivered via
an endotracheal tube. An intravenous infusion of Lactated
Ringers solution (10 mL/kg/h) was administered throughout
anaesthesia. Meloxicam (0.2 mg/kg IV) and morphine (0.2
mg/kg/2h IV) were given to provide analgesia. Fentanyl
patch was used on dogs presenting major abdominal pain on
admission. Cephalexin (30 mg/kg IV) was administered at
induction and repeated every other hour during surgery.
FIGURE 1 : Prostate is inspected with a 7.5 MHz sectorial transducer.
Cavities are located and emptied with a 21-gauge needle attached to
a 10 mL syringe under ultrasound monitoring.
SURGICAL PROCEDURE
A retrograde urethral catheterization was performed to
allow location of the urethra during surgery. Dogs were castrated. A caudal median celiotomy extending from the umbilicus
to the pubic brim was performed. A stay suture was placed
on the cranial aspect of the bladder to pull the prostate cranially to the pubis. Ventral peri-prostatic fat was dissected
medially and reflected laterally allowing good access to the
ventral aspect of the prostate. A 7.5 MHz sectorial transducer
(LOGIQ e, GE Medical Systems, SCIL, Altorf (67), France,
Europe) was placed in a sterile polyethylene arthroscopic
sheet and a surgical glove filled with ultrasound gel. The left
lobe was first inspected and cavities were located. Using a
ventral approach, each cavity was emptied with a 21-gauge
needle (0.8x50mm) connected to a 10 mL syringe under
ultrasound-guided control (figure 1). Then a 5 mm incision
was made on the cranio-ventral aspect of the prostate allowing
the introduction of forceps to open the cavity’s capsule. The
same procedure was performed on the right lobe. Prostatic
samples were taken for bacteriological culture and microscopic
FIGURE 2 : After opening of cavity’s capsule with forceps, prostatic capsule are incised with an 11 blade on the cranial and caudal aspect of
each lobe. Forceps are passed through the prostate caudocranially. A
leaf of omentum is grasped, gently pulled cranially to caudally
through the prostatic lobe with the forceps and secured at the caudal
exit with mattress sutures.
Revue Méd. Vét., 2010, 161, 5, 239-244
DRAINAGE AND OMENTALIZATION OF PROSTATIC CAVITIES IN DOGS
241
given. Antibiotic therapy was adapted when necessary, based
on culture and sensitivity results. The urethral catheter was
maintained to collect urine until hematuria was resolved.
Dogs were examined each day until discharge. After two
weeks and after one month postoperatively, a complete physical
examination was performed, owners were questioned about
complications such as urinary incontinence, discomfort or
recurrence of clinical signs. Prostatic size and aspect were
checked by ultrasound examination. Six months postoperatively,
an ultrasound examination was performed; evolution thereafter
was monitored by telephone contact with owners.
Results
FIGURE 3 : Per-operative transversal view of the prostate after drainage.
Omentum leaves are visible in each prostatic lobe (white arrows).
Signalment and clinical signs for the dogs in this study are
listed in Table I. Ten dogs, ranging from 6 to 12 years (mean
age: 8.7 years, median: 8 years) were included in the current
study. All dogs were large-breed dogs and were intact males.
In most of the cases, referring veterinarians had administered
antibiotics and synthetic progestins for at least one month.
Clinical signs onset before surgery ranged from 1 month to
Case and Signalment
Clinical signs
Diagnosis1,2
N°1: Beauce sheepdog
12 years old
Abdominal pain
Dysuria
Lethargy
N°2: Bull terrier
8 years old
12 months (mean: 4.9 months, median: 3 months). Urinary
dysfunction was the most frequently reported clinical sign
(60%): dysuria, hematuria and/or incontinence were observed
in 6 cases. In 5 cases (50%), dogs presented abdominal pain.
