ttp://www.bsava.

com REVIEW

Feline ureteral obstructions

Part 1: medical management
D. L. Clarke1

Department of Clinical Sciences and Advanced Medicine, University of Pennsylvania School of  Veterinary Medicine, Philadelphia,
Pennsylvania 19104, USA
1
Corresponding author email: clarked@vet.upenn.edu

Feline ureteral obstructions are an increasingly recognised and challenging diagnostic and management
problem. Many cats with ureteral obstructions are critically ill at the time of diagnosis, especially if
there is dysfunction of the contralateral kidney. They may present with varying severities of acute kidney
injury, electrolyte disturbances, and may have comorbidities such as heart disease that complicate
perioperative and long-term management. Medical management, which may consist of rehydration and
restoration of intravascular volume with intravenous fluid therapy, osmotic diuresis, ureteral muscle
relaxation, and antimicrobials for infection, is important in feline ureteral obstruction patients. Despite
medical management, many cats with ureteral obstructions will require decompression of the obstructed
kidney to relieve pressure-nephropathy and restore urine flow. However, some cats may be too unstable
for traditional medical management and require more emergent intervention to relieve the obstruction
and address the life-threatening sequelae to acute kidney injury, such as hyperkalaemia and fluid
overload. Both surgical and interventional methods to address ureteral obstructions have been described
in veterinary medicine, though debate continues as to the ideal approach.

Journal of Small Animal Practice (2018)

DOI: 10.1111/jsap.12844
Accepted: 26 September 2017

INTRODUCTION: AETIOLOGY part a function of improved awareness and investigation, as well

In cats, ureteral obstructions can be secondary to ureterolithiasis,
ureteral strictures, infection, dried solidified blood calculi, iat-
rogenic ureteral ligation, ureteral ectopia, retoperitoneal fibrosis
after renal transplantation and neoplasia (Speakman et al. 1983,
Aronson 2002, Hardie & Kyles 2004, Lekcharoensuk et al. 2005,
Kyles et al. 2005a, 2005b, D’Ippolito et al. 2006, Westropp et
al. 2006, Cannon et al. 2007, Houston & Moore 2009, Berent
2011, Roberts et al. 2011, Zaid et al. 2011, Berent et al. 2012,
Cohen et al. 2012, Wormser et al. 2013, 2016, Berent et al. 2014,
Johnson et al. 2015). Multiple studies have documented uretero-
liths to be the most common aetiology of feline ureteral obstruc-
tion (Kyles et al. 2005a, 2005b, Lekcharoensuk et al. 2005,
Wormser et al. 2016, Berent et al. 2014, Roberts et al. 2011). In
the largest study of feline ureteral calculi conducted at two U.S.
academic veterinary institutions, there was a 30-fold increase in
recognition of ureteral stones during the 12-year study period
(Kyles et al. 2005a). It is possible the increased incidence is in
as advances in ultrasound technology and digital radiography.
In the same study, 87% of ureteroliths analysed contained cal-
cium oxalate, with an additional 11% containing calcium in
addition to a second mineral source in the stone (Kyles et al.
2005b). A 20-year study evaluating over 5000 feline urinary
tract stone sample submissions showed a significant increase in
calcium oxalate stone diagnosis in cats as compared to struvite,
including a significant increase calcium oxalate-containing stones
removed from the upper urinary tract (Cannon et al. 2007). This
trend of increasing proportion of calcium oxalate uroliths was
also seen at University of Minnesota, but was not repeated in
a Canadian study of feline urolith submissions (Osborne et al.
2008, Houston & Moore 2009). While the aetiology of calcium
oxalate stone formation in cats is unknown, the same 20-year
study by Cannon showed that Persians and Himalayan purebred
cats had significantly more calcium oxalate stones, suggesting a
possible genetic predisposition (Cannon et al. 2007). Since 98%
of feline upper urinary tract stones contain calcium, medical and

Journal of Small Animal Practice • © 2018 British Small Animal Veterinary Association 1
 D. L. Clarke

dietary dissolution of these stones is not possible and should not

be considered in cases of ureteral obstruction. (Lekcharoensuk et
al. 2005, Kyles et al. 2005a, Cannon et al. 2007, Roberts et al.
2011, Berent et al. 2014, Wormser et al. 2016).
In the human literature, three locations along the human ure-
ter are reported to have normal anatomic narrowings that can
predispose to lodgement of stones: the ureteropelvic junction
(UPJ), ureterovesicular junction (UVJ) and the ureteral crossing
of the iliac vessels (Ordon et al. 2013). Evaluation of radiographs
of human patients referred for shockwave lithotripsy showed that
there was an increased prevalence of stone entrapment at the
UPJ and UVJ, but not where the iliac vessels crossed the ureter.
No veterinary studies specifically evaluating the sites of stones
becoming lodged within the feline ureter exist. However, in the
large case series by Kyles et al. (2005b) in which cats underwent
ureteral surgery for ureterolithiasis, 50 ureterotomies were per-
formed in the proximal one third of the ureter, 15 ureterotomies
were performed in the mid-ureter and nine were performed in the
distal ureter. The location of the ureterotomy was not recorded
for three cases.
Westropp et al. (2006) described an increase in non-crys-
talline, dried blood calculi submitted for analysis, which were
almost exclusively retrieved from the feline urinary tract and
submitted in the previous 2 years’ data collection, suggesting an
emerging trend in feline uroliths. In cats for which additional
clinical data was available, there was haematuria and evidence
of ureteral obstruction without radio-opaque or ultrasonographi-
cally recognised mineral opacity, emphasising the importance of
dried solidified blood stones as a differential diagnosis for cats
with ureteral obstructions in the absences of radiographic or
ultrasonographically visible mineral densities (Westropp et al.
2006, Cannon et al. 2007) (Fig 1).
Strictures of the ureter are an interesting and increasingly
reported cause of ureteral obstructions in cats (Leib et al. 1998,
Kyles et al. 2005a, Berent 2011, Zaid et al. 2011, Berent et al.
2012, Foster & Pinkerton 2012, Horowitz et al. 2013, Belanger
et al. 2014, Lee et al. 2014, Zotti et al. 2004). Three cases of
congenital ureteral strictures have been reported in young cats, FIG 1. Urine obtained from pyelocentesis during ureteral stent placement
in a cat with dried solidified blood stones along the length of the ureter.
with two of those cases having histopathologic confirmation of The urine from renal pelvis has overt haematuria as well as small dried
the stricture obtained at necropsy (Leib et al. 1998, Lee et al. solidified blood stones
2014). An additional young cat had progressive renal failure and
hydronephrosis with bilateral UPJ stenosis confirmed at nec- et al. (2011) had prior history of haematuria, and six of 10 had
ropsy (Foster & Pinkerton 2012). In 2011, a case series of 10 evidence of stones in other locations in the urinary tract at the
cats with ureteral strictures causing ureteral obstruction, as con- time of stricture diagnosis. In addition, two of 10 cats had uri-
firmed by ureteropyelography, was reported (Zaid et al. 2011). nary tract infections preoperatively. Three cats in this case series
In these cats, four had previous surgery for ureterolithiasis, with had ureteral histopathology that confirmed ureteritis (2) and
two developing evidence of stricture in the immediate postop- mural granulation tissue (1), and were the cats treated with ure-
erative period and two developed strictures long term. One of teral reimplantation (2) and ureteronephrectomy (1). The differ-
the cats developed a ureteral stricture after a ureteral reimplanta- ences in aetiology of the stricture cases raises the question about
tion was performed for revision of a previous ureteral stricture. the differentiation between true congenital strictures, surgically-
Stricture development is a known complication of feline ureteral induced strictures and narrowing secondary to inflammation and
surgery (Hardie & Kyles 2004, Kochin et al. 1993, Kyles et al. irritation from the passage of stones, blood clots and infection.
2005a, Roberts et al. 2011, Wormser et al. 2016). Therefore, the The reason this third category may warrant additional investiga-
aetiology behind the ureteral stricture in these five cats likely tion and definition is that, in cases of suspected strictures treated
differs from the other cats in the case series in which no prior with the ureteral bypass (discussed below), postoperative follow-
ureteral procedure was performed. Two cats reported by Zaid up has demonstrated recannulation of the ureter over time with-

