ttp://www.bsava.

com REVIEW

Feline ureteral obstructions

Part 2: surgical management
D. L. Clarke1

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

Feline obstructive ureteral disease will likely remain a common and frustrating cause of critical illness in
cats for the foreseeable future. Since many cats are uraemic and cardiovascularly unstable secondary to
obstructive nephropathy, prompt recognition using clinical intuition, blood work and diagnostic imaging
is essential to make a timely diagnosis and decision about timing for intervention, if indicated. Multiple
surgical and interventional procedures exist for the management of feline ureteral obstructions but
there is no ideal technique and all currently available procedures carry risk of infection, re-obstruction,
urine leakage and the need for additional procedures in the future. Therefore, until clear, evidence-
based guideline exist, the decision about which ureteral procedure to perform in cats should be guided
by nature of the obstruction, location, concurrent urolithiasis, infection and surgeon preference. In all
likelihood, ureteral surgery, stents and ureteral bypass devices will continue to remain viable options and
the decision about which procedure to use will be made on a case-by-case basis.

Journal of Small Animal Practice (2018) 59, 385–397

DOI: 10.1111/jsap.12861
Accepted: 26 September 2017; Published online: 20 May 2018

INTRODUCTION
Surgical management techniques have been traditional in the
management of ureteral obstructions in cats. Described tech-
niques include single or multiple ureterotolithotomies (ureterot-
omy/ureterotomies), ureteral resection and anastomosis, ureteral
reimplantation (ureteroneocystostomy), and ureteronephrec-
tomy (Kochin et al. 1993, Hardie & Kyles 2004, Kyles et al.
2005a, 2005b, Adin & Scansen 2011, Roberts et al. 2011, Culp
et al. 2016, Wormser et al. 2016). When a ureteral reimplanta-
tion is performed, if there is concern for tension on the ureter
upon retraction of the bladder, a renal descensus, which involves
dissection of the kidney from its retroperitoneal attachments for
increased caudal mobility, and cystopexy are techniques for ten-
sion relief described in conjunction with ureteral surgery (Kyles
et al. 2005a). Given the small size of the ureter in cats (1 mm
outer diameter, 0·4 mm luminal diameter), magnification (×8
to ×15) is often needing for surgery, making it technically chal-
lenging (Fig 9). In additional, instrumentation for microvascular
surgery, such as jeweler’s forceps, adventitial scissors and dissect-
ing (Pott’s) scissors, as well as small suture sizes ranging from
6-0 to 10-0, are needed for primary ureteral closure. Complica-
tions of ureteral surgery include oedema and inflammation caus-
ing re-obstruction, stricture, recurrence of obstructive calculi,
including migration of nephroliths, persistence of azotaemia and
urine leakage. Urine leakage is the most common complication
– reported in up to 16% of patients (Kochin et al. 1993, Hardie
& Kyles 2004, Kyles et al. 2005a, 2005b, Adin & Scansen 2011,
Roberts et al. 2011, Culp et al. 2016, Wormser et al. 2016).
Major postoperative complication rates in cats are reported to be
as high as 31% and mortality rates for cats undergoing ureteral
surgery are reported to be as high as 21% (Kyles et al. 2005b,
Adin & Scansen 2011, Roberts et al. 2011, Wormser et al. 2016).
Given the equipment, expertise and complications associated
with ureteral surgery, especially in cats, alternative techniques for
decompression of ureteral obstruction warrant consideration and
investigation.
Novel surgical techniques for dealing with ureteral obstruc-
tions have also been described. A 2011 case report of a 10-year-old
female spayed cat with multiple mid- and distal ureteral calculi
and a ureteral stricture distal to the lodged calculi that could not
be addressed with standard surgical techniques described a novel

