|Year : 2019 | Volume
| Issue : 4 | Page : 104-111
Evaluation of autologous composite colo-peritoneal grafts in the repair of experimental urinary bladder defects in dogs
Sa'idu Tanko Muhammad1, Cheh Augustine Awasum2, Bisalla Mohammed3, Adamu Zoaka Hassan2
1 Veterinary Teaching Hospital, Ahmadu Bello University Zaria, Nigeria
2 Veterinary Surgery and Radiology, Ahmadu Bello University Zaria, Nigeria
3 Veterinary Pathology, Ahmadu Bello University Zaria, Nigeria
|Date of Submission||30-Mar-2020|
|Date of Acceptance||05-Jun-2020|
|Date of Web Publication||11-Nov-2020|
Dr. Sa'idu Tanko Muhammad
Veterinary Teaching Hospital, Ahmadu Bello University Zaria
Source of Support: None, Conflict of Interest: None
Background: Urinary bladder (UB) defects are most often associated with embryologic development and pelvic trauma. The cause of the defects could be congenital abnormalities or various aetiologies connected with modern life, including road traffic accidents, assault (gunshot injuries) and occupational hazards (neoplasia). industrial, and criminal activities. Medical treatment for these defects is mostly limited thereby necessitating surgical intervention. This study was aimed at finding alternative reconstruction tissue for restoring bladder storage and voiding capability.
Materials and Methods: The surgical procedure was aseptically performed under general anesthesia. The dorsal aspect of the urinary bladder served as the recipient site, while sero-muscular colonic pedicle flap of the descending colon along with free peritoneal sheath formed a composite tissue (donor), colo-peritoneal pedicle graft. The surgical procedure included preparation of the colonic pedicle flap, preparation of free peritoneal flap, formation of composite colo-peritoneal graft, preparation of urinary bladder graft bed, and colo-peritoneo-cystoplasty. The dogs were evaluated in the post-operative period by physical examination, urinalysis, and cystography within the duration of 14 weeks.
Results: Cystographic evaluations performed on the 2nd, 10th, and 14th weeks post surgery revealed gradual transition of the urinary bladder architecture at the point of graft with clear delineation and minimal blurring at initial assessment, which gradually disappeared later. Complications observed were straining and constipation, which responded positively following appropriate interventions. Post surgical urinalysis showed transient changes in specific gravity and urine pH values, but returned to pre surgical level after day 18 post surgery. Post surgical proteinuria was observed for the first 7 days, but disappeared on day 12. Hematuria occurred within the first 16 days post surgery.
Conclusion: It was concluded that autologous composite colo-peritoneal tissue graft was successfully formed and effectively used in the repair of urinary bladder defects in the dogs. This surgical management intervention could be evaluated in human subjects with similar urinary bladder defects.
Keywords: Autologous composite graft, colocystoplasty, colo-peritoneal tissue, dogs, urinary bladder reconstruction
|How to cite this article:|
Muhammad ST, Awasum CA, Mohammed B, Hassan AZ. Evaluation of autologous composite colo-peritoneal grafts in the repair of experimental urinary bladder defects in dogs. Arch Int Surg 2019;9:104-11
|How to cite this URL:|
Muhammad ST, Awasum CA, Mohammed B, Hassan AZ. Evaluation of autologous composite colo-peritoneal grafts in the repair of experimental urinary bladder defects in dogs. Arch Int Surg [serial online] 2019 [cited 2021 May 12];9:104-11. Available from: https://www.archintsurg.org/text.asp?2019/9/4/104/300556
| Introduction|| |
Deformities of tissue may lead to damage or loss of function, necessitating its reconstruction or an eventual replacement of the organ. The defects could be congenital or acquired as a result of trauma, neoplasia and iatrogenic aetiologies.,,,,, Urinary bladder defectsare one of the severest form of soft tissue defects, with tremendous impact on the patient's survival and quality of life. Modernism, social conflicts, human and natural disasters, and pelvic surgical complications have been reported as the major causes of extensive urinary bladder damage.,, Surgical repairs have previously utilized variety of autologous, homologous, and heterologous tissues such as fascia, skin, peritoneum, and omentum but with minimal success rates.,, Composite tissue transplantation (CTT) may provide more functional and durable tissue replacements to defective or severely damaged tissue/organ, in addressing complex tissue grafts, such as urinary bladder defects., Although ingenious attempts have been made in the management of diseased, defective, or injured urinary bladder in both humans and animals, persistent functional and anatomical deficits remains a challenge.