2 Journal of Small Animal Practice • © 2018 British Small Animal Veterinary Association
 Feline ureteral obstructions I
out any intervention aside from relief of the ureteral obstruction
via a path of alternative urinary diversion (Berent et al. 2014).
This finding raises the question whether the imaging diagnosis of
a ureteral stricture in these cases is actually an acquired ureteral
narrowing secondary to irritation and inflammation that can
resolve with relief of the ureteral spasm and excessive intralumi-
nal pressures associated with a ureteral obstruction.
Given that stone passage, previous ureteral surgery, neoplasia,
retroperitoneal fibrosis and circumcaval ureteral course are associ-
ated with ureteral narrowing or stricture in human patients, it
raises the question as to whether similar anatomic localisations
are seen in in cats (Goldfischer & Gerber 1977, Baker et al. 1987,
Saltzman 1998, Salonia et al. 2006, Acharya et al. 2009, Corco-
ran et al. 2009, van Bommel et al. 2009). In the case series of
10 cats with ureteral strictures, nine had ultrasound-confirmed
proximal ureteral strictures with a median distance of 3.5 cm dis-
tal to the kidney (range = 1 to 6 cm) and one had a surgically
confirmed distal ureteral stricture (Zaid et al. 2011). Further clas-
sification of location in terms of stricture occurrence at the UPJ
or UVJ was not performed. Four of the 10 cats had right-sided
circumcaval ureters but additional information regarding correla-
tion of the location of the stricture and proximity to the circum-
caval ureter was not provided (Zaid et al. 2011). A cohort of 22
cats with circumcaval ureters and concurrent ureteral obstruction
were reported in comparison to 106 obstructed cats without cir-
cumcaval ureters and 65 necropsy cases without ureteral obstruc-
tion (Steinhaus et al. 2015). However, the definition of ureteral
obstruction at necropsy was based on the ability to pass a guide-
wire. Given that cats with ureteral strictures have been treated
with ureteral stents, which requires passage of a guidewire, the
ability pass a guidewire may not be the best diagnostic test for
confirmation of a stricture and therefore may have resulted in
under-diagnosis of ureteral strictures in the necropsy population
(Zaid et al. 2011, Berent et al. 2012, Horowitz et al. 2013, Kulen-
dra et al. 2014, Steinhaus et al. 2015). Steinhaus et al. (2015)
reported that circumcaval ureters were predominantly right-sided
(80% of obstructed cats and 89% circumcaval ureters identified
at necropsy) and were present in 22/128 (17%) of obstructed
cats. Ureteral obstruction cats with circumcaval ureter(s) (40%)
were significantly more likely to have strictures than those with-
out the anomalous ureteral course (17%) (Steinhaus et al. 2015).
However, a detailed description of the ureteropyelographic loca-
tion of the stricture in relation to the location of the circum-
caval course of the ureter observed at surgery was not provided
(Fig 2). Therefore, it is possible that the ureteral narrowing and
circumcaval ureter association may not be the sole explanation
of causation for the ureteral obstruction. In addition, given the
normal anatomic narrowings described in the human ureter, it
is possible the feline ureter may have similar findings in health
that are exacerbated in ureteral disease creating the appearance
of ureteral stricture that is actually a temporary worsening of a
normal anatomic narrowing. Currently, a necropsy and imaging
study evaluating the hypothesis of normal narrowings at the UPJ
and UVJ in the feline ureter is being conducted at my institution.
Retroperitoneal fibrosis is a rare, poorly-understood condi-
tion in human and feline transplant patients and is defined by
Journal of Small Animal Practice • © 2018 British Small Animal Veterinary Association 3
FIG 2. Intraoperative picture of a cat with a right ureteral circumcaval
ureter. The ureter courses dorsal to the vena cava in the mid- to distal
ureter and was not associated with a ureteral stricture or the location of
the obstruction
the formation of fibroinflammatory tissue in the retroperitoneal
space (Aronson 2002, Wormser et al. 2013). In a series of 29
feline transplant recipients that developed retroperitoneal fibro-
sis, representing 21% of the cats the study, fibrosis occurred at a
median of 62 days post-transplantation, with a range of 4 to 730
days (Wormser et al. 2013). Clinically, the cats showed anorexia,
lethargy, azotaemia and anaemia that was progressive from their
postoperative values. In the 25 cats for which fibrosis was sus-
pected based on ultrasound, imaging characteristics consistent
with ureteral obstruction (hydroureter, hydronephrosis) were
present in all cases. Exploratory laparotomy and careful surgical
dissection to free the encased ureter to relieve the extraluminal
fibrotic tissue obstruction were performed successfully in the 25
cats that underwent surgery but six cats had recurrence of fibrosis
requiring an additional procedure (Wormser et al. 2013).
Pathophysiology of obstructive nephropathy
Regardless of the aetiology, the pathophysiology of obstructive
nephropathy to the kidney is similar. Acute kidney injury is the
result of increased pressure within the renal pelvis and ureter that
decreases renal blood flow and glomerular filtration rate (GFR),
resulting in renal tubular inflammation and injury (Meldrum
2016). Three phases of changes in renal blood flow and ureteral
pressure occur during experimental animal models of unilateral
ureteral obstruction. There is an initial increase in pressure within
the renal tubules, resulting in a decreased GFR. Compensation for
the reduced GFR to maintain renal blood flow is achieved through
vasoactive mediators such as prostaglandin E and nitric oxide release
which lasts for 1 to 2 hours after the initiation of the obstruction
(Allen et al. 1978, Lanzone et al. 1995, Meldrum 2016). In the
second phase, which lasts 3 to 4 hours, renal blood flow declines in
the face of continued elevation in the ureteral pressures. The final
phase is characterised by loss of renal function due to decreased
renal blood flow and ureteral pressures, and occurs within 24 hours
of the obstructive event (Allen et al. 1978, Lanzone et al. 1995,
Meldrum 2016). Interestingly, the decrease in GFR and renal blood
 D. L. Clarke
flow is more pronounced in unilateral ureteral obstructions than in
bilateral ­obstructions (Siegel et al. 1977, Meldrum 2016). With par-
tial ureteral obstructions, the degree of ureteral pressure increase and
reduction in GFR is variable and less predictable (Meldrum 2016).
The extent of damage is dependent on the degree and duration of
the obstruction as well as the presence of any preexisting renal dis-
ease (Wen et al. 1999, Coroneos et al. 1997, Wilson 1997, Fink et
al. 1980, Kerr 1954, Vaughan et al. 1973, Berent 2011, Meldrum
2016). Increased inflammatory cell infiltration is one of the earliest
changes in obstructed kidneys, with macrophage infiltration occur-
ring within 4 hours of an obstructive event (Schreiner et al. 1988,
Meldrum 2016). Fibrosis can result from prolonged obstruction and
intrarenal hypertension which causes scarring and nephron loss. The
clinical phenomenon that results is referred to as “big kidney, little
kidney”, which is commonly seen in cats that have had prolonged
obstruction, nephron loss and fibrosis of one kidney with adequate
function and compensatory hypertrophy the contralateral kidney
(Kerr 1954, Vaughan et al. 1973, Fink et al. 1980, Coroneos et al.
1997, Wilson 1997, Wen et al. 1999, Berent 2011, Meldrum 2016).
CLINICAL PRESENTATION
Clinical signs in cats with ureteral obstructions are often vague
and non-specific, including lethargy, decreased appetite or
anorexia (38 to 87%), vomiting (15 to 48%), polyuria and poly-
dipsia (18 to 25%), abdominal pain (8%) and weight loss (15 to
58%) (Kyles et al. 2005a, Berent et al. 2012, Nicoli et al. 2012,
Wormser et al. 2016). Cats often have more than one clinical
sign. Lower urinary tract signs, such as haematuria, stranguria,
pollakiuria, incontinence and inappropriate urination, may also
occur and have been described in up to 25% of cats (Kyles et al.
2005a, Zaid et al. 2011, Berent et al. 2012, Nicoli et al. 2012,
Wormser et al. 2016). The severity of patient illness will depend
on the function of the contralateral kidney as well as other comor-
bidities, including hypertrophic cardiomyopathy, inflammatory
bowel disease, hepatic lipidosis, hyperthyroidism, hypercalcae-
mia, renal haematuria, renal insufficiency and diabetes mellitus
(Kyles et al. 2005b,Berent et al. 2012 , Wormser et al. 2016).
Physical exam findings may also be non-specific in cats with
ureteral obstructions, and include depression, abdominal pain,
especially on renal palpation and varying degrees of hydration