Surgery
(min)
Postoperative complications
Follow up (months) and
comments
Cyst
1L/3R
120
None
18
Hematuria
Cyst
Numerous L / 2 R
115
None
16
N°3: Porcelaine
8 years old
Abdominal pain
Incontinence
Cyst
2L/2R
110
None
15. Incontinence resolved
10 days after
N°4: Crossed
11 years old
Dysuria
Incontinence
Faecal tenesmus
Perineal hernia
Cyst
3L/2R
100
Few drops released
after miction (10 days)
15
N°5: German Shepherd
6 years old
Incontinence
Abdominal pain
Perineal hernia
Incontinence
Perineal hernia
Test. Neo.
Cyst
2L/1R
120
Cyst
2L/1R
120
N°7: Labrador Retriever Abdominal pain
8 years old
Cyst
Numerous L /
Numerous R
110
Few drops released after miction
(20 days)
Two cavities visible (1 month)
14. One cyst located after
8 month without
clinical sign
N°8: Springer Spaniel
7 years old
Cyst
Numerous L /
Numerous R
95
Urinary retention for 48 hours
10. Removal of multiple
small paraprostatic cysts
N°9: Labrador Retriever Abdominal pain
11 years old
Lethargy
Cystitis
Cyst
2L/2R
95
None
10. Removal of 1 paraprostatic
cyst
N°10: Weineramen
7 years old
Cyst
Numerous L /
Numerous R
100
One cavity visible in the left lobe
(1 month)
10. No cavity (3 months)
N°6: Rottweiler
9 years old
1
Faecal tenesmus
Perineal hernia
None
Temporary incontinence
15. Removal of 1 paraprostatic
(faecal and urinary)
cyst and a mass (8cm diameter)
Abdominal wall suture dehiscence
caudally to the prostate
Few drops released after miction
14. One paraprostatic cyst
(20 days)
(Leydigome)
Nature of the lesions (cysts or abcess); 2 Number and location on the left (L) and right (R) lobes; Test. Neo.: Testicular Neoplasia.
TABLE I : Signalment, clinical signs, diagnosis, surgical time and outcome in 10 dogs with prostatic cavities.
Revue Méd. Vét., 2010, 161, 5, 239-244
242
Associated with the prostatic disease, four perineal hernias
(40%) were diagnosed on physical examination and faecal
tenesmus was reported in 2 cases.
Cavitary lesions ranged from 1 cm to 2 cm in diameter
(median: 1.6 cm in diameter). Surgery (celiotomy, cavities
drainage and omentalization, wound closure) lasted between
90 and 120 minutes (mean: 108.5 minutes, median: 110
minutes). No peri-operative complication was encountered
such as fluid leakage from the cavity into the abdomen or
urethral injury. Using the ventral approach, all the cavities
were emptied even the dorsal ones. In two cases, the glove
covering the ultrasound probe was pierced with the needle
without any effect on outcome. In the case n°5, a necrotic
mass was located caudally to the prostate and adhesions with
descending colon were observed. It was removed by blunt
dissection. All the lesions found in prostate were cysts but in
four cases, other paraprostatic cysts were also reported and
removed during surgery. In 6 cases, bacteriological cultures
of prostatic samples were positive and evidenced the presence
of Staphylococcus sp in 5 cases, and Escherichia coli in one
case. In all the cases, chronic prostatitis was confirmed by
histological examination.
All dogs recovered uneventfully from surgery. Hematuria
was observed less than 6 hours postoperatively in all cases.
Urinary retention developed in dog n°8 during the first 48
hours after surgery and resolved spontaneously. Except this
dog which was hospitalized 3 days to manage urinary retention,
all dogs were discharged within 48 hours (mean: 1.4 day,
median: 1 day). The dog n°5 presented faecal incontinence
probably resulting from nervous injury during the removal of
the necrotic mass, but this incontinence resolved within 3
months. Three owners reported that their dog was dribbling
urine after a normal urine flow, and this minor problem resolved
spontaneously within 20 days postoperatively in each case.