Several attempts leading to major advancement have been made by reconstructive urologic surgeons and researchers in the surgical treatment of defective urinary bladder. The outcomes of the attempts strongly suggest the need to use autologous intestinal segment, which is autologous enterocystoplasty (either colonic or small intestinal).,,,,, However, the benefits of the enterocystoplasty have been limited by complications, including mucus production, stone formation, chronic low-grade infection, metabolic disturbance, and potential malignancy due to long-term exposure of the bowel mucosa to urine.,,,, The new technique of bladder reconstruction using colo-peritoneal CTT in dogs (in vivo) was suggested to address these complications. The technique, which may facilitate the restoration of offunctional and anatomic deficits is considered a quality-of-life intervention., Reconstructive urologic surgery enhances successful restoration of form and function of any defective urologic organ utilizing autogenous tissue but may be grossly inadequate in cases of extensive defects.,, The aim of the study was to employ autologous composite colo-peritoneal grafts in the repair of urinary bladder defects in dogs.
| Materials and Methods|| |
Ethical clearance was obtained in accordance with the statutory regulations guiding animal care and use as approved by Ahmadu Bello University Committee on Animal Use and Care with reference number, ABUCAUC/2016/010.
The study was conducted at the Veterinary Teaching Hospital, Ahmadu Bello University, Zaria, Nigeria. Two Nigerian indigenous dogs (NIDs), a male (1-year, 2 month-old) and female (1-year-old) with live weights of 17 and 18 kg, respectively, were used for the study. The dogs were housed and pre conditioned for 2 weeks prior to the commencement of the study. They were fed maize, rice, beans, blood meal, soft bones, fish and palm oil, and given access to water ad libitum. During the pre-conditioning period, the dogs were subjected to physical and laboratory examinations. The theater, and dog kennel of the Veterinary Teaching Hospital were used for the surgical procedures, pre- and postoperative management throughout the study period.
Pre-surgical considerations and patient preparation
Food and water were withheld for 36 and 12 h, respectively prior to the surgery. Prophylactic metronidazole (Trimetro IV (R)— J. B. Chemicals and Pharmaceuticals Ltd., India) at dose rate of 25 mg/kg was administered intravenously 24 h before the commencement of the surgical procedure. In preparation for surgery, the ventral abdominal region from the xiphoid extending to the perineum, including the stifle joints and 20 cm on either side of the ventral mid line of each dog was shaved, and scrubbed-clean with soap and water.
The surgical procedures were performed under general anesthesia achieved through a cannulated cephalic venopuncture. Premedication was performed intravenously using 0.05 mg/kg of atropine sulphate (Amopin (R) – Yanzhou Xier Kangtai Pharma. Co., Ltd, China) and chlorpromazine hydrochloride (Clomazin (R)-Maxheal Pharmaceuticals, Karnal, India) at 4 mg/kg. Thiopentone sodium (Thiopental (R)-Rotex Medica Trittau, Germany) at a dosage of 15 mg/kg (IV) was used for induction of anesthesia. The dogs were intubated with size 7.5 endotracheal tubes post-induction, and Halothane (Halothane (R) - Nicholas Pharmal India Limited, India) at 2% concentration was employed for the maintenance of anesthesia. The dogs were placed in dorsal recumbency with fore- and hind-limbs extended and restrained on the surgical table. The surgical site (the shaved ventral abdominal region) was fine swapped with 0.05% chlorhexidine gluconate (Purit (R) — Saro Life Care Ltd., Lagos, Nigeria) and 10% povidone iodine solutions (Wosan (R)-Jawa International Ltd., Lagos, Nigeria) and draped in a rectangular pattern. Aseptic conditions were adhered to strictly throughout the procedures. Pentazocine injection (2 mg/kg) was administered IV during the surgery.
