RETROGRADE

CYSTOGRAPHY
DIAGNOSING A URINARY BLADDER TUMOR
REBECCA ENGLAND, RVT
TARLETON STATE UNIVERSITY

MEET HOFBRAU

PATIENT HISTORY
Hofbrau is a 9-year-old black sable and white Akita / Husky mix
He was neutered at 10 months of age and adopted from the shelter
thereafter
He is current on all of his vaccinations and has had consistent
veterinary care he also has a history of severe separation anxiety
and corneal dystrophy
He is on three medications for anxiety; the corneal dystrophy has
not needed any treatment thus far; no other major medical
problems
He was presented to our clinic for intermittent hematuria, noted by
the owner over the last 7 to 10 days no other abnormal urinary
habits (such as pollakiuria or dysuria) were noted
The owner had no other complaints upon presentation

ASSESSMENT
Initial examination:
General appearance BAR, excited; this is normal per the owner when in non-routine
environments
EENT WNL
Integument WNL
Musculoskeletal WNL
Abdominal palpation WNL

Respiratory WNL, no discharge from nose, no abnormal breath sounds

Cardiovascular WNL, no murmur or arrhythmia heard, no pulse deficit
Urogenital hematuria per owner, bladder palpated not obviously distended
Nervous PLRs intact, deep pain present in all 4 limbs, rectal tone WNL, gait and CP
WNL

TPR: 100.0F, 82, 45 and panting

Weight: 59.8 lbs., BCS 5/9

DIAGNOSTICS
Bloodwork
Blood was obtained from his Right hind lateral saphenous vein to run a Chem
25, CBC, and Electrolyte panel
Urine was also collected to run urinalysis
All blood tests were WNL; urinalysis revealed 3+ red blood cells and 2+
epithelial cells; no crystals or other abnormalities noted

Other Diagnostics
Survey plain radiographs (lateral Right and VD) were taken of the caudal
abdomen to assess the abdomen and bladder for abnormalities
No significant findings on radiographs bladder appeared to be small in size,
no opacities
A brief ultrasound was performed to assess the bladder a small mass was
possibly noted, but the bladder was not fully distended at the time of imaging
A retrograde cystography with double-contrast media was recommended and
scheduled with a specialist for the following day

RETROGRADE CYSTOGRAPHY USING

DOUBLE-CONTRAST MEDIA
This type of diagnostic tool may be used based on the history,
clinical signs, radiographs, ultrasound images, and character of the
urine sample
Double-contrast cystography includes the use of a positivecontrast medium (such as water-soluble iodide) AND a negativecontrast medium (such as nitrous oxide or carbon dioxide)
This study is the best method for assessing bladder wall lesions
and intraluminal filling defects

INDICATIONS FOR RETROGRADE

CYSTOGRAPHY
Unresponsive clinical signs due to abnormal urine such as
hematuria, crystalluria, or bacteriuria
Abnormal urination signs such as dysuria or pollakiuria
Trauma
Abnormalities on survey radiographs such as changes in urinary
bladder opacity or wall, or change in location
To define other abnormalities such as uroliths, polyps, masses, or
foreign bodies

POTENTIAL COMPLICATIONS
Iatrogenic trauma, bacterial infections, and kinked or knotted urethral
catheters
Intramural or subserosal accumulation of contrast media
Usually does not cause clinical problems

Mucosal ulceration, inflammation, or granulomata reactions

Transitory with no serious clinical problems

Rare complications include a gas embolism after administration of

negative contrast media
DO NOT use room air in patients with hematuria blood in the urine is evidence
of communication between the bladder and the vascular system
Nitrous oxide or carbon dioxide is 20 times more soluble in serum than air/oxygen
Embolism is potentially fatal

PREPARATION
Sedation should be considered for all pets having this procedure
performed, as urinary bladder distention can be uncomfortable
Food should be withheld for 24 hours before the procedure this
will minimize superimposition of fecal matter of the urinary bladder
An enema should be given 4 hours before the procedure this will
minimize gas artifacts
USE PROPER STERILE TECHNIQUE WHEN HANDLING CATHETERS
AND SAMPLES!
If urine samples are needed for testing, they should be collected
prior to the procedure, as contrast can alter results

SUPPLIES NEEDED
Sterile urinary catheter
Vaginal speculum or otoscope (for females only)
Sterile lubricating jelly and 2% lidocaine jelly
Light source
Large syringe (20- to 50ml ideal)
Three-way stopcock
Container to deposit urine
Contrast media of choice
Antibiotics may be given on a case-to-case basis
Access to radiographic equipment and PPE (personal protective
equipment)

EXAMPLE OF POSITIVE-CONTRAST
MEDIUM USED FOR CYSTOGRAPHY

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HOW THIS PROCEDURE IS

PERFORMED: THE BASICS
Survey radiographs should be taken prior to the study (lateral Right and VD views)
A sterile urinary catheter should be measured appropriately and lubricated with
lidocaine jelly
The catheter is inserted until the tip reaches the bladder BE GENTLE!
Apply the 3-way stopcock and syringe to the end of the catheter
Completely empty the bladder of urine (also note the quantity removed)
Once empty, infuse negative-contrast medium until the bladder is appropriately
distended; then close the stopcock so medium does not escape
Take 3 radiographic views immediately (lateral Left, lateral Right, and VD) centered
over the bladder
Then infuse the positive-contrast medium SLOWLY
In order for the medium to coat the inside of the patients bladder wall, the patient
must be rotated from side to side then repeat radiographs as before
When finished, drain the bladder of any remaining contrast media and instill antibiotics
if desired
Lastly, remove the urinary catheter

HOFBRAUS PROCEDURE
He was sedated and a retrograde cystography using water-soluble organic iodide
(positive-contrast medium) and nitrous oxide (negative-contrast medium) was
performed
He was continuously monitored during the procedure and had no complications
When the procedure was finished, he recovered well and was sent home with his
owner
Based on the radiographs that were taken, it was suspected that he had a urinary
bladder tumor
It was recommended that the owner take him to an oncologist to discuss the options:
Possible debulking surgery
Chemotherapy
Or other diagnostics / treatments

The owner was able to schedule an oncology consult for the following morning
A bladder tumor antigen (BTA) test was sent to the laboratory, and is still pending
Further advanced imaging has been scheduled to determine the specifics of the mass

RADIOGRAPHIC EXAMPLE FEMALE

CANINE WITH A URINARY BLADDER
TUMOR, DIAGNOSED VIA DOUBLECONTRAST MEDIA

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SEDATION RECOVERY AT HOME

REFERENCES
Brown, M. and Brown, L. (2014). Lavins Radiography for
Veterinary Technicians, 5th ed. St. Louis, MO: Saunders
Elsevier.
Vaden, S. L., Knoll, J. S., Smith Jr., F. W. K., and Tilley, L. P.
(2009). Blackwells Five-Minute Veterinary Consult: Laboratory
Tests and Procedures, Canine and Feline. Ames, IA: WileyBlackwell.
Images without a source listed are from personal photography
library