However, no dog exhibited a real incontinence, such as urine
leakage during rest or activity. Moreover, no minor or major
postoperative complication occurred in 4 cases (40%). The
mean follow-up time was 13.7 months (range: 10 to 18
months, median: 14.5 months). At the ultrasound examination
6 months postoperatively, only one dog (case n°7) presented
a small prostatic cavity without any discomfort or clinical
sign. No dog treated for abscesses presented recurrence.
Discussion
Management of prostatic cysts and abscesses is a subject
of controversy. Many procedures have been described to
treat prostatic cavities but most of them were associated with
a high rate of complications. Some argue that medical treatment
associated with ultrasound-guided percutaneous drainage is
the treatment of choice, while others consider surgical treatment
as the best option. Cavities size could be a decisive criterion.
Many studies have been published but little information related
to the size has been given. BOLAND et al. [6] treated prostates presenting cavities ranging from 0.5 to 6.5 cm in diameter. Because of the lack of data, dogs were firstly treated
with finasteride for at least 4 weeks in the current study. If
cavities larger than 1 cm in diameter did not reduce, it was
COLLARD (F.) AND COLLABORATORS
stated that castration could not promote cyst resolution.
The first surgical technique published was prostatectomy.
Prostatic disease did not recur but most of the dogs were
incontinent after surgery [3, 4, 14, 17]. For the last 30 years,
the main surgical procedures performed included marsupialisation [11], prostatic drainage by suction or Penrose drain
[9, 16], partial prostatectomy [18] and intra-capsular prostatic
omentalization [7, 20]. The major problem is the complication
rate associated with the former techniques. Marsupialisation
requires postoperative care and is often associated with leakage or drainage occurring for several months, ascending
infection and recurrence due to premature closure of the
stoma [10]. The prostatic drainage technique presented a
number of early postoperative complications, which include
sepsis (33%) and death (20%). Long-term complications
were recurrence of abscess (20%) and incontinence (25%)
[16]. RAWLINGS et al. [18] described another alternative to
entire prostatectomy by performing an intracapsular partial
prostatectomy with an ultrasonic surgical aspirator. One dog
presented cyst recurrence twice within a month due to persistent urethral fistula. Five out of 20 dogs were reported as
being intermittent and infrequently urinary incontinent, 3
were considered to urinate normally with some incontinence
after micturition when excited and one had nocturnal enuresis.
Of the 15 dogs followed after one year, 2 were suspected of
having a cyst without any clinical sign and one had a recurrence of prostatic abscess 18 months later [18].
Omentalization of the prostate is the other possibility to
treat prostatic cavities. WHITE and WILLIAMS treated 20
dogs with prostatic abscesses by performing bilateral capsulectomy incision and packing omentum after digitally exploring cavities. Nineteen were reported to be clinically normal
after one month but no ultrasound examination was performed
[20]. The omentum has several useful properties such as
enhancement of local immune function, improvement of
lymphatic drainage and promotion of angiogenesis [7, 12,
20]. By performing omentalization, drainage of prostatic
secretions, vascular supply and immune function against
ascending prostatic or urogenital contamination [7] are
expected to increase. Furthermore, the prostate possesses a
blood-prostate barrier formed by glandular epithelial cells,
and this limits penetration of many antibiotics. By increasing
vascular supply, their release in the prostatic tissue is improved
[19, 21]. A second study was published concerning partial
resection and omentalization of prostatic retention cysts [7].
Postoperatively, one dog developed urinary retention during
the first 24 hours and 5 dogs showed urinary stress incontinence (1 persisted 2 years after, 1 developed 3 months postoperatively). In that study, no ultrasound examination was
carried out. In the present study, short-term complications
are similar to those described by RAWLINGS et al. [18],
WHITE and WILLIAMS [20] and BRAY et al. [7] with the
main difference that no dog presented urethral incontinence.