The abdominal cavity was accessed via caudal mid-ventral [Figure 1] abdominal incision (laparotomy)., The skin incision in the male dog [Figure 1]a was paramedian at the level of prepuce. A 24 Fr Foley catheter was inserted rectally and advanced to the proposed site of sero-muscular flap harvest in the colon [Figure 2]. The cuff of the Foley catheter was inflated with physiologic saline solution to a considerable size to provide support and firmness to the colon [Figure 2]a. The pre-determined sero-muscular layer of the colon [Figure 2]b was incised lengthwise and transversely from the ante-mesenteric border [Figure 3]a. To aid separation, four stay sutures were preplaced at the four different angles of the incised sero-muscular layer [Figure 3]b. The sero-muscular layer was bluntly separated from the lamina propria [Figure 4]. Saline-soaked gauze was used to wrap the pedicle flap [Figure 5]b. The sero-muscular edges from the remaining bowel were then apposed and sutured (using size 2/0 Ethicon-Vicryl (R)), “intussuscepting” the desero-muscularised mucosa [Figure 5]a. The mesenteric defect was also closed (with 2/0 Ethicon-Vicryl (R)).
|Figure 1: Mid line and paramedian abdominal incision in a male dog (a) and in a female dog (b)|
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|Figure 2: Colon preparation for sero-muscular harvest. Note the inflated Foley catheter within the selected descending colon (arrowed) to provide firmness to the colon (a) during measurement, marking (b) andg sero-muscular harvest|
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|Figure 3: Sero-muscular incisions along the marked borders. Note a b the de-tubularization at the antemessenteric border (a) and pre replacement of stay sutures at the four different angles on the incised sero-muscular layer at ante-messenterc surface (b)|
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|Figure 4: Blunt separation (dissection) of the colonic sero-muscular layer from its lamina propria (a) and harvested colonic sero-muscular layer with its preserved vascular supply (b)|
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|Figure 5: Apposition of sero-muscular edges of the remaining (cranial and caudal) colonic segments (a) ''intussuscepting'' the desero-muscularised mucosa. Note the harvested and preserved colonic sero-muscular pedicle (arrowed) flap, wrapped around saline-soaked gauze (b)|
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Preparation of free peritoneal flap
The desired graft size of the parietal peritoneum caudal to the umbilicus was exposed, measured, and marked with a surgical pen. Stay sutures were then preplaced at four different angles, connecting the marked borders of the peritoneal graft site. Linear incisions (joining the marked borders) were made and bluntly advanced laterally, thereby lifting the full thickness peritoneum off the underlying muscular tissue [Figure 6]. The harvested free peritoneal graft was immediately transplanted to the harvested sero-muscular colonic pedicle flap on the same dog to form a composite tissue. The donor site was reconstructed during abdominal (laparotomy) closure. The peritoneum was opposed along during closure of the linea alba, thereby overlaying the donor (exposed abdominal muscle) site.
|Figure 6: Pre-placed stay sutures (at four different angles) on the marked borders and harvest of the peritoneal graft|
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Formation of composite colo-peritoneal graft
The muscular surface of the sero-muscular pedicle flap was opposed with the muscular surface of the pre-harvested free parietal peritoneal flap [Figure 7]a held together with stay sutures and tissue forceps [Figure 7]b, as composite [Figure 8]. The apposed composite tissue was then sutured using size 4/0 Ethicon-Vicryl (R) in an interrupted pattern to form the composite colo-peritoneal pedicle flap in preparation for grafting. The composite pedicle tissue was then wrapped with saline-soaked gauze.
|Figure 7: Formation of composite colo-peritoneal pedicle flap. Note the muscular surface of sero-muscular pedicle flap in contact with the muscular surface of the pre-harvested peritoneal flap (a), the peritoneal sheath apposed with sero-muscular colonic pedicle flap in preparation for placement of interrupted sutures to hold the tissues as “a composite colo-peritoneal” pedicle graft (b)|
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|Figure 8: Formed composite colo-peritoneal pedicle flap in preparation for grafting|
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Preparation of urinary bladder graft bed
The urinary bladder was then isolated, exteriorized, and positioned to expose dorsal (recipient) surface. Thereafter, stay sutures were placed on the apex and the body [Figure 9]a as described by Desch and Wagner, and a predetermined 2 × 4 cm dimension of a full thickness rectangular flap was excised [Figure 9]b on the dorsal surface (partial cystectomy). The bladder was then emptied of urine and blood using an electric suction machine during bladder-wall resection. The urinary bladder was packed with moist saline-soaked gauze to arrest hemorrhage and spillage of urine.