ranging from dehydration to overhydration. Other examination
findings include hypersalivation/nausea, uraemic oral ulceration,
renomegaly, one small or irregular kidney with a contralateral
normal or enlarged kidney, variable bladder size and evidence of
loss of muscle mass (Kyles et al. 2005b, Zaid et al. 2011, Berent et
al. 2012, Nicoli et al. 2012, Wormser et al. 2016). Interestingly,
two retrospective studies on cats undergoing ureteral stenting
or ureteral surgery noted heart murmurs in 48 to 54% of cats,
which could be due to concurrent anaemia, cardiac dysfunction
secondary to uraemia, fluid therapy resulting in volume overload
or underlying structural heart disease. These findings empha-
sise the importance of careful cardiovascular monitoring in this
critically ill feline population (Berent et al. 2012, Wormser et al.
2016).
4 Journal of Small Animal Practice
DIAGNOSTIC TESTING
Diagnostic testing, including blood testing and imaging, is essen-
tial for patients with suspected ureteral disease. The most com-
mon biochemical abnormality is azotaemia, which is detected in
up to 95% of cats, followed by hyperphosphataemia, hypercal-
caemia or hypocalcaemia and hyperkalaemia. (Kyles et al. 2005a,
2005b, Zaid et al. 2011, Berent et al. 2012, Nicoli et al. 2012,
Horowitz et al. 2013, Kulendra et al. 2014, Steinhaus et al. 2015,
Culp et al. 2016, Wormser et al. 2016). In cats, anaemia is a
common haematologic finding, in up to 68% cats in one study
(Kyles et al. 2005a, Berent et al. 2012, Culp et al. 2016, Worm-
ser et al. 2016). Concurrent urinary tract infections are noted in
32% of cats. (Kyles et al. 2005a, Berent et al. 2012, Horowitz et
al. 2013, Kulendra et al. 2014, Steinhaus et al. 2015, Wormser
et al. 2016). The most commonly implicated pathogens are Esch-
erichia coli, Streptococcus species, Enterococcus and Staphylococcus
species (Berent et al. 2012, Kulendra et al. 2014, Culp et al. 2016,
Wormser et al. 2016). Other abnormalities noted on urinalysis
include isosthenuria, haematuria, pyuria, bacteruria and crystal-
luria (Kyles et al. 2005a, Berent et al. 2012, Kulendra et al. 2014,
Manassero et al. 2014, Culp et al. 2016, Wormser et al. 2016).
Diagnostic imaging is essential in patients with ureteral dis-
ease. Abdominal radiography and ultrasonography are most
commonly utilised, though CT may also be valuable to detect
ureteroliths not detected with radiography or ultrasonography
(Kyles et al. 2005a). However, the use of intravenous iodinated
contrast agents may be dangerous in patients with decreased glo-
merular filtration and renal function because iodinated contrast
agents induce vasoconstriction and cause direct cytotoxicity to
renal tubular cells (McCullough 2008) (Fig 3). Contrast-induced
nephropathy has been documented in up to 10% of human
patients undergoing outpatient contrast-enhanced CT examina-
tion (McCullough 2008, Mitchell et al. 2010).
On abdominal radiographs, radio-opaque calculi or miner-
alisation may be noted anywhere along the upper or lower uri-
nary tract. However, many ureteroliths in cats are smaller than 2
mm, which is less than the limit of detection with radiographs,
yet are large enough to cause ureteral obstruction due to the
extremely small internal luminal diameter of the cat ureter (0.4
mm) (Kochin et al. 1993, Hardie & Kyles 2004). In cats with
confirmed ureterolithiasis, abdominal radiographs alone have
an 81% sensitivity for diagnosing ureteral calculi. The sensitiv-
ity can increase to 90% when combined with ultrasonography
(Kyles et al. 2005a). Dried solidified blood stones cannot be seen
radiographically (Westropp et al. 2006, Cannon et al. 2007).
Abdominal radiographs may also reveal decreased abdominal
detail secondary to peritoneal fluid accumulation, uroabdo-
men or peritonitis. Decreased retroperitoneal detail may also be
noted secondary to nephritis/ureteritis and retroperitoneal effu-
sion accumulation. Renomegaly, small kidney size, irregularity of
the renal margins and “big kidney/little kidney” may be noted as
changes to the kidney size and shape.
Abdominal ultrasound provides more detailed evaluation of
the urinary tract because it allows for assessment of renal blood
• © 2018 British Small Animal Veterinary Association
 Feline ureteral obstructions I
FIG 3. CT examination of cat with multiple mineralised opacities in the
right kidney and right ureter. CT revealed proximal and mid-ureteroliths
not noted on ultrasonography
FIG 4. Ultrasonographic image of an obstructed renal pelvis
flow, changes to the echotexture of the parenchyma, evalua-
tion of renal pelvis, echogenicity of the urine, small stones in
the renal pelvis and ureter, ureteral narrowing, ureteral inflam-
mation, retroperitoneal effusion, ureteral ectopia, urinary tract
neoplasia and regional lymph node involvement (Widmer
et al. 2004, Holloway & O’Brien 2007, D’Anjou 2011) (Fig
4). Ultrasonography alone is reported to have a sensitivity of
77% for diagnosing ureteral stones in cats (Kyles et al. 2005a).
However, dried solidified blood stones often cannot be recog-
nised on ultrasonography (Westropp et al. 2006, Cannon et al.
2007). In one study, six of 10 cats with ureteral strictures, showed
Journal of Small Animal Practice • © 2018 British Small Animal Veterinary Association 5
­ yperechoic periureteral tissue on ultrasonography, which was the
h
first description of these changes in association with obstructive
strictures (Zaid et al. 2011). In cats with retroperitoneal fibrosis
after renal transplantation, in addition to the typical obstructive
ultrasonographic changes of hydroureter and hydronephrosis,
the inability to trace the allograft ureter was noted in 23/25 cats
with obstructive fibrosis (Wormser et al. 2013). One of the most
useful ultrasonographic findings for diagnosis of ureteral obstruc-
tion is dilation of the renal pelvis, especially when stone disease
is not concurrently seen or there is concern about whether or
not the stones are obstructive. While renal pelvis dilation can
be ultrasonographically detected in animals with structurally and
functionally normal kidneys, the degree of dilation increased
with renal dysfunction, pyelonephritis and ureteral obstruction.
In retrospective study of normal dogs and cats and those with
varying degrees of renal disease, renal pelvis dimensions >13mm
had 100% sensitivity for diagnosis of obstructive nephropathy
(D’Anjou 2011). However, there was a wide range of overlap of
the smaller renal pelvis sizes among the diseases studied, includ-
ing renal insufficiency, pyelonephritis and ureteral ectopia.
Therefore, renal pelvis sizes <13mm are not pathognomonic for
specific upper or lower urinary tract diseases (D’Anjou 2011).
However, there is no standardised method for evaluation of renal
pelvic dimensions, and interobserver variability, asymmetry in
the renal pelvis, distortion from stones within the renal pelvis
and patient cooperation can influence the accuracy of repeated
measurements.
Anterograde pyelography is performed under general anaes-
thesia using ultrasound guidance for access to the renal pelvis
and radiographs or fluoroscopy are used to assess contrast flow
through the ureter. It can be helpful to assess for filling defects
in the renal pelvis and ureter, as well as to determine whether
a partial or complete obstruction is present (Rivers et al. 1977,
Ackerman et al. 1980, Adin et al. 2003). Alternatively, an open
surgical approach for direct puncture of the renal pelvis via
the greater curvature of the kidney can be used with intraop-
erative fluoroscopy when ureteral interventions, such as stenting
or ureteral bypass placement, is planned (Berent 2011, Berent
et al. 2012). Access to the kidney is obtained aseptically with a
22-gauge needle when percutaneous ultrasound guidance is used
or an 18 to 22 gauge over-the-needle catheter during surgery (Fig
5). Once the tip of the needle/catheter is within the renal pelvis,
urine is aspirated using a syringe attached to a 3-way stopcock for
urinalysis and culture and sensitivity testing. An equal volume of
iodinated contrast agent to that of the urine removed is injected
into the renal pelvis via a second syringe attached to the stopcock
under ultrasound or fluoroscopic guidance to gently distend the
pelvis and allow contrast movement into the ureter (Fig 6). Its
clinical utility has been documented in cats with ureteral obstruc-
tions to have 100% sensitivity and specificity when a diagnostic
study was achieved, but can also be associated with complica-
tions such as contrast leakage, haemorrhage, and laceration of the
renal pelvis, all of which can limit the diagnostic abilities of ante-
grade pyelography (Adin et al. 2003) (Fig 7). Given the concerns
for contrast leakage, preparedness for intervention of a ureteral
obstruction diagnosed via anterograde pyelography is essential,
 D. L. Clarke