Journal of Small Animal Practice • Vol 59 • July 2018 • © 2018 British Small Animal Veterinary Association 385
 D. L. Clarke
FIG 9. Operating microscope image during a feline ureterotomy (a) and
primary repair of the ureter (b)
intestinal graft technique. A vascularised segment of ileum was
sterilised with dilute povidone-idodine and attached to the prox-
imal dilated ureter and apex of the bladder (Brourman 2011).
Postoperative intravenous pyelonephrography confirmed patency
of the ileal graft and improvement in renal pelvis distension. The
cat had normalisation of its renal values by 3 days postoperatively
and was discharged. The cat developed a urinary tract infection
with Staphylococcus species, which was managed with antimicro-
bial therapy. At more than 3 years postoperatively the cat was
reported to be doing well clinically (Brourman 2011). It is not
clear from the case report whether or not there was enough length
of ureter proximal to the stricture location to have utilised ure-
teral reimplantation with or without concurrent renal descensus.
Use of flexible endoscopy for the retrieval of an obstructing
ureterolith has also been described in 9-year-old spayed female
cat (Kuntz 2005). The cat had a large ureterolith approximately
4 cm distal to the renal pelvis and marked uraemia. A 14-gauge
needle was used to create a tract through the renal parenchyma
and into the renal pelvis to facilitate passage of a flexible uretero-
scope. Once the stone was visible, the scope was removed and
exchanged for endoscopic grasping forceps which, along with
external digital pressure on the ureter, was used to grasp the stone
and extract it through the renal pelvis access site (Kuntz 2005).
The cat’s uraemia improved in response to removal of the calcu-
lus, though the cat died under anaesthesia during MRI to inves-
tigate the cause of seizures at 4 months postoperatively.
386 Journal of Small Animal Practice • Vol 59 • July 2018 • © 2018 British Small Animal Veterinary Association
A recent case report described the use of a modified Boari
flap for a cat with a proximal ureteral obstruction suspected to
be secondary to stricture, as no intraluminal filling defect was
found (Aronson et al. 2016). The Boari flap has been described
in human patients requiring ureteral reconstruction and involves
the creation of a tube from a bladder flap that extends to and is
attached to the ureteral orifice (Wheeless & Roenneburg 2005).
In this case, non-specific clinical signs of azotaemia, decreased
appetite, vomiting and abdominal pain prompted abdominal
ultrasonography and, ultimately, anterograde pyelography, which
confirmed proximal ureteral narrowing and obstruction. To per-
form the modified Boari technique, a bladder flap was created
from the ventral bladder. The ureter was transected proximal
to the obstruction, attached to the bladder flap and closed in
a simple interrupted pattern. The technique was reported to be
straightforward and did not result in tension on the ureteroneo-
cystotomy site. The cat’s azotaemia and imaging evidence of ure-
teral obstruction resolved and that cat continued to do clinically
well at the time of its 7-month postoperative last follow-up time
point (Aronson et al. 2016).
URETERAL STENTING
The earliest reports of ureteral stenting in people were as early as
1915, where stents were used to facilitate healing after ureteral sur-
gery (Davis et al. 1948, Adin & Scansen 2011). Cystoscopic ureteral
stenting was first reported in people to relieve a ureteral obstruction
secondary to ureteroliths in 1967 (Gibbons et al. 1974). Since that
time, multiple design iterations, including introduction of the “Dou-
ble J” configuration, which was designed to prevent migration into
the kidney and bladder in 1978 (Finny 1978). Indwelling ureteral
stents cause passive dilation of the ureter within the days to weeks
after placement, facilitating stone passage and urine drainage (Berent
2011, Adin & Scansen 2011, Lennon 1997, Betschart 2017). In
human urology, ureteral stents are most commonly used after ure-
terolith intervention, such as ureteroscopy and extracorporeal shock-
wave lithotripsy (SWL; Haleblian et al. 2008). Other indications are
ureteral stricture and obstruction secondary to neoplasia (Saltzman
1998, Lange et al. 2015). Complications associated with indwell-
ing ureteral stents in people include dislodgement, infection, stent
encrustation, discomfort, reflux of urine, haematuria and increased
urinary urgency (Denstedt & Cadieux, 2009, Lange et al. 2015,
Christopher et al. 2016, Saltzman 1998). Due to these complications
and associated morbidity, ureteral stents in people are generally used
as a short-term implant or exchanged regularly due to infection and
encrustation concerns (Saltzman 1998, Lange et al. 2015).
Two of the most common indications for ureteral stents in
people are after ureteroscopy and SWL. However, in cats, SWL
is not currently recommended because the stone size that results
from the treatment – generally approximately 1 mm – is still too
large to pass down the normal feline ureter given its 0·4 mm
diameter (Adams et al. 2005, Adams & Goldman 2011, Adams
2013). In addition, calcium oxalate stones are more resistant to
shockwave treatment (Adams et al. 2005). Ureteroscopy is not
possible in cats due to small ureteral size.
 Feline ureteral obstructions II
In cats, ureteral stents have been described for the manage-
ment of ureterolithiasis, dried solidified blood stones, ureteral
strictures, intraluminal bypass to facilitate healing after ureteral
surgery or trauma, and neoplasia (Berent 2011, Zaid et al. 2011,
Berent et al. 2012, Nicoli et al. 2012, Horowitz et al. 2013,
Kulendra et al. 2014, Manassero et al. 2014, Steinhaus et al.
2015, Culp et al. 2016, Wormser et al. 2016). Both temporary
and long-term use are described for veterinary patients, which is
in contrast to most uses in humans. Benefits of ureteral stenting
include passive ureteral dilation and ability to remove if infection
or irritation become concerns. Most ureteral stents are made of
multi-fenestrated polyurethane and have a double pig-tail con-
struction such that one coil is placed in the renal pelvis and one is
placed in the bladder to guard against migration. Stent length is
described as the distance between both pig-tail coils-also known
as the shaft length. The diameter of the pig-tail coil varies with
stent size and manufacturer. They are placed over a hydrophilic
wire, the size of which is based on the ureteral stent diameter
intended for use (Table 2). Ureteral stents designed for humans
can be used in dogs, but are often too large for the small feline
ureter (luminal diameter of 0·4 mm and external diameter of 1
mm) (Kochin et al. 1993, Roberts et al. 2011). Ureteral stents
optimised for the feline ureter are commercially available in a
2+ French diameter, which is slightly larger than 2 French, and
are available in 12, 14 and 16 cm lengths (Infiniti medical Vet-
Table 2. Ureteral stent diameters and corresponding
compatible wire and catheter sizes
Intravenous Wire size* Ureteral catheter Ureteral stent size*
catheter size (g) size* (French)
24 ≤0·018 3 2+ French (Infiniti
Medical), 3 French
22 ≤0·018 3 2+ French (Infiniti
Medical), 3 French
20 ≤0·025 4 3·7 French
18 ≤0·035 5 4·7 French, 6
French, 7 French
16 ≤0·038 6 6 French, 7 French
Always confirm catheter, stent, dilator, and wire compatibility for a given brand
*Ensure ureteral dilator and stent are tapered to the chosen wire size to prevent gapping
and tissue trauma. Adapted with permission from Degner & Clarke (2015)
FIG 10. Appropriately sized ureteral stent in a cat spanning from the
renal pelvis to mid-bladder, such that the stent coil positioning within the
trigone is avoided since that may worsen irritation
Journal of Small Animal Practice • Vol 59 • July 2018 • © 2018 British Small Animal Veterinary Association 387
Table 3. General equipment list for feline ureteral stent
and SUB interventions
Surgical anterograde ureteral stenting Ureteral bypass (SUB) placement
Intraoperative fluoroscopy Intraoperative fluoroscopy
Routine laparotomy surgical set Routine laparotomy surgical set
and drapes, including right angle and drapes, including right
(Mixter) forceps angle (Mixter) forceps
22 g over-the-needle intravenous 18 g over-the-needle intravenous
catheter catheter
Angled hydrophilic wires (0·018ʺ) Angled hydrophilic wires (0·035ʺ)
Ureteral stent with dilator (2+ to 3 Feline SUB kit (Norfolk Veterinary
French) Products) which includes 0·035ʺ
J-tipped wire, 6·5 French locking
loop nephrostomy catheter,
6·5 French cystotomy catheter,
body wall port with blue boot
adapters, Huber needles
Iodinated contrast Sterile cyanoacrolate glue
±Open-ended ureteral catheter Iodinated contrast
(3 French).
Stent Ureter feline ureteral stent). They are also made of a tem-
perature-sensitive polymer that is stiffer at room temperature to
facilitate placement and softens at body temperature for patient
comfort (Infiniti Medical Thermo-Star Adaptive polymer). Ure-
teral stents made specifically for veterinary patients are also pack-
aged with a combined pusher/dilator, with one end tapered to
the appropriate wire diameter to facilitate ureteral dilation and
the other end cut straight to sit flush against the caudal end of
the stent while pushing the stent through a cystoscope or vascular
sheath (Infiniti medical Vet-Stent Ureter feline ureteral stent).
The selected ureteral stent length is based on the distance from
the renal pelvis to the bladder, with a small additional length
(2 to 4 cm) to allow the stent to curve comfortably towards the
bladder apex, directing the coil away from the trigone in order
to minimise trigonal irritation (Fig 10). The necessary length can
be approximated preoperatively with abdominal radiographs or
intraoperatively using a marker catheter placed with the colon,
direct measurement of the ureter length with a sterile ruler or
extrapolation of wire or catheter length needed to span ureter
from the renal pelvis to the bladder. Intraoperative fluoroscopy
is essential for ureteral stenting, especially for the initial antero-
grade pyelogram and for final positioning of the stent coil within
the renal pelvis. Additional equipment for feline ureteral stenting
is listed in Table 3.
Ureteral stenting in cats is more challenging than in dogs due
to the small size of the feline ureter. Retrograde cystoscopic place-
ment has been described in female cats, but is extremely difficult
and requires diffuse ureteral dilation since digital manipulation and
assistance for ureteral dilation and stent passage is not possible (Zaid
et al. 2011, Berent et al. 2012, Kulendra et al. 2014). Percutaneous
anterograde stenting is also rarely performed in cats. Therefore, for a
comprehensive discussion on cystoscopic and percutaneous antero-
grade ureteral stent placement, the reader is directed to sources on
canine ureteral stenting utilising these techniques.
The vast majority of cats require laparotomy for ureteral
stent placement, which can be performed in both a retrograde
or anterograde fashion, though anterograde surgical placement
is preferred (Berent et al. 2012, Culp et al. 2016, Wormser et al.
 D. L. Clarke

