Veterinary Vertex

Navigating the Challenges of Obstructive Urolithiasis in Small Ruminants

November 14, 2023 AVMA Journals
Veterinary Vertex
Navigating the Challenges of Obstructive Urolithiasis in Small Ruminants
Show Notes Transcript Chapter Markers

Strap in for a riveting discussion with Rachel Oman, the investigator behind an innovative approach to managing obstructive urolithiasis in small remnants. We will unravel the complexities of her modified tube cystostomy technique to manage obstructive urolithiasis in small ruminants. Rachel will share the lessons learned from her journey, highlighting the pivotal role of patient selection and the necessity of pre-planning for urethra patent restoration. She'll also provide an inside look into the financial aspects surrounding the treatment of obstructive urolithiasis, an often overlooked yet significant factor in veterinary care.

Our conversation also takes a realistic look at the potential drawbacks of Rachel's technique, particularly in a field setting - the risk of re-obstruction and the need for both veterinarians and clients to be prepared for it. We'll explore the peculiarities of goat diets, and the crucial role of comprehensive home management in securing successful treatment outcomes. You'll hear from co-hosts Sarah Wright and Lisa Fortier as we delve into the significant impact Rachel's work has had on the field of veterinary medicine. Lastly, we'll touch on the indispensable role that research plays in veterinary care, and take a moment to appreciate journals like JAVMA, which facilitate such essential care. Be sure to tune in, absorb Rachel's valuable insights, and let us know your thoughts by leaving a rating and review on your preferred podcast platform.

Full article: https://doi.org/10.2460/javma.23.07.0427

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Sarah Wright:

You're listening to Veterinary Vertex, a podcast of the AVMA Journals. In this episode, we chat about a modified tube system technique for the management of obstructive urolithiasis in small ruminants with our guest, Rachel Oman.

Lisa Fortier:

Today we have Rachel joining us. Rachel, thank you so much for being here. I'm super excited to hear about your modified technique. This is certainly very commonly done in large animal hospitals.

Rachel Oman:

Well, thank you so much for having me on your podcast. It's my pleasure.

Sarah Wright:

All right, let's dive right in. Obstructive urolithiasis is a commonly encountered emergency condition of small ruminants. Your study discusses a new technique for the management of this condition. Can you give our listeners a bit of background on this study?

Rachel Oman:

Absolutely, so it was actually quite a few years ago when one of my resident mates and co-author, Dr. Leslie Weaver, found an article that described a minimally invasive tube cystostomy and she brought the article to our journal club and what resonated with me about that description was that it was a technique that was sort of a compromise between full surgical tube cystostomy and some of the percutaneous techniques that have been described. So when I was a resident we tried to recreate the technique that was described in that paper and we had variable success and there were some challenges. One of the things was that we didn't have the same trocar that they had used, which was a custom made trocar, and there were some different tubing combinations that tended to get clogged, so made it somewhat difficult to replicate. And then I was at a conference and there was a description of using these, the other sort of catheters that we used in this in our project, and I thought that could be the perfect solution if I could combine the technique with this different catheter kit using these human super pubic fully catheters. And that was sort of the start of this research project.

Sarah Wright:

Lisa is commiserating with you on the various catheter techniques.

Rachel Oman:

Yes, the challenges there were things like you know they don't. There's pigtails and curved tips and sort of expandable ends, and a lot of them tended to be just temporary because they would come dislodged or clogged.

Sarah Wright:

I know I saw a few cases just as a vet student I remember but these are always the cases that you get like a Friday evening and you're trying to go home and the blocked goat comes in and you're like all right.

Rachel Oman:

Yeah, I don't think that goats tend to block any time other than the middle of the night.

Sarah Wright:

Yeah, I think you're right. So the study is obviously very important. But of the findings, what are the most important findings from the study?