FIG 5. Ultrasound-guided pyelocentesis and anterograde pyelogram in

a cat. The ultrasound probe is covered with a sterile sleeve and a 22G
hypodermic needle is being positioned for ultrasound-guided access into
the renal pelvis. An empty syringe is connected to a three-way stopcock
for renal pelvis urine sample collection. Iodinated contrast is also
connected to the three-way stopcock for infusion into the renal pelvis
under ultrasound guidance

because urine will follow the path of least resistance. In the case
of a partial or complete ureteral obstruction, urine may leak
through the hole created in the capsule for the diagnostic study,
resulting in urine accumulation in the retroperitoneal or perito-
neal spaces. Retrograde ureteropyelography is also beneficial to
confirm the nature of a ureteral obstruction, but is performed
via cystoscopy-guided catheter access to the UVJ in the bladder
(Berent 2011, Zaid et al. 2011). Aspiration of urine from the
renal pelvis for urinalysis and bacteriologic culture and sensitiv-
ity testing is also possible via retrograde ureteral catheterisation.

MEDICAL MANAGEMENT OF URETERAL

OBSTRUCTIONS

Medical management for acute kidney injury and the uraemic

and electrolyte disturbances secondary to ureteral obstruction
is essential. Fluid therapy with balanced isotonic crystalloids to
restore intravascular volume and correct dehydration should be
based on physical examination parameters, including weight, skin
turgor, mucous membranes, evidence of interstitial oedema. In
additional to physical exam findings, fluid therapy is also guided
by basic diagnostics to assess intravascular volume, perfusion
and hydration including blood pressure, blood lactate, central or
mixed venous oxygen saturation, minimum database, electrolyte
status and urine production (Langsten & Eatroff 2015). The use
of colloids has been associated with adverse effects such as pro-
longed hospitalisation, fluid overload, coagulopathies, acute kid-
ney injury and need for renal replacement therapies in critically
ill human patients (Guidet et al. 2012, Myburgh et al. 2012). FIG 6. Abdominal radiographs (lateral (a) and ventrodorsal (b)) after an
These severe consequences have led marked reduction in the use ultrasound-guided anterograde pyelogram in a cat demonstrating a mid-
ureteral obstruction
of colloids in human medicine. Initial retrospective veterinary
data regarding the renal safety of colloids is veterinary patients