Whereas in the study of White and Williams [20], abscesses
were so dilated that the cavities could be digitally explored
and the urethra located, ultrasound monitoring was necessary
in the present study to empty out and open cavities due to
their smaller size and their intra-prostatic location. With
ultrasound assistance, prostatic approach was minimized;
only the ventral aspect of the prostate was dissected, which
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DRAINAGE AND OMENTALIZATION OF PROSTATIC CAVITIES IN DOGS
avoided excessive prostatic manipulation. During prostatic
manipulation, the prostate turned on itself and the urethra did
not stay in the median plane, which increased the risk of urethral injury.
An ultrasound-guided percutaneous drainage has also been
described as a useful alternative to surgery [8]. As reported
by BOLAND et al. [6], ultrasound examination revealed
recurrence in 7 of the 13 treated dogs and all required at least
a second drainage. In a second study, they combined ultrasound-guided trans-abdominal drainage with injection of tea
tree oil. They reported that a second treatment was necessary
in 60% of the cases [13]. BRAY et al. [7] reported one case
of infected cyst treated by trans-abdominal aspiration, which
developed a localized, low-grade peritonitis due to continuous leakage into the abdomen. Ultrasound-guided drainage
represents an interesting technique by providing the opportunity
to treat each cavity for the clinician. Using ultrasonography,
clinicians are able to locate and empty all the cavities. The
surgical technique performed in our study allowed us to open
cavities with a forceps and facilitate communication between
cysts. This difference could explain the lower rate of recurrence
in our cases. In most of the cases, recurrence was observed
within the first 4 weeks, but some studies reported recurrence
at least one year later [18].
The main drawback of using ultrasonography during surgery
is the longer length of its installation. Surgeon needs approximately 5 minutes to place sectorial transducer in a sterile
polyethylene arthroscopic sheet and a surgical glove filled
with ultrasound gel. Furthermore, 2 surgeons have to collaborate for cavity drainage and omentalization: while the one
is holding the transducer and empting cavities or pulling the
omentum leaf through the prostate, the other has to limit prostate mobility. This procedure can be performed alone but
with difficulty; we recommend the surgeon to be assisted.
In the present study, longitudinal omentalization was performed instead of transversal as WHITE and WILLIAMS
described [20]. To the author’s knowledge, this procedure
has never been described before. The interest of this technique is to allow prostatic omentalization with a lower risk of
urethral injury. WHITE and WILLIAMS explored digitally
first and then passed omentum through the prostate [20]. In
the majority of cases as in our study, the cavities were within
the parenchyma and did not allow digital exploration. In
these cases, omentum has to be passed blindly through the
prostate with forceps without any digital location of the urethra susceptible to increase the risk of injury. By performing
bilateral cranio-caudal omentalization, omentum leaves are
passed parallel to the urethra. It allows a good prostatic drainage of each lobe and avoids urethral injury Ultrasonography
was used to assist in the placement of omentum leaves in
cysts through the lobe and appeared to be helpful in locating
the catheterized urethra.
Currently, hospitalization duration is an important criterion.
BRAY et al. [7] reported that most dogs were discharged
within 48 hours of surgery and 2 within 24 hours whereas
RAWLINGS et al. [18] reported a mean duration of hospitalization of 10.1 days and 3 days for BOLAND et al. [6]. In
the current study, 7 dogs were discharged within 24 hours
and the mean hospitalization rate was 1.4 days.
Revue Méd. Vét., 2010, 161, 5, 239-244
243
As a conclusion, results of this study indicate that cavity
drainage and longitudinal omentalization of the prostate
under ultrasound control is a safe procedure, which allows
treatment of abscesses or cysts with a minimal prostatic
approach and without injuring the urethra. All dogs experienced fast resolution of clinical signs and no urinary
incontinence was induced by the surgery. The main advantages of this technique are that it allows each cavity to be
treated and limits prostatic manipulation. The complication
rate and hospitalization duration are low, which is probably
related to a less invasive procedure and a more accurate treatment of cavities.
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