Rachel Oman:

Yeah, I think that for me, some of the biggest takeaways were, firstly, the importance of patient selection, because not every animal is a good candidate for this procedure. One of the limiting factors is the length of the introducer. That's included in these kits or you can actually buy the introducer by itself and use your own fully catheter, which works just fine. But I found that patient size was the limiting factor, in that the largest animal that I tried this on was actually too large in retrospect. It was a hundred plus kilogram sheep and it was a really, really fat animal and it was extremely challenging to get that done. So patient size is important. It's also very important that the urinary bladder is intact and distended, because you have to be able to feel it blindly through this small incision and if it's not distended it's difficult to discern the urinary bladder versus other viscera. And so those were two of the main points. And then I think the third main point for me was just the importance of planning ahead for how you're going to get the urethra patent again, because that still remains the biggest challenge. I think these techniques are tube cystosomies percutaneous or this modified technique is just the start of really treating these animals, because it's all the stuff afterwards that still remains very challenging.

Lisa Fortier:

Yeah, it's a really good point. We had a really nice JAVMA manuscript written by McConey from Cornell that laid out a nice paradigm. Day one, day two, day four. Did this happen? Nope, Go back to that. Block them off, clamp the catheter. So they're difficult, each one's a little bit different and they can really add up and be costly.

Rachel Oman:

Absolutely. Cost is a major factor, I think, for a lot of folks in treating obstructive urolithiasis in these small ruminants.

Lisa Fortier:

Yeah, was there a specific case? Or just keeping you up all night? Or what an animal of your own? What sparked your interest in small ruminant obstructive urolithiasis?

Rachel Oman:

It wasn't any case in particular, but my residency was at Oklahoma State University and there are a lot of small ruminants at Oklahoma and a lot of show weathers and that means there's a lot of blocked show weathers, and so I was lucky to train there under Dr. Bob Streeter and he has a strong interest in obstructive urolithiasis and as a resident, that was certainly influential for me and I think that I was lucky to watch Dr. Streeter and other faculty at Oklahoma State struggle with treating obstructive urolithiasis and try different techniques, and they were very open to things like my resident mate bringing an article to journal club and then saying let's try it, and so I think that was the environment in which my interest was sparked.

Lisa Fortier:

That's great. Yeah, it's really nice to have a culture of openness and discussion and really trying to do the best thing for the animals in the end. We can always improve these techniques.

Rachel Oman:

Yes, I very much appreciated that, and certainly as a house officer, having the support and the trust of your faculty to try new things is, I think, sometimes rare and I was lucky in that situation.

Lisa Fortier:

My estimation is that's going to be the same answer to this next question I have for you. But what really inspired you not to just think about this technique, but to go through and then write this manuscript?

Rachel Oman:

Well, I tried this technique in a couple of different circumstances. I tried universities really. I was working at Colorado State University most recently and then I was working at the University of Missouri. Before that I had a colleague the resident mate who found the article, Leslie. She works at Kansas State University. There were people in different universities doing this and we had built up enough cases that I felt like there was data there. I had presented on this technique and this topic quite a few times at different veterinary conferences and it seemed like this technique was what sparked the most interest for folks. I know that I taught house officers to do this, and I bet students have seen me do it, but certainly the best way to reach the largest audiences to publish it or to come on a podcast like this.

Lisa Fortier:

Thank you for sharing it with us. You answered Sarah earlier when she asked you what may be the most important findings, but what findings in this manuscript really surprised you?

Rachel Oman:

Well, I think that I was surprised, when I was writing it and reviewing the literature, that the outcome for the animals in this study treated using this modified technique were not all that different from outcomes that are reported for small ruminants treated with traditional tube cystostomy techniques and under general anesthesia and even other techniques that we have. It seems to me that we're still in the process, as veterinarians and researchers, of figuring out the best or a really effective way to manage these cases.

Sarah Wright:

Yeah, I think that can be said for a lot of things in veterinary medicine, because I was so glad that we have this evidence to say hey, this is published, let's try this, like you said.