2016). Ureterotomy to facilitate stone removal and aid in wire

and stent passage may be necessary, regardless of whether an
anterograde or retrograde approach is used (Berent et al. 2012,
Kulendra et al. 2014, Culp et al. 2016). In both approaches, dila-
tion with the tapered end of the provided 0·034ʺ pusher/dilator
of any normal diameter ureter is often needed to facilitate stent
placement. This is due to the fact that even the smallest available
stents for cats, which are 2+ French in diameter (less than 1 mm
outer diameter, 3 French = 1 mm), are still more than twice the
diameter of the normal internal diameter of the feline ureter (0·4
mm) (Kochin et al. 1993, Roberts et al. 2011, Berent et al. 2012,
Culp et al. 2016, Wormser et al. 2016, Infiniti medical Vet-Stent
Ureter feline ureteral stent). Patience and gentle tissue handling
are essential for feline ureteral stent placement. In cases where
there is marked ureteritis, the ureter can be tortuous, making
wire passage challenging and increases the risk of wire perforation
through the ureter. Gentle digital manipulation of the ureter, cra- FIG 11. Access to the renal pelvis in a cat via puncture of the greater
curvature with a 22 guage over-the-needle catheter
nial retraction of the kidney and caudal retraction of the bladder
can help straighten the ureter and aid wire and stent passage.
Anterograde ureteral stenting via direct puncture of the renal
pelvis is often preferred in cats due to the ability to have wire
access through both the kidney and bladder, which facilitates
ureteral dilation and stent passage and positioning. The greater
curvature of the affected kidney is cleared of its retroperitoneal fat
using right angle forceps, cotton-tipped applicators and bipolar
cautery. Access to the renal pelvis is performed with a 22-gauge
over-the-needle catheter and urine is collected for culture/sen-
sitivity testing directly from the pelvis (Fig 11). Dilute (50:50)
iodinated contrast agent is injected into the renal pelvis under
fluoroscopic guidance to delineate the renal pelvis and identify
the location of the ureteral obstruction (Fig 12). A specialised
0·018ʺ×50 cm length angled hydrophilic wire is made specifically
for feline ureteral stenting and is far less cumbersome than tradi-
tional 150-cm hydrophilic wire lengths in small patients (Infiniti
Medical 0·018ʺ×50 cm angled hydrophilic wire). The wire is
passed down the ureter, using fluoroscopy and digital guidance
as needed until the wire is passed through the UVJ and into the
bladder. If the ureter is tortuous, meticulous dissection of the ure-
ter can allow digital manipulation and straightening to aid wire
passage. As previously mentioned, concurrent ureterotomy may
also be needed to facilitate wire passage. With ureteral disease, FIG 12. Intraoperative ureteropyelogram in a cat showing marked
even a small diameter angled-tip hydrophilic wire can perforate proximal ureteral narrowing suggestive of a ureteral stricture
the ureteral wall, so care must be taken during wire passage. A
1 to 2 cm, ventral, distal mid-line cystotomy is made, exercis- kidney and down the ureter. The wire is passed out of a side fenes-
ing caution not the transect the wire. Once the wire is visible in tration of the stent at the kidney coil, not out at the distal end, so
the bladder, it is secured at the kidney access site and cystostomy as to see the coil’s appropriate position in the renal pelvis (Fig 14).
access with haemostats to prevent loss of access to the urinary Once the kidney coil is contained within the renal pelvis and stent
tract (Fig 13). Stent length is chosen based on the length of ureter appropriately positioned within the bladder, the wire is removed.
with an additional 2 to 4 cm of stent length to allow appropriate The renal access site through the renal capsule generally does not
positioning in the bladder. The tapered dilator end of the pusher/ need to be sutured. The bladder is closed routinely, being cautious
dilator can be advanced anterograde through the kidney and retro- not to suture the stent into the cystotomy closure. Routine use of
grade through the bladder as needed to facilitate ureteral dilation abdominal drains is not required. The use of urethral catheters is
and stent passage. If necessary, a small incision with a no. 11 blade controversial, as they could increase the risk of ascending urinary
over the ureteral papilla (papillotomy) may be needed to facilitate tract infections but do allow for more accurate monitoring of urine
passage of the dilator anterograde (Manassero et al. 2014). Once production. Lateral and ventrodorsal images are taken with fluo-
the ureter is dilated, the stent is passed over the wire, through the roscopy to confirm final ureteral stent positioning.