6 Journal of Small Animal Practice • © 2018 British Small Animal Veterinary Association
 Feline ureteral obstructions I

Fluid therapy needs are calculated as the sum of maintenance

fluid needs plus deficit from dehydration plus ongoing losses (Sil-
verstein 2009, Langsten & Eatroff 2015). Fluid volumes from
enteral nutrition and water, diluted medications and heparin-
ised saline flushes should also be accounted for when consider-
ing total fluid therapy amounts, especially in cats in which those
volumes can become a significant portion of their total daily
allotment. Fluid overload and overhydration must be avoided,
because decreased renal excretion of water and electrolytes,
sodium containing fluids and overzealous fluid therapy can cause
oedema of all tissues, including the kidneys, gastrointestinal tract
and pulmonary parenchyma and is associated with decreased sur-
vival in human and veterinary patients (Mazzafero 2008, Vaara
et al. 2012). Signs of overhydration include a 10% weight gain,
the development of chemosis, serous nasal discharge, increased
respiratory rate or effort, harsh lung sounds or crackles on aus-
cultation, decreased skin turgor and a “gelatinous” feel to the
skin and subcutaneous tissues (Mazzafero 2008, Langsten & Eat-
roff 2015). Interstitial and intravascular fluid balance should be
­monitored frequently (every 4 to 6 hours) in patients with acute
kidney injury to prevent development of dehydration, hypovo-
laemia or fluid overload.
Other aspects of medical management for ureteral obstruc-
tions include osmotic diuretics such as mannitol, alpha-receptor
antagonists, ureteral smooth muscle relaxants and antibiotics
(Table 1). The goal of mannitol therapy, which is generally
administered as an initial bolus followed by a constant rate
infusion, is to increase the volume of urine excreted in effort to
FIG 7. Retroperitoneal haemorrhage noted at surgery following “push” stones or debris through the ureter. Since mannitol can
percutaneous ultrasound-guided anterograde pyelography
increase intravascular volume, and is solely excreted via the kid-
ney, its use is contraindicated in anuric patients and those with
has resulted in mixed conclusions (Hayes et al. 2016, Yozova significant cardiac disease because it can result in life-threatening
et al. 2016). Therefore, until definitive evidence of the safety of complications of fluid overload, including pulmonary oedema.
colloids in veterinary patients is available, caution should be used There are limited clinical ­veterinary data regarding the efficacy
when colloids are administered with acute kidney injury. of ureteral relaxation with alpha-reception antagonists such as

Table 1. Medical management options for ureteral obstruction in cats (Adapted with permission from Degner & Clarke 2015)
Drug Drug type and mechanism of action Dose in cats Comments
Amitryptyline HCl Tricyclic anti-depressant 0.5 to 2 mg/kg orally every 24 hours May cause sedation
Ureteral smooth muscle relaxation (Extra-label use and dose) Multiple potential drug interactions, consult
of ureter by opening of potassium veterinary formulary prior to use
dependent voltage channels
Glucagon Polypeptide hormone 0.05 to 0.1 mg/cat intravenous every Vomiting, diarrhoea, nausea, and hypokalemia
Ureteral smooth muscle relaxation & 8 to 24 hours may result
relief of ureteral colic (Extra-label use and dose)
Prazosin Alpha-1 antagonist 0.25 to 0.5 mg/cat orally every Sedation, third eyelid elevation, and hypotension
Ueteral smooth muscle relaxation 12 to 24 hours can result
Tamsulosin Alpha-1 antagonist 0.004 to 0.006 mg/kg orally every Safety, efficacy, dose have not studied in cats
Ueteral smooth muscle relaxation 12 to 24 hours May cause lethargy, vomiting, and
(Extra-label use and dose)May take hypotensionDose size will require compounding
3 days to be effective
Mannitol Osmotic diuretic to increase flow of 0.25 to 1 g/kg intravenous over 20 to Contraindicated with anuria and fluid overload
urine through the ureter 30 minutes; may repeat if effective May cause fluid overload so use caution with
 60 to 120 mg/kg/hour CRI cardiac disease and overhydrated patients
Furosemide Loop diuretic for increased flow of 0.1 to 1 mg/kg intravenous, if effective, Can increase urine output but does not effect GFR
urine through the ureter can use 0.25 to 1 mg/kg/hour CRI Can result in hypochloremia and hypokalemia
(Extra-label use and dose)
Amlodipine Calcium channel blocker 0.625 to 1.25 mg orally per cat every Limited veterinary evidence for ureteral disease
besylate Smooth muscle relaxation via 24 hours Slow onset of actionMay cause anorexia and
blockade of calcium channels (Extra-label use and dose) hypotension