Rachel Oman:

I guess there are a couple other surprising things to me. I think that one of the benefits of this procedure is the speed with which it can be done, and especially in a field setting that's important and, as you pointed out, in the middle of the night, when you're alone and you don't have the support staff that you would typically want to have, it's nice to have a procedure that you can get done and move on, and this is this offered, that we didn't time the surgeries, but even in situations where I let an inexperienced house officer do 90 plus percent of the procedure, they still took less than 45 minutes, and I think, having done a couple, you can get this done in 15 to 30 minutes easily, which is so different from some of the other techniques that we have.

Sarah Wright:

Yeah, that sounds great. I think it'll be really beneficial to small ruminant practitioners. I did just want to put this on the radar that we do have a technical tutorial video manuscript. So if you or your colleagues have anything that you think would be useful to practitioners, such as this technique, we have a video manuscript category where you can do a video showing the technique and talking about it and still providing the evidence behind it and do a little literature review too. We'll send you some information after this about that. But just something to consider. You touched already a little bit on your advanced training, but how did your advanced training prepare you to write this manuscript?

Rachel Oman:

Well, I sort of did touch on probably the primary thing in my advanced training, which was the support that I gained from my mentors, and then the exposure I had to cases and it was interesting at Oklahoma State because there was interest from the faculty in obstructive urolithiasis. I was exposed to some of the advanced techniques that are less commonly performed, like laser lithotripsy, and I saw my mentors experimenting with techniques like using curved tip angiographic catheters for retrograde urethral catheterization. So I think that helped stimulate me to research this topic and then also to publish it, because you know, if it's one thing to try these things sort of in your privacy of your own practice, but then if you figure something out that you think could be useful, I was certainly encouraged to spread the word.

Sarah Wright:

And thank you again for spreading the word in JAVMA. We really appreciate it. This next set of questions is really important for our listeners. First, what is one piece of information the veterinarian should know before discussing obstructive urolithiasis with the client?

Rachel Oman:

I think that for me, one of the biggest things to discuss with a client with obstructive urolithiasis is that we don't know a great way of predicting outcome. There are certainly factors that contribute to having a better success rate or a more likely, higher likelihood of an animal surviving to discharge and then beyond that long term, but we still don't know. And the other thing about it is that I think with this procedure in particular, it's important for veterinarians to know, if they're considering this as a treatment option, this modified technique, that this isn't meant to replace surgical tube cystostomy under general anesthesia as the gold standard technique for treating obstructive urolithiasis, because there are certainly some important disadvantages to this technique that people veterinarians need to be aware of. Probably the biggest one is that, because it's done with this keyhole incision and blindly, you don't have the opportunity to evacuate any uroliths from the urinary bladder and so, because of that, anything that remains has to either be dissolved with urinary acidification and we know that not all stones will dissolve or you have to be lucky enough to have any remaining uroliths come out through the foley catheter, and sometimes that happens, and I've gotten very lucky a couple times where that has happened, but sometimes they're too big or, you know, gravity is not your friend and you can't get them out, and those cases, re-obstruction is more likely and I think that, for all small ruminants that are undergoing treatment for obstructive urolithiasis, re-obstruction is a challenge and something that we need to discuss with our clients.

Sarah Wright:

Speaking of stone forming animals, my cat's a stone former and trying to explain everything to my husband is challenging. He's like "we're going to do an expensive procedure and it might not work. She could form more stones."

Rachel Oman:

Yes, absolutely. And I think that's one of the other huge challenges as veterinarians, when we try to talk to clients about this, is that they times, times so, so they want to know what the chances are of success. And if you say, well, 50/ 50, and it's going to cost a couple thousand dollars, that starts to be a challenging decision for folks.

Lisa Fortier:

Our most recent blocked goat was w hen I was on clinics last week. The owner was feeding it chicken feed because the goat liked it and it needs to browse it's what they do and she just refused not to feed it chicken feed because she felt that it was a pet and she felt that she was being mean to it because it wanted to get into the chickens.

Rachel Oman:

Pet goats definitely have some strange diets. I've had goats that eat potato chips and sweet tea and chicken feed. So yeah, that would be. Management at home is probably the next biggest thing to talk about.