388 Journal of Small Animal Practice • Vol 59 • July 2018 • © 2018 British Small Animal Veterinary Association
 Feline ureteral obstructions II

FIG 13. Passage of the 0·018ʺ angled hydrophilic wire though the
ureteral papilla and externalised through a ventral cystotomy

FIG 15. Retrograde-placed hydrophilic wire in the renal pelvis of a cat

FIG 14. Wire passage out of a side fenestration, allowing coiling of the
kidney end of the ureteral stent, which allows confirmation of proper
stent placement in the renal pelvis

For retrograde ureteral stent placement, a ventral distal cys-

totomy and urethrotomy is performed to identify the ureteral
papillae, which are located in the feline proximal urethra. The
ureteral opening is cannulated with a 0·018ʺ angled hydrophilic
wire and advanced retrograde into the distal ureter. Since passage
of a 3 French ureteral catheter is often challenging in a normal
diameter distal feline ureter, the tapered end of the pusher/dila-
tor can be advanced into the distal ureter, and wire removed, FIG 16. Retrograde ureteral stent placement in a cat
to facilitate a retrograde ureteropyelogram through the open
end of the pusher/dilator. Using a retrograde approach in cats,
it often not possible to collect urine from the renal pelvis and dilated, the stent is passed retrograde over the wire and coiled
ureter before infusion of iodinated contrast agent, which is bac- in the renal pelvis (Fig 16). After confirming appropriate posi-
teriostatic. Using fluoroscopic guidance, with straightening of tioning of the stent within the renal pelvis, the wire is removed.
the ureter and/or ureterotomy as needed, as well as care not to The bladder and proximal urethra are carefully closed routinely
perforate the ureteral wall with the wire, the wire is advanced to ensure the stent is not entrapped and the contralateral ureteral
into the renal pelvis and coiled (Fig 15). The ureter is dilated as papilla is not inadvertently incorporated into the closure. Lateral
needed with the provided pusher/dilator, being careful to not lose and ventrodorsal images are taken with fluoroscopy to confirm
wire access during exchanges and manipulation. Once adequately final ureteral stent positioning.

Journal of Small Animal Practice • Vol 59 • July 2018 • © 2018 British Small Animal Veterinary Association 389
 D. L. Clarke

Intraoperative complications during ureteral stenting include

the need for multiple pyelocentesis attempts, need for ureterotomy
to facilitate wire or stent passage, ureteral tearing during dilator
advancement, stent migration out of the nephrostomy access site,
need for papillotomy (up to 40% of cases), ureteral perforation
by the guidewire (up to 17% of cases) and urine leakage from the
pyelocentesis, ureterotomy or cystotomy incisions (Berent et al.
2012, Kulendra et al. 2014, Manassero et al. 2014, Culp et al.
2016, Wormser et al. 2016). Postoperative complications include
urine leakage and uroabdomen (up to 8·7%), stent positioning in
the renal parenchyma, pollakiuria and stranguria, congestive heart
failure, pancreatitis, hepatic lipidosis, anaemia requiring packed
red blood cell transfusion and cardiac arrest. (Berent et al. 2012,
Kulendra et al. 2014, Manassero et al. 2014, Wormser et al. 2016).
Culp et al. (2016) documented that cats undergoing ureteral stent-
ing were more likely to have resolution of their azotaemia (62%)
at the time of discharge as compared to historic ureteral surgery
FIG 17. Ureteral stent migration into the bladder of a cat
control patients (31%). In the five published studies on ureteral
stenting in cats, 75 to 92% of cats were discharged from the hos-
pital after a median stay of 4 to 6 days (range = 1 to 19 days).
When evaluating published survival times from four of the studies,
median survival time was 514 to 742 days (range = 2 to 2800 days)
(Berent et al. 2012, Kulendra et al. 2014, Manassero et al. 2014,
Culp et al. 2016, Wormser et al. 2016).
Long-term complications include re-obstruction, stent migra-
tion, encrustation, ureteritis, infection and urinary tract irritation
(Figs 17 and 18). In cats, poststent infection and lower urinary
tract symptoms, including haematuria, stranguria, pollakiuria,
have been reported in 18 to 37·7% of cats (Berent et al. 2012,
Nicoli et al. 2012, Wormser et al. 2016). For most cats, lower
urinary tract irritation was transient and could be medically man-
aged with a combination of corticosteroids, prazosin and analge-
sics, though 2 to 40% of cats were documented to have signs for
long periods (Berent et al. 2012, Wormser et al. 2016). Some cats
had such severe lower urinary tract irritation that stent modifica-
tion (trimming), exchange, removal or conversion to a ureteral
bypass device was necessary (Berent et al. 2012, Kulendra et al.
2014, Manassero et al. 2014, Wormser et al. 2016). In Wormser’s
study comparing ureterotomies and ureteral stents in cats, 11%
of cats had chronic lower urinary infections, with the incidence of
infection significantly greater in those with ureteral stents (26%)
compared to those who underwent ureteral surgery alone (2%).
In the same study, the proportion of cats with chronic lower uri-
nary tract signs was significantly higher in stented cats (37%)
than those without stents (2%). However, when evaluating the
overall 22% re-obstruction rate in this study (19/87 cases), which
occurred at a median of 203 days (range = 22 to 3650 days) from
FIG 18. Encrusted feline ureteral stent that required stent exchange
the initial procedure, there was no significant difference between
re-obstruction in stent cats (10%) and those for which ureteral
surgery alone was performed (11%) (Wormser et al. 2016). imal third of the ureter (46·9% versus 85%). Ureteral stricture was
In Berent’s study (2012) on feline ureteral stent patients, ure- identified in 22/79 (28%) of cases in this study and were attrib-
teral stent exchange was required in 27% of cases for migration, uted to previous ureteral surgery or circumcaval ureteral course.
irritation or occlusion, which was the most common indication The vast majority of these were located in the right ureter within
for exchange. Significant risk factors identified for predicting 1 to 3 cm of the ureteropelvic junction. This is consistent with
need for stent exchange were urinary tract infection after ureteral one of risk factors for stent exchange, as this was likely a stricture
stent placement (18% versus 57·9%) and obstruction in the prox- location and therefore passive ureteral dilation did not occur in