Journal of Small Animal Practice • © 2018 British Small Animal Veterinary Association 7
 D. L. Clarke
FIG 8. Locking loop nephrostomy catheter within the renal pelvis of a cat
prazosin and tamsulosin or ureteral smooth muscle relaxation
with glucagon or amitriptyline, but may be considered in some
patients (Bahn Zobbe et al. 1986, Achar et al. 2003, Berent
2011). Meta-analyses of expulsion therapies in humans have
shown that alpha-antagonists and calcium channel blockers
improve passage of distal ureteral stones ≤5mm, although up to
4% of patients receiving alpha-antagonists and 15% of patients
receiving calcium channel blockers experienced adverse side
effects (Singh et al. 2007). Since up to 32% of cats have urinary
tract infections, antibiotic therapy is often indicated, especially
if there are ultrasonographic changes suggesting an infectious
process (Kyles et al. 2005a, Westropp et al. 2006, Berent 2011,
Berent et al. 2012, Wormser et al. 2016, D’Anjou 2011). One
retrospective study of medical management for feline ureteral
calculi showed that 13% had significant improvement in azo-
taemia at the time of discharge, with 57% of these cats hav-
ing documented stone passage from the proximal ureter to the
bladder (Kyles et al. 2005b). However, 30% of cats in the same
study did not have a significant improvement in azotaemia with
medical management despite documented stone passage in 71%
of these cats (Kyles et al. 2005b).
In anuric patients, especially those that are fluid-overloaded,
those with severe hyperkalaemia refractory to medical manage-
ment, or those significantly impacted by their degree of uraemia,
extracorporeal therapies such as continuous renal replacement
or intermittent haemodialysis can be a life-saving bridge until
definitive relief of the ureteral obstruction is available. Limited
availability, cost, dialysis disequilibrium syndrome and complica-
tions associated with placement of large-bore central catheters,
anti-coagulation, removal of large volumes of total vascular vol-
ume and transfusion needs can limit the utility of this treatment
modality for acute kidney injury (Pantaleo et al. 2004, Bloom &
Labato 2011, Palm & Kanakubo 2015). In addition, extracor-
poreal therapies do not address the renal pathophysiology and
insult caused by obstructive nephropathy. Therefore, relief of the
obstructive process as soon as possible is the preferred method
for patient stabilisation. When this is not possible, surgical or
percutaneous nephrostomy tube placement may be considered
8 Journal of Small Animal Practice
as a temporary intervention for relief of the ureteral obstruction.
This technique provides relief of obstructive nephropathy as well
as assessment of renal function prior to definitive i­ntervention,
which can be delayed by availability or safety of prolonged
anaesthesia. Technical success with locking loop catheters placed
within the renal pelvis in both dogs and cats has been described,
and may be associated with less dislodgement complications than
red rubber catheters (Hardie & Kyles 2004, Kyles et al. 2005b,
Berent et al. 2012) (Fig 8).
Conflict of interest
None of the authors of this article has a financial or personal
relationship with other people or organisations that could inap-
propriately influence or bias the content of the paper.
References
Achar, E., Achar, R., Paiva, T., et al. (2003) Amitriptyline eliminates calculi through
urinary tract smooth muscle relaxation. Kidney International 64, 1356-1364
Acharya, S., Jindai, B., Yadar, D., et al. (2009) Retrocaval ureter: a rare cause of
hydronephrosis in children. Journal of Pediatric Surgery 44, 846-848
Ackerman, N., Ling, G. & Ruby, A. (1980) Percutaneous nephropyelocentesis and
antegrade urography: a fluoroscopically assisted diagnostic technique in canine
urology. Veterinary Radiology & Ultrasound 21, 117-122
Adams, L. (2013) Nephroliths and ureteroliths: a new stone age. New Zealand
Veterinary Journal 61, 1-5
Adams, L. & Goldman, C. (2011) Extracorporeal shock wave lithotripsy. In: Nephrol-
ogy and Urology of Small Animals. Eds D. Polzin and J. Bartges. Blackwell Pub-
lishing, Ames, IA, USA. pp 340-348
Adams, L., Williams, J., McAteer, J., et al. (2005) In vitro evaluation of canine and
feline urolith fragility by shock wave lithotripsy. American Journal of Veterinary
Research 66, 1651-1654
Adin, C. & Scansen, B. (2011) Complications of upper urinary tract surgery in compan-
ion animals. Veterinary Clinics of North America: Small Animal Practice 41, 869-888
Adin, C., Herrgesell, E., Nyland, T., et al. (2003) Antegrade pyelography for sus-
pected ureteral obstruction in cats: 11 cases (1995-2001). Journal of the
American Veterinary Medical Association 222, 1576-1581
Allen, J., Vaughan, E. & Gillenwater, J. (1978) The effect of indomethacin on renal
blood flow and uretral pressure in unilateral ureteral obstruction in a awake
dogs. Investigative Urology 15, 324-327
Andoinian, S., Zorn, K., Paraskevas, S., et al. (2005) Artificial ureters in renal
transplantation. Urology 66, 1109e9-1109e11
Aronson, L. (2002) Retroperitoneal fibrosis in four cats following renal transplanta-
tion. Journal of the American Veterinary Medical Association 221(984-9), 975
Aronson, L., Cleroux, A. & Wormser, C. (2016) The use of a modified Boari flap
for the treatment of a proximal ureteral obstruction in a cat. Veterinary Surgery
45, E23
Azhar, R., Hassanain, M., Aljiffry, M., et al. (2010) Successful salvage of kidney
allografts threatened by ureteral stricture urine pyelovesical bypass. American
Journal of Transplantation 10, 1414-1419
Bahn Zobbe, V., Rygaard, H., Rasmussen, D., et al. (1986) Glucagon in acute ure-
teral colic. A randomized trial. European Urology 12, 28-31
Baker, L., Mallinson, W., Gregory, M., et al. (1987) Idiopathic retroperitoneal fibro-
sis. A retrospective analysis of 60 cases. British Journal of Urology 60, 497-503
Belanger, R., Shmon, C., Gilbert, P., et al. (2014) Prevalence of circumcaval ureters and
double caudal vena cava in cats. American Journal of Veterinary Research 75, 91-95
Berent, A. (2011) Ureteral obstructions in dogs and cats: a review of traditional
and new interventional diagnostic and therapeutic options. Journal of Veterinary
Emergency and Critical Care 21, 86-103
Berent, A., Weisse, C., Todd, K., et al. (2012) Use of locking-loop pigtail nephros-
tomy nephrostomy catheters in dogs and cats: 20 cases (2004-2009). Journal
of the American Veterinary Medical Association 241, 348-357
Berent, A., Weisse, C., Todd, K., et al. (2014) Technical and clinical outcomes
of ureteral stenting in cats with benign ureteral obstruction: 69 cases (2006-
2010). Journal of the American Veterinary Medical Association 244, 559-576
Bloom, C. & Labato, M. (2011) Intermittent hemodialysis for small animals. The
Veterinary Clinics of North America. Small Animal Practice 41, 115-133
van Bommel, E., Jansen, I., Hendriksz, T., et al. (2009) Idiopathic retroperitoneal
fibrosis: prospective evaluation of incidence and clinicoradiologic presentation.
Medicine (Baltimore) 88, 193-201
Burgos, F., Bueno, R., Gonzalez, J., et al. (2009) Endourologic implants to treat
complex ureteral stenosis after kidney transplantation. Transplantation Pro-