Sarah Wright:

That actually leads very well to my next question. On the other side of the relationship what is one piece of information that clients should know about urolithiasis?

Rachel Oman:

So, yes, that does lead well into this topic, because to me, the biggest thing that clients should be made aware of is that the ultimate success of this procedure, or probably any treatment for obstructive urolithiasis, depends largely on the aftercare that they're going to get and the management that the animal receives at home. So in the case of this modified technique, that includes keeping the animal isolated and quiet where it's not going to be jumping around. Where the tube could become dislodged, I have to have the E-collar, which for the goats, I find that she or maybe just not clever enough to figure out how to bite their tube out, but goats will do it the second they get a chance. And then, if it's really important that the owners monitor the tube closely so that means they have to watch this dripping and it hasn't become clogged. And then, finally, really the hardest thing, is rectifying any management like feeding chicken feed that is going to have contributed to the goat getting stones in the first place, and if we can manage them better or differently, maybe prevent them in the future.

Lisa Fortier:

Yeah, those goats are sure percocious little animals If they even if you get a nice inner tube around their neck or an E-collar. I've seen them scratch them out with their little hind feet and it's amazing, you think. How did you bend like that? Are you a yoga goat?

Rachel Oman:

Yes, it is shocking how good they are at getting those tubes out. And I was also shocked when I had that it's in the manuscript, but one where chickens pecked out the tube and the owner called me and was in a panic because the tube was out and he said he found the hens had been pecking it and he was worried that the balloon was still in the goat. And I said can you take a photo of the tube and send it to me? And he texted it to me and thankfully the whole thing was there and honestly the chickens probably did him a favor because he'd kind of just left the tube in a little bit long and things are going well, so even other animals will take them out.

Lisa Fortier:

That's probably something you only hear in veterinary medicine. The chicken pecked out your cystostomy tube.

Rachel Oman:

Yes, I was tickled because it worked out fine, Otherwise I probably would have been more annoyed.

Lisa Fortier:

You talk a lot about training and the mentorship you received and it takes a village to get to where you are and a lot of resilience. Where do you think you got your resilience or determination from?

Rachel Oman:

I think for me, the support of my friends and family has been instrumental in making me the person that I am and giving me a path to success. Some of my best friends are my veterinary colleagues, I think, especially the ones that I went through residency training with. There's those late nights and many, many hours. Those shared struggles, I think, forged a lifelong bond that I am so grateful for, because it's those people, like Leslie and my other resident mates, who I still lean on for support and who inspire me with new ideas and give me pep talks, remind me of why I do this job when I need it.

Lisa Fortier:

That's a fantastic answer. As we start to wind down, just a little bit more of a personal question what was the first concert you attended?

Rachel Oman:

I can't remember the exact chronology of my early concert going days. It's either one of two fantastic groups. Either it was the Red Hot Chili Peppers, which I guess sort of dates me, or Shakira. Both were fantastic, but I think as far as a show to watch and a performer, Shakira was the best. That had to be awesome. It was fantastic. It was in Albuquerque, where I was born and raised. The crowd was also quite enthusiastic.

Sarah Wright:

Oh, I bet. Yeah, I enjoyed her Super Bowl performance that one year. That was good yes she's great and just thank you so much again, Rachel. We appreciate you being here today and for sharing your manuscripts, too, with JAVMA.

Rachel Oman:

Thank you so much for having me. It's been my pleasure Of course, and to our listeners.

Sarah Wright:

you can read Rachel's manuscript in print JAVMA or on our journal's website. I'm Sarah Wright with Lisa Fortier. You want to thank each of you for joining us on this episode of the Veterinary Vertex Podcast. We love sharing cutting edge veterinary research with you. We want to hear from you. Be sure to leave us a rating and review on Apple Podcasts or whatever platform you listen to.

Modified Tube System for Urethiasis
Discussion on Obstructive Urolithiasis Treatment
Veterinary Research and Appreciation