390 Journal of Small Animal Practice • Vol 59 • July 2018 • © 2018 British Small Animal Veterinary Association
 Feline ureteral obstructions II
the abnormal segment of ureter. Strictures in this population were
based on imaging diagnosis; no histopathology was performed.
NEPHROVESICAL SUBCUTANEOUS URETERAL
BYPASS/ARTIFICIAL URETERS IN HUMANS
The creation of a subcutaneous ureteral bypass (SUB) was first
described by Desgrandchamps in 1995 for human patients with
ureteral obstructions secondary to urinary tract malignancies as an
alternative to palliative permanent nephrostomy tube placement
(Desgrandchamps et al. 1995). The original subcutaneous (SC)
pyelovesical bypass graft (SPBG) called Detour described by Des-
grandchamps consisted of a Teflon nephrostomy tube that tunnelled
subcutaneously between the kidney and bladder. Since Desgrand-
champs’ original 21-patient case series documenting technical suc-
cess, relief of hydronephrosis and improved patient quality of life,
additional case studies have described its use for urinary tract and
pelvic malignancies. Reported complications in patients with pel-
vic malignancies include urinary reflux, occlusion and encrustation
requiring device exchange, single episode urinary tract infections
and recurrent urinary tract infections (Nissenkorn & Gdor 2000,
Schmidbauer et al. 2006, Desgrandchamps et al. 2007, Wang et al.
2015). However, since many of the patients in these case series had
terminal cancer, long-term follow-up was limited.
One of the most common urinary tract complications sec-
ondary to renal transplantation in people is the development of
ureteral stricture, most often diagnosed in the distal segment of
the ureter (Andoinian et al. 2005). Treatment strategies include
balloon dilation, ureteral stenting, nephrostomy tube placement,
ureteroneocystostomy, anastomosis to the native ureteral and
intestinal grafting techniques (Andoinian et al. 2005, Wheeless &
Roenneburg 2005). If these options do not successfully resolve the
stricture and ureteral obstruction, the use of nephrovesical SUB
(Detour) has also been described for renal transplant recipients,
with similar success rates for up to 15 years (Jabbour et al. 2001,
Desgrandchamps et al. 2007, 2008, Azhar et al. 2010, Haddad et
al. 2013). However, urinary tract infection, Candida species posi-
tive urine cultures, fungal ball occlusion, stone occlusion, encrus-
tation and death secondary to fungal infection-induced septic
shock have been described in association with the device. (Burgos
et al. 2009, Gerullis et al. 2010, Muller et al. 2011, Wilhelm et
al. 2014). Patients are advised to increase their water intake and
intermittently compress the subcutaneous tubing to help prevent
obstructions. Current human recommendations are that the SPBG
be used for allograft salvage when open surgery has failed or is con-
traindicated, and for patients with terminal pelvic malignancies in
whom the quality-of-life implications of permanent nephrostomy
tubes are deemed unacceptable (Nissenkorn & Gdor 2000, Jab-
bour et al. 2001, Haddad et al. 2013).
SUBCUTANEOUS URETERAL BYPASS
Given the challenges of feline ureteral obstructions, especially
with regard to small ureteral size, surgical complications, diffi-
Journal of Small Animal Practice • Vol 59 • July 2018 • © 2018 British Small Animal Veterinary Association 391
culty of placing ureteral stents in an undilated ureter and dys-
uria associated with ureteral stents in cats, an adaptation of a
human SPBG was developed (https://www.google.com/patents/
US20120157833). The device involves the use of a locking loop
nephrostomy catheter and a multi-fenestrated cysostotomy cath-
eter, each of which is attached to a SC shunt port secured to the
ventrolateral body wall (Norfolk Veterinary Product’s Subcutane-
ous Ureteral Bypass [SUB] System).
Placement of a SUB device requires ventral midline lapa-
rotomy, with additional clipping and aseptic preparation of
the ventrolateral abdomen as compared to routine preparations
(Table 3). Retroperitoneal fat is dissected away from the caudal
pole of the kidney using cotton-tipped applicators, cautery and
sharp and blunt dissection to facilitate access to the renal pelvis
and direct attachment of the Dacron cuff of the nephrostomy
catheter to the renal capsule. Access to the renal pelvis is per-
formed with an 18-gauge over-the-needle catheter and urine is
collected for culture/sensitivity testing, as with anterograde access
for ureteral stenting (Fig 11). Dilute (50:50) iodinated contrast
agent is injected into the renal pelvis under fluoroscopic guid-
ance to delineate the renal pelvis and identify the location of the
ureteral obstruction (Fig 12). A 0·035ʺ angled hydrophilic wire
or 0·035ʺ J-tip wire is advanced into the catheter under fluoros-
copy and positioned within the renal pelvis (Fig 19). Extreme
care must be taken during manipulation of this large wire to pre-
vent inadvertent passage out of the renal pelvis into the paren-
chyma, which can cause haemorrhage and urine leakage. The 6·5
French locking loop nephrostomy catheter is flushed completely
with saline, and advanced over the wire, again ensuring the wire
does not perforate the renal pelvis. The nephrostomy catheter
has a radio-opaque black band, the distal aspect of which must
FIG 19. J-tipped 0·035ʺ wire in the renal pelvis of a cat undergoing SUB
placement
 D. L. Clarke
FIG 20. Black band of the nephrostomy catheter contained within the
renal pelvis
FIG 21. Subcapsular contrast leakage due to inadvertent renal pelvis
perforation during placement of the nephrostomy catheter
be fully seated within the pelvis to prevent parenchymal and sub-
capsular leakage of urine (Fig 20). Once positioned within the
renal pelvis, the string lock of the nephrostomy catheter is gen-
tly pulled to create a locked loop within the pelvis and secured
with a haemostat on the suture without damaging the distal end
of the nephrostomy catheter. Care must be taken to not over-
tighten the locking loop, which will occlude the nephrostomy
392 Journal of Small Animal Practice • Vol 59 • July 2018 • © 2018 British Small Animal Veterinary Association
drainage holes located on the inner surface of the loop. A repeat
contrast study is performed through the nephrostomy catheter to
ensure appropriate pelvic positioning, closure of the locking loop
and no subcapsular contrast leakage caused by perforation of the
renal pelvis (Fig 21). Once appropriate position is confirmed,
the Dacron cuff on the catheter is pushed distally to contact the
renal capsule and secured to the renal capsule with sterile cyano-
acrolate glue (Gluture, World Precision Instruments). For place-
ment of the cystostomy catheter, a purse-string suture is placed
in the ipsilateral apex of the bladder, followed by a stab inci-
sion with a number 11 blade. The nephrostomy catheter is fully
flushed, and the sharp stylette is secured via Luer-lock for expo-
sure out of the distal tip of the cystostomy catheter. The catheter
is advanced into the bladder lumen, followed by removal of the
sharp stylette. A similar radio-opaque band is positioned on the
cystostomy catheter, which must be contained within the bladder
to prevent leakage. Four simple interrupted sutures are placed
through the silicone disk and into the bladder mucosa, equidis-
tant around the disk. Sterile glue is use to secure the Dacron cuff
to the external bladder surface between each suture placement.
SC tissues are dissected away from the body wall to facilitate two
trans-abdominal stab incisions for passage of the nephrostomy
and cystostomy catheters into the SC space. The nephrostomy
catheter connects to the caudal barb of the shunting port and
the cystostomy catheter connects to the cranial barb. The port is
positioned on the ventrolateral body wall in such a location that
both catheters are not kinked as they are passed through the body
wall and have 2 to 3 finger widths between the port site and body
wall entry site. Both blue connector boots are positioned on each
catheter. Each catheter is connected to the barbs of the shunting
port. The suture from the nephrostomy catheter is cut after posi-
tioning the catheter on the first rung of the barb to prevent urine
leakage. Once the catheters are positioned on the barbs, the blue
boots are advanced over the catheter/barb connection for added
security. The patency of the system and confirmation of no leak-
ing is performed with a contrast study through the port using a
Huber needle. The abdomen is closed routinely, exercising care
not to incorporate the catheters into the incision. Local analgesia
with bupivacaine is applied as a splash block in the SC space
before closure. Once the abdomen is closed with the appropri-
ate catheter positioning, no kinks are confirmed with lateral and
ventrodorsal fluoroscopic images (Figs 22 and 23).
The use of the SUB device has been described in three case
series, one case report, and in an abstract (Horowitz et al. 2013,
Berent et al. 2014, Johnson et al. 2015, Steinhaus et al. 2015).
In the case report by Johnson et al. (2015), a 17-week-old spayed
female sphinx was evaluated for anorexia, vomiting and lethargy
3 weeks after ovariohysterectomy. Iatrogenic left ureteral ligation
was suspected at surgery based on the appearance of scar tissue
at surgery. A SUB device relieved the hydroureter and hydrone-
phrosis, and the kitten was reported to be doing well during the
16-month follow-up period aside from two Enterococcus faecalis
urinary tract infections (Johnson et al. 2015). In Horowitz et al.
(2013)’s study evaluating outcomes of cats undergoing ureteral
stenting versus SUB placement, six of seven perioperative com-
plications were associated with the SUB device and included
 Feline ureteral obstructions II