ceedings 41, 2427-2429
Cannon, A., Westropp, J., Ruby, A., et al. (2007) Evaluation of trends in urolith com-
position in cats: 5,230 cases (1985-2004). Journal of the American Veterinary
Medical Association 231, 570-576
• © 2018 British Small Animal Veterinary Association
 Feline ureteral obstructions I
Cohen, L., Shipov, A., Ranen, E., et al. (2012) Bilateral ureteral obstruction in a
cat due to a ureteral transitional cell carcinoma. Canadian Veterinary Journal
53, 535-538
Corcoran, A., Smaldone, M., Ricchiuti, D., et al. (2009) Management of benign
ureteral strictures in the endoscopic Era. Journal of Endourology 23, 1-4
Coroneos, E., Assouad, M., Krishnan, B., et al. (1997) Urinary obstruction causes
irreversible renal failure by inducing chronic tubulointerstitial nephritis. Clinical
Nephrology 48, 125-128
Culp, W., Palm, C., Hsueh, C., et al. (2016) Outcome in cats with benign ureteral
obstructions treated by means of ureteral stenting versus ureterotomy. Journal
of the American Veterinary Medical Association 249, 1292-1300
Davis, D., Strong, G. & Drake, W. (1948) Intubated ureterotomy: experimental work
and clinical results. Journal of Urology 59, 851-862
D’Anjou, M. A., Be’Dard, A. & Dunn, M. E. (2011) Clinical significance of renal pelvic
dilatation on ultrasound in dogs and cats. Veterinary Radiology & Ultrasound
52, 88-94
Degner, D. A. & Clarke, D. L. (2015) Ureteral obstructions. In: Small Animal Surgical
Emergencies. Ed L. A. Aronson. Wiley Blackwell, Hoboken NJ, USA. pp 224-236
Desgrandchampts, F., Leroux, S., Ravery, V., et al. (2007) Subcutaneous pyelovesi-
cal bypass as replacement for standard percutaneous nephrostomy for pallia-
tive urinary diversion: prospective evaluation of patient’s quality of life. Journal
of Endourology 21, 173-176
D’Ippolito, P., Nicoli, S. & Zatelli, A. (2006) Proximal ureteral ectopia causing hydro-
nephrosis in a kitten. Journal of Feline Medicine and Surgery 8, 420-423
Fink, R., Caradis, D., Chmiel, R., et al. (1980) Renal impairment and its reversibility
following variable periods of complete ureteric obstruction. Australian and New
Zealand Journal of Surgery 50, 77-83
Finny, R. (1978) Experience with new double J ureteral catheter stent. Journal of
Urology 120, 678-681
Foster, J. & Pinkerton, M. (2012) Bilateral ureteropelvic junction stenosis causing
hydronephrosis and renal failure in an adult cat. Journal of Feline Medicine and
Surgery 14, 938-941
Gerullis, H., Ecke, T., Schwartmann, K., et al. (2010) Nephrocutaneous bypass in
ureteral obstruction. Urology 76, 480-485
Gibbons, R., Mason, J. & Correa, R. (1974) Experience with indwelling silicone
rubber ureteral catheters. Journal of Urology 111, 594-599
Goldfischer, E. & Gerber, G. (1977) Endoscopic management of ureteral strictures.
Journal of Urology 157, 770-775
Guidet, B., Martinet, O., Boulain, T., et al. (2012) Assessment of hemodynamic effi-
cacy and safety of 6% hydroxyethylstarch 130/0.4 vs. 0.9% NaCl fluid replace-
ment in patients with severe sepsis: the CRYSTMAS study. Critical Care 16, R94
Haddad, N., Andonian, S. & Anidjar, M. (2013) Simultaneous bilateral subcutane-
ous pyelovesical bypass as a salvage procedure in refractory retroperitoneal
fibrosis. Canadian Urological Association 7, 417-420
Hardie, E. & Kyles, A. (2004) Management of ureteral obstruction. The Veterinary
Clinics of North America. Small Animal Practice 34, 989-1010
Hayes, G., Benedicenti, L. & Mathews, K. (2016) Retrospective cohort study on
the incidence of acute kidney injury and death following hydroxyethyl starch
(HES 10%/250/0.5/5:1) administration in dogs (2007-2010). Journal of Veteri-
nary Emergency and Critical Care 26, 35-40
Holloway, A. & O’Brien, R. (2007) Perirenal effusion in dogs and cats with acute
renal failure. Veterinary Radiology & Ultrasound 48, 574-579
Horl, W. (2010) Other blood and immune disorders in chronic kidney disease. In:
Comprehensive Clinical Nephrology. 4th edn. Eds J. Floege, R. Johnson and J.
Feehally. Elsevier, St. Louis, MO, USA. pp 959-968
Horowitz, C., Berent, A., Weisse, C., et al. (2013) Predictors of outcome for cats
with ureteral obstructions after interventional management using ureteral
stents or a subcutaneous ureteral bypass device. Journal of Feline Medicine
and Surgery 15, 1052-1062
Houston, D. & Moore, A. (2009) Canine and feline urolithiasis: Examination of
over 50 000 urolith submissions to the Canadian Veterinary Urolith Centre from
1998 to 2008. Canadian Veterinary Journal 50, 1263-1268
Jabbour, M., Desgrandchamps, F., Angelescu, E., et al. (2001) Percutaneous
implantation of subcutaneous prosthetic ureters: long-term outcome. Journal
of Endourology 15, 611-614
Johnson, C., Culp, W., Palm, C., et al. (2015) Subcutaneous ureteral bypass device
for treatment of iatrogenic ureteral ligation in a kitten. Journal of the American
Veterinary Medical Association 247, 924-931
Kerr, W. (1954) Effect of complete ureteral obstruction for one week on kidney
function. Journal of Applied Physiology 6, 762-772
Kim, J., Baek, C., Min, J., et al. (2015) Desmopressin improves platelet function
in uremic patients taking antiplatelet agents who require emergent invasive
procedures. Annals of Hematology 94, 1457-1461
Kochin, E., Gregory, C., Wisner, E., et al. (1993) Evaluation of a method of uretero-
neocystotomy in cats. Journal of the American Veterinary Medical Association
202, 257-260
Kulendra, N., Syme, H., Benigni, L., et al. (2014) Feline double pigtail ureteric
stents for management of ureteric obstruction: short- and long-term follow-up
of 26 cats. Journal of Feline Medicine and Surgery 16, 985-991
Kyles, A., Hardie, E., Wooden, B., et al. (2005a) Clinical, clinicopathologic, radio-
graphic, and ultrasonographic abnormalities in cats with ureteral calculi: 163
cases (1984-2002). Journal of the American Veterinary Medical Association
226, 932-936
Journal of Small Animal Practice • © 2018 British Small Animal Veterinary Association 9
Kyles, A., Hardie, E., Wooden, B., et al. (2005b) Management and outcome of cats
with ureteral calculi: 153 cases (1984-2002). Journal of the American Veteri-
nary Medical Association 226, 937-944
Lange, D., Bidnur, S., Hoag, N., et al. (2015) Ureteral stent associated complica-
tions – where we are and where we are going. Nature Reviews. Urology 12, 17-25
Langsten, C. & Eatroff, A. (2015) Acute kidney injury. In: Small Animal Critical Care
Medicine. 2nd edn. Eds D. Silverstein and K. Hopper. Saunders Elsevier, St
Loius, MO, USA. pp 665-660
Lanzone, J., Gulmi, F., Chou, S., et al. (1995) Renal hemodynamics in acute uni-
lateral ureteral obstruction: contribution of endothelium-derived relaxing factor.
Journal of Urology 153, 2055-2059
Lee, H., Kim, Y., Jeong, J., et al. (2010) Desmopressin improves platelet dysfunc-
tion measured by in vitro closure time in uremic patients. Nephron. Clinical
Practice 114, 248-252
Lee, N., Choi, M., Keh, S., et al. (2014) Bilateral congenital ureteral strictures in a
young cat. Canadian Veterinary Journal 55, 841-844
Leib, M., Allen, T., Konde, L., et al. (1998) Bilateral hydronephrosis attributable to
bilateral ureteral fibrosis in a cat. Journal of the American Veterinary Medical