|Figure 9: Pre-placement of four stay sutures on the exposed dorsum of the urinary bladder (UB) (a) for partial cystectomy (b) in preparation for reconstruction (Colo-peritoneo-cystoplasty)|
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Urinary bladder repair (colocystoplasty)
The composite colo-peritoneal pedicle (accompanied by its mesenteric supply) flap was finely “tailored” and grafted to the defective site of the urinary bladder to correct the defect by initial placement of four interrupted sutures, anchoring the colo-peritoneal tissue at the four right angles of the defect in preparation for the bladder reconstruction (colo-peritoneo-cystoplasty) using size 4/0 Vicryl (R). The moistened gauze was then removed and simple continuous (interlocked after every three bites) suture pattern using size 4/0 Vicryl (R) was employed to close the bladder defect [Figure 10]a. The urinary bladder of each dog was catheterized transabdominally [Figure 10]b before the final closure of the defect with a 2-way standard Foley catheter (10FR) (Becton (R) - Zhanjiang Star Enterprise Co. Ltd., Zhanjiang, China). The cuff of the catheter was inflated to occupy the urinary bladder cavity and make the bladder wall turgid in order to drain the bladder post surgery [Figure 10]c. The suturing was continued [Figure 11]a and the bladder defect was closed into its initial water-tight state [Figure 11]b. The Foley catheter was connected to the tube of sterile urine collection bag (U-MEC, DRAINAGE BAG (R) — Jiangsu Kaishou Medical Apparatus Co. Ltd., China) for periodic urine collection (14–28 days) after surgery and occasional bladder flushing.
|Figure 10: Colo-peritoneo-cystoplasty: Note the reconstruction of the urinary bladder defect with composite colo-peritoneal pedicle (a) tissue using size 4/0 Vicryl(R), transabdominal catheterization (b) using in-dwelling, 2-way Foley catheter (10FR) which was inflated (c) intra-cystic, making the bladder wall turgid|
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|Figure 11: Anastomotic point (a) of the composite colo-peritoneo-cystoplasty (reconstructed urinary bladder) and reconstructed urinary in a dog engorged with inflated Foley catheter (10FR) intra-cystic (b)|
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Abdominal closure was performed in three layers using size 1/0 Ethicon-Vicryl (R) (Polyglactin 910- Johnson-Johnson Jult, Belgium), size 1 Ethicon-Vicryl (R) (Polyglactin 910- Johnson-Johnson Jult, Belgium), and size 1 Nylon (OGOTEX, NYLON MONOFILAMENT (R)- Shenzhen Runch Industrial Corporation, China) for the linea alba, subcutis, and skin, respectively. The dogs were monitored until recovery from anesthesia, after which they were moved to their individual kennels for postoperative recovery and monitoring.
Post surgical care and evaluation
An Elizabethan collar was attached to the collar belt for each dog to prevent interference with the surgical site. The dogs were maintained daily on dextrose-saline (DANA Pharmaceuticals Ltd., Nigeria) solution and metronidazole at dose rate of 25 mg/kg IV for a period of 5 days IV and portable water provided ad libitum. Feeding with bland diet (a paste composed of water, ground millet and guinea corn, sugar, blood meal, and fried fish) commenced on the 5th day. Pentazocine injection (2 mg/kg) was administered intramuscularly for 5 days post surgery. Urine collected in the urine-collection bag was emptied every 12 h for 2 weeks, and the urine-collection bag was changed every other day. The Foley catheter was removed at week 2 post surgery. The dogs were monitored daily and evaluated twice weekly for the first 3 weeks post surgically by physical examination, urinalysis, and diagnostic imaging (2nd week) evaluations.
5 mm of urine was aseptically collected by catheterization from each dog twice weekly for 3 weeks post surgery into a clean sterile sample bottle for analysis. The sampling was thereafter performed weekly for the next 3 weeks. The urine sample was evaluated immediately within 60 min of collection. Two different urine analysis test strips, namely: Medi-Test Combi 9(R) (Macherey-Nagel GmbH, Germany) and ACCU-ANSWER (R) Uric 11V (Fas Test Tech Limited, London) were used for the urinalysis according to the manufacturer's instructions and values were recorded.
Cystography was performed at the 2nd, 10th, and 14th weeks post surgery as described by Muhammad et al. Briefly, each dog was fasted for 24 h before commencement of the contrast study. Diazepam injection (0.5 mg/kg IM) was administered for sedation, and the dog was restrained in a lateral recumbency, with the upper leg held away from the prepuce. The prepucial/vulva area was then prepared aseptically. Sterile lubricant (K-Y Lubricating jelly (R) - Johnson-Johnson Jult, Belgium) and 2% lidocaine hydrochloride solution (Labcalin (R) - LABORATE Pharmaceutical, India) were then placed on a sterile gloved hand. The sterile 10-Fr Foley catheter was lubricated with the K-Y jelly on the gloved hand, inserted into the urethra, which was gradually advanced to the urinary bladder. The contrast medium (Urografin76%(R)- Berlimed S.A. Spain, reconstituted to 20% solution) administered at 5 mL/kg was then infused into the urinary bladder through the catheter. Lateral and ventro-dorsal radiographic views of the abdomino-pelvic region were taken.
| Results|| |
Post surgically, the dogs were calm but inactive within the first 4 days, and complications observed were straining and constipation. The complications were appropriately handled through supportive interventions in form of drenching with liquid paraffin for 3–5 days twice daily and soapy enema once daily for 3 days.