FIG 23. Kinked SUB nephrostomy catheter as seen on immediate

postoperative fluoroscopy

FIG 24. A SUB nephrostomy catheter removed because of blood clot occlusion

to be significantly associated with outcome, which is the first

FIG 22. Complete SUB system in place in ventrodorsal (a) and lateral (b)
projections.
nephrostomy tube leakage, leakage around the SUB port, neph-
rostomy tube migration and occlusion of the SUB with a blood
clot (Fig 24). Four cats (10%) had long-term complications. All
four were cats with ureteral stents had previously described ure-
teral stent complications. Overall, cats treated with ureteral stents
or SUBs had an 88% survival to discharge rate and no episodes
of re-obstruction. Interestingly, fluid overload was documented
time this has been documented in cats with ureteral obstructions
(Horowitz et al. 2013). In the Steinhaus et al. (2015) case series,
outcome was similar for SUB and stent cats, but the SUB device
obstructed significantly less often (8%) as compared to ureteral
stents (44%) in cats with obstructed circumcaval ureters. How-
ever, there was no discussion of how or why a given device was
chosen for each cat.
A 2016 abstract detailed the short- and long-term results of 137
cats with 174 obstructed ureters treated with the SUB device for
ureterolithiasis, ureteral strictures, combined strictures and ure-
teroliths and obstructive pyonephrosis (Berent et al. 2014). While
placement was successful in all cats, reported perioperative com-