Association 192, 795-797
Lekcharoensuk, C., Osborne, C., Lulich, J., et al. (2005) Trends in the frequency of
calcium oxalate uroliths in the upper urinary tract of cats. Journal of the Ameri-
can Animal Hospital Association 41, 39-46
Lennon, G. (1997) Double pigtail ureteric stent versus percutaneous nephros-
tomy: effects on stone transit and ureteric motility. European Urology 31, 24-29
Manassero, M., Decambron, A., Viateau, V., et al. (2014) Indwelling double pigtail
ureteral stent combined or not with surgery for feline ureterolithiasis: compli-
cations and outcome in 15 cases. Journal of Feline Medicine and Surgery 16,
623-630
Mazzafero, E. (2008) Complications of fluid therapy. Veterinary Clinics of North
America 39, 607-619
McCullough, P. (2008) Contrast-induced acute kidney injury. Journal of the Ameri-
can College of Cardiology 51, 1419-1428
Meldrum, K. (2016) Pathophysiology of urinary tract obstruction. In: Campbell-
Walsh Urology. Eds A. Wein, L. Kavoussi and A. Partin. Elsevier, Philadelphia,
PA, USA. pp 1089-1103
Mitchell, A., Jones, A., Tumlin, J., et al. (2010) Incidence of contrast-induced
nephropathy after contrast-enhanced computed tomography in the outpatient
setting. Clinical Journal of the American Society of Nephrology 5, 4-9
Muller, C., Meria, P. & Desgrandchamps, F. (2011) Long-term outcome of subcuta-
neous pyelovesical bypass in extended ureteral stricture after renal transplanta-
tion. Journal of Endourology 25, 1389-1392
Myburgh, J., Finfer, S., Bellomo, R., et al. (2012) Hydroxyethyl starch or saline for
fluid resuscitation in intensive care (CHEST Trial). The New England Journal of
Meidicine 367, 1901-1911
Nicoli, S., Morello, E., Martano, M., et al. (2012) Double-J ureteral stenting in nine
cats with ureteral obstruction. The Veterinary Journal 194, 60-65
Nissenkorn, I. & Gdor, Y. (2000) Nephrovesical subcutaneous stent: an alternative
to permanent nephrostomy. Journal of Urology 163, 528-530
Ordon, M., Schuler, T., Ghiculete, D., et al. (2013) Stones lodge at three sites of
anatomic narrowing in the ureter: clinical fact or fiction? Journal of Endourology
27, 270-276
Osborne, C., Lulich, J., Kruger, J., et al. (2008) Analysis of 451,891 canine uro-
liths, feline uroliths, and feline urethral plugs from 1981 to 2007: perspec-
tives from the Minnesota Urolith Center. The Veterinary Clinics of North America.
Small Animal Practice 39, 183-197
Palm, C. & Kanakubo, K. (2015) Renal replacement therapies. In: Small Animal
Critical Care Medicine. 2nd edn. Eds D. Silverstein and K. Hopper. Saunders
Elsevier, St Louis, MO, USA. pp 1059-1061
Pantaleo, V., Francey, T., Fischer, J., et al. (2004) Application of hemodialysis for
the management of acute uremia in cats: 119 cases (1993-2003). Journal of
Veterinary Internal Medicine 18, 418
Rivers, B., Walter, P. & Polzin, D. (1977) Ultrasound guided, percutaneous ante-
grade pyelography: technique and clinical application in the dog and cat. Journal
of the American Animal Hospital Association 33, 61-68
Roberts, S., Aronson, L. & Brown, D. (2011) Postoperative mortality in cats after
ureterolithotomy. Veterinary Surgery 40, 438-443
Salonia, A., Maccagnano, C., Lesma, A., et al. (2006) Diagnosis and treatment of
circmcaval ureter. European Urology Supplements 5, 449-462
Saltzman, B. (1998) Ureteral stents: indications, variations, and complications.
Urologic Clinics of North America 15, 481-491
Schmidbauer, J., Kratzik, C., Klingler, H., et al. (2006) Nephrovesical subcutaneous
ureteric bypass: long-term results in patients with advanced metastatic disease—
improvement of renal function and quality of life. European Urology 50, 1073-1078
Schreiner, G. F., Harris, K. P., Purkerson, M. L., et al. (1988) Immunological aspects
of acute ureteral obstruction: immune cell infiltrate in the kidney. Kidney Inter-
national 34, 487-493
Siegel, N. J., Feldman, R. A., Lytton, B., et al. (1977) Renal cortical blood flow dis-
tribution in obstructive nephropathy in rats. Circulation Research 40, 379-384
Silverstein, D. (2009) Daily intravenous fluid therapy. In: Small Animal Critical Care
Medicine. Eds D. Silverstein and K. Hopper. Saunders Elsevier, St Louis, MO,
USA. pp 271-275
Singh, A., Alter, H. & Littlepage, A. (2007) A systematic review of medical therapy to
facilitate passage of ureteral calculi. Annals of Emergency Medicine 50, 552-563
 D. L. Clarke
Speakman, C., Pechman, R. & D’Andrea, G. (1983) Aortic thrombosis and unilat-
eral hydronephrosis associated with leiomyosarcoma in a cat. Journal of the
American Veterinary Medical Association 182, 62-63
Steinhaus, J., Berent, A., Weisse, C., et al. (2015) Clinical presentation and out-
come of cats with circumcaval ureters associated with a ureteral obstruction.
Journal of Veterinary Internal Medicine 29, 63-70
Vaara, S., Korhonen, A., Kaukonon, K., et al. (2012) Fluid overload is associated with
an increased risk for 90-day mortality in critically ill patients with renal replace-
ment therapy: data from the prospective FINNAKI study. Critical Care 16, R197
Vaughan, D., Sweet, R. & Gillenwater, J. (1973) Unilateral ureteral occlusion: pattern
of nephron repair and compensatory response. Journal of Urology 109, 979-982
Wang, U., Wang, G., Hou, P., et al. (2015) Subcutaneous nephrovesical bypass:
treatment for ureteral obstruction in advanced metastatic disease. Oncology
Letters 9, 387-390
Wen, J., Frokiaer, J., Jorgensen, T., et al. (1999) Obstructive nephropathy: an
update of the experimental research. Urological Research 27, 29-39
Westropp, J., Ruby, A., Bailiff, N., et al. (2006) Dried solidified blood calculi in the
urinary tract of cats. Journal of Veterinary Internal Medicine 20, 828-832
Wheeless, C. & Roenneburg, M. (2005) Ureteroneoscystostomy and ureteroneo-
cystostomy with bladder flap. Atlas of Pelvic Surgery 66, 751-753
10 Journal of Small Animal Practice
Widmer, W., Biller, D. & Adams, L. (2004) Ultrasonography of the urinary tract
in small animals. Journal of the American Veterinary Medical Association 225,
46-54
Wilson, D. (1997) Renal function during and following obstruction. Annual Reviews
in Medicine 28, 329-339
Wormser, C., Philips, H. & Aronson, L. (2013) Retroperitoneal fibrosis in feline
renal transplant recipients: 29 cases (1998-2011). Journal of the American
Veterinary Medical Association 243, 1580-1585
Wormser, C., Clarke, D. & Aronson, L. (2016) Outcomes of ureteral surgery and
ureteral stenting in cats: 117 cases (2006-2014). Journal of the American Vet-
erinary Medical Association 248, 518-525
Yozova, I., Howard, J. & Adamik, K. (2016) Retrospective evaluation of the effects
of administration of tetrastarch (hydroxyethyl starch 130/0.4) on plasma cre-
atinine concentrations in dogs (2010-2013): 201 dogs. Journal of Veterinary
Emergency and Critical Care 26, 568-577
Zaid, M., Berent, A., Weisse, C., et al. (2011) Feline ureteral strictures: 10 cases
(2007-2009). Journal of Veterinary Internal Medicine 24, 660-795
Zotti, A., Poser, H. & Chiavegato, D. (2004) Asymptomatic double ureteral stricture
in an 8-month-old Maine Coon cat: an imaging based case report. Journal of
Feline Medicine and Surgery 6, 371-375
• © 2018 British Small Animal Veterinary Association