The urine specific gravity (SG) ranged between 1.015 ± 0.002 and 1.021 ± 0.002 prior to the commencement of the surgery. The pre-surgical mean SG (1.018 ± 0.003) decreased post-surgically on days 7 (1.006 ± 0.002), 10 (1.005 ± 0.005), and 13 (1.010 ± 0.004), but later rose and fluctuated between 1.008 ± 0.002 and 1.020 ± 0.004. The rise continued up to termination of the sampling on day 42. The pre surgical pH value (6.81 ± 0.50) in the dogs fluctuated post surgically and was maintained from the range of 6.50 ± 0.15 to 7.50 ± 0.29 for 18 days. On days 21, 28, 35, and 42, the urine pH later dropped to 5.75 ± 0.48, 6.25 ± 0.25, 6.00 ± 1.00, and 6.00 ± 0.00, respectively, at the termination of the experiment. Protein was observed post surgically in the urine of the dogs for the first 7 days, but gradually reduced and disappeared completely on day 12 till completion of the experiment. Glucose was only detected in the urine of the female dog on day 7 post surgery. Hematuria observed was persistent within the first 16 days post surgery, and it gradually subsided on day 16 post surgery. Thereafter, the bloody urine ceased completely up to the termination of the experiment. The leukocyturia was observed and persisted in the dogs from day 1 to 18 post surgery. Contrast radiographic evaluation of the reconstructed urinary bladder at different periods of the study was performed in ventro-dorsal and lateral views to assess the urinary bladder silhouettes. There was gradual transition of the urinary bladder architecture at the point of patch. It appeared with clear delineation and minimal blurring at week 2 post surgery [Figure 12] that gradually disappeared following subsequent evaluations at weeks 10 and 14 postoperatively ([Figure 13] and [Figure 14], respectively). The cystogram revealed an intact and engorged urinary bladder at day 21 post surgery with irregularity at the point of patch. Slight dent was observed at the point of patch (10th week), final uniformity, and regular smooth topography (14th week).
|Figure 12: Cystograph 2 weeks after colo-peritoneo-cystoplasty, ventro-dorsal (a) and lateral views (b) in dogs. Note the clear delineation of the urinary bladder architecture and irregularity at the point of patch (circled)|
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|Figure 13: Contrast cystograph of the reconstructed urinary bladder 10 weeks post-cystoplasty, ventro-dorsal (a) and lateral (b) views in dogs. Note the clear delineation of the urinary bladder architecture and slight dent at the point of patch (arrowed) in a dog|
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|Figure 14: Ventro-dorsal (a) and lateral (b) contrast cystograph of the reconstructed urinary bladder 14 weeks post-colo-peritoneo-cystoplasty. Note the clear delineation of the urnary bladder architecture and uniform regularity in dogs|
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| Discussion|| |
Most of the aberration of the anatomic and physiologic endowment of the urinary bladder detected early makes its treatment successful. Sometimes the body naturally heals itself without adjunctive therapy provided the patient is stable, underlying cause of the trauma has been addressed, no evidence of devitalization and bladder tonicity has not been compromised, which all rely on the extent and severity of the bladder injury. The inactiveness of the dogs observed within the first 4 days in this study was attributable to the intramuscular administration of an opioid pain reliever, pentazocine. Similarly, the straining and constipation observed were apparently due to the colo-colic intussusceptions,, where the intussuscepting de-seromuscularized donor colonic segment (intussusceptum) caused partial or transient stenosis of the colon. The stenosis led to transient interference of normal intestinal peristalsis, discomfort, and straining. However, these complications (straining and constipation) were addressed appropriately by enhancing smooth intestinal evacuation through supportive interventions in form of drenching with liquid paraffin and soapy enema.
The relative decreases in SG observed within the first 2 weeks and the maintenance of urine pH around the