Journal of Small Animal Practice • Vol 59 • July 2018 • © 2018 British Small Animal Veterinary Association 393
 D. L. Clarke
plications included blood clot occlusion (7·5%) (Fig 24), kinking
(5%) and urine leakage (3·4%). There was an 8·2% rate of dys-
uria at any time point. Interestingly, over time (median 364 days),
catheter occlusion with mineral debris occurred in 25% of cases,
with only 13% of cases requiring an exchange of the system due to
clinically significant re-obstruction (Berent et al. 2014). The low
percentage of clinically significant re-obstructions, despite the high
rate of mineral debris occlusion suggests restoration of urine flow
down the native ureter over time. Stricture accounted for 13%
of the stents placed, and stone/stricture combination accounted
for 20% of the cases, which argues that at least a portion of the
cats with a stricture developed patency of their ureter over time
without specific intervention aside from an alternative course for
urine flow. If this is true, it is possible that these ureteral strictures
are not permanent inflammatory ureteral changes, but are instead
temporary narrowings that can resolve or improve.
Recently, a case series of 13 cats that received a combination
of ureteral surgery and 19 SUB devices described placement of
the device without fluoroscopic guidance (Livet et al. 2016).
The only described intraoperative complication was kinking
of the nephrostomy catheter. Postoperatively, SUB obstruction
occurred in one cat. A total of five cats (two SUB cats and three
surgery cases) died in the perioperative period, which is higher
than expected (Livet et al. 2016). Given the challenges of posi-
tioning the wire in the renal pelvis while avoiding perforation of
the pelvis, especially in less-dilated renal pelvises, need for confir-
mation of appropriate locking loop morphology and positioning
(Fig 19), as well as inability to confirm system leaking or kinking
prior to completion of surgery (Figs 20 and 21), placement of this
device without intraoperative fluoroscopy is not recommended.
In addition, for small renal pelvises, the SUB catheter can be
placed in the proximal ureter using an 0·035ʺ angled hydrophilic
wire instead of the renal pelvis, without use of the locking string.
However, this cannot be accomplished without image guidance.
URETERAL OBSTRUCTION DECISION-MAKING
At this time, no clear-cut guidelines exist for when to use which
surgical or interventional options for feline ureteral obstructions
requiring definitive treatment. Important considerations include
nature and location of the obstruction, severity of patient illness,
concurrent nephrolithiasis, comorbidities, surgeon preference
and equipment availability. Regardless of the technique, appro-
priate training and procedural comfort is essential for successful
outcomes given the challenges of feline ureteral disease.
Uraemia-thrombopathia is well described in human patients
with acute kidney injury and is a major cause of morbidity and
mortality (Horl 2010, Lee et al. 2010, Kim et al. 2015). This
phenomenon is suspected, but not proven, in veterinary patients,
especially in cats, since there is conflicting data on an appropri-
ate reference range for platelet function assays and the decreased
utility of buccal mucosal bleeding time with concurrent anaemia.
Since bleeding into the SUB nephrostomy catheter is a described
complication of the procedure, the severity of azotaemia and inci-
dence of bleeding in patients undergoing ureteral interventions
394 Journal of Small Animal Practice • Vol 59 • July 2018 • © 2018 British Small Animal Veterinary Association
is currently being investigated. In addition, for cats with marked
elevation in their creatinine (>8 mg/dL), 1 mcg/kg desmopres-
sin given subcutaneously 30 minutes before surgical or interven-
tional procedures in attempt do decrease haemorrhage may be
considered.
In Wormser et al. (2016)’s study, nephroliths were present in
32% of cases and renal mineralisation was detected in 18% of
cats. In Berent et al. (2012)’s case series, of 69 cats treated with
ureteral stents, 85% had at least one nephrolith. Since passage
of nephroliths into the ureter has been documented to occur in
cats undergoing ureteral surgery, significant concern exists for
immediate and delayed re-obstruction by a nephrolith (Kyles et
al. 2005b). For such cases, this information must be incorporated
into the discussion with clients regarding which surgical or ure-
teral intervention is chosen because of the risk of re-obstruction.
There is an approximately 22% risk of re-obstruction with stents
or ureteral surgery and preliminary abstract data shows obstruc-
tion of the SUB device in approximately 25% of cats, though
only 13% required intervention. Therefore, regardless of the sur-
gical or interventional option chosen, the risk for recurrence of
the obstruction exists, and the client must be counselled about
the potential need for additional procedures in the future (Berent
et al. 2012, Wormser et al. 2016).
In cats that can have their ureteral obstruction addressed by
ureterotomy or re-implantation, without concurrent nephroli-
thiasis, ureteral surgery continues to be a reasonable and endur-
ing option if appropriately trained individuals and equipment is
available.
In cats with concurrent urinary tract infection or those at risk
for recurrent infections, such as cats previously treated with peri-
neal urethrostomy, a stent may be preferable to a SUB since the
intraluminal bypass device can be readily exchanged in the event
of chronic infection or biofilm.
For cases of proximal ureteral obstruction, whether by stone or
stricture that are not amenable to surgical intervention, the SUB
device may be preferable to a ureteral stent in cats to avoid the
challenge of traversing the length of normal, non-dilated feline
ureter. However, it is important to note that stents have been used
successfully for ureteral strictures in several published reports, so
may still be considered a viable option for intervention in this
group of cats (Zaid et al. 2011, Berent et al. 2012, Horowitz et
al. 2013, Kulendra et al. 2014, Steinhaus et al. 2015). SUBs may
also be indicated in cases that have had stent-associated lower uri-
nary tract signs that are refractory to medical management. How-
ever, chronic urinary signs have also been noted in cats with the
SUB device as well as ureteral surgery, so clients must be advised
that this complication can occur in any cat undergoing urinary
procedures (Zaid et al. 2011, Berent et al. 2012, 2014, Horowitz
et al. 2013, Kulendra et al. 2014, Wormser et al. 2016)
POSTOPERATIVE MANAGEMENT AND
FOLLOW-UP
In critically ill cats undergoing surgical or interventional manage-
ment of ureteral obstruction, perioperative preparation is essen-
 Feline ureteral obstructions II
tial. Anaemia and packed red blood cell transfusion requirements
have been documented in multiple studies of cats undergoing a
variety of ureteral interventions (Berent et al. 2012, Culp et al.
2016, Wormser et al. 2016). Cross-matched, type-specific blood
is preferred in cats, because typing alone does not ensure com-
patibility given the presence of other antigens on feline red cells.
Postoperatively, I prefer to place an oesophageal tube and multi-
lumen catheter in the jugular vein. The E-tube provides an easy
route for enteral water to supplement intravenous fluid support
in an effort to avoid fluid overload and allows for early institu-
tion of enteral feeding, especially in this population of cats which
often have a history of anorexia, weight loss and oral ulceration.
The central venous multi-lumen catheter in the jugular vein is
convenient for repeated venous sampling, well-tolerated in cats,
and allows for removal of peripheral catheters which are often
urine-soaked in polyuric postoperative patients. It can also be
used for central venous pressure monitoring to help guide intra-
venous fluid therapy.
Indwelling urethral catheters are controversial in cats with
ureteral implants (SUBs and stents) due to concerns for ascend-
ing infection and colonisation of the urinary implant. However,
catheters greatly improve the ability to accurately quantify urine
output. Since frequent urinary monitoring is needed, often every
1 to 2 hours in patients with a significant postobstructive diure-
sis, absorbent, plastic-backed pads are used to line the cage when
urethral catheters and closed collection systems are not used. The
pads can be weighed once soiled, with the weight of pad sub-
tracted from the total. The remaining weight is approximated as
volume since 1 g of water is equivalent to 1 mL.
Careful monitoring of the cat’s intravascular volume and
hydration is of paramount importance in the postoperative man-
agement of cats with ureteral obstructions. Recent literature has
demonstrated that cats undergoing ureteral stenting had a more
substantial postobstructive diuresis and faster resolution of azo-
taemia as compared to those undergoing ureteral surgery (Culp
et al. 2016). Postobstructive diuresis rates of urine production
that ranged from 3 to 36·5 mL/kg/hour with a median urine out-
put of 7·75 mL/kg/hours (Culp et al. 2016). These exceptionally
high rates of urine production emphasise the need for frequent
monitoring of body weight (every 2 to 6 hours), urine produc-
tion (every 1 to 4 hours), minimum database/lactate/electrolytes
(every 4 to 6 hours), central venous pressure (every 2 to 4 hours)
and ultrasonographic assessment of left atrial to aortic root diam-
eter ratio (La:Ao) (every 4 to 6 hours). Intravenous fluid rates
are tailored to match urinary output in addition to maintenance
fluid therapy needs and volume to restore intravascular deple-
tion. Aggressive fluid therapy (enteral and intravenous) is con-
tinued until there is a plateau in the creatinine, after which point
intravenous fluid therapy is gradually reduced to limit or reverse
medullary washout.
Postoperative pain control is an additional important con-
sideration for cats undergoing SUB placement. The dissection
of ventrolateral SC tissues away from the abdominal body wall
for port placement causes significant discomfort in the first 24
to 48 hours postoperatively. Postoperative splash block with
bupivacaine is a helpful adjunctive modality. Epidural analgesia
Journal of Small Animal Practice • Vol 59 • July 2018 • © 2018 British Small Animal Veterinary Association 395
can be considered, though may be avoided due to concerns for
platelet dysfunction and bleeding in severely uraemic patients.
For postoperative analgesia, I prefer doses of 0·01 to 0·02 mg/
kg buprenorphine intravenously every 6 to 8 hours and 0·25 to
1 mcg/kg/hour dexmedetomidine by CRI. This combination has
provided reliable analgesia with less perceived dysphoria than
pure mu-opioids in cats.
Changes in azotaemia, phosphorus, magnesium and albumin
are typically monitored every 24 hours, unless the cat’s clinical
picture dictates more frequent monitoring. Frequency of electro-
lyte and minimum database monitoring can often be decreased
to once or twice daily as the patient’s diuresis subsides and fluid
needs become more stable.
Follow-up after patient discharge is usually dependent on
the severity of azotaemia at discharge, dependence on oesoph-
ageal tube water and nutritional support, and whether or not
skin sutures were placed. For cats with SUBs, I prefer to per-
form the first flush to confirm patency 1 month postoperatively,
then every 3 to 4 months. This can be done with ultrasound or
fluoroscopic guidance, and most cats require light sedation for
thorough examination of the device, including shunting port and
native urinary tract. Ideally, urinalysis and urine culture are col-
lected from the SUB at every flush. For cats with ureteral stents
or surgery, recheck imaging is often performed within the first 1
to 2 months to evaluate for renal pelvis size and stent position-
ing. An acute change in urinary signs in cats with stents should
prompt imaging and urinalysis/urine culture to evaluate for
migration, infection, encrustation and recurrence of obstruction
(Figs 16 and 17).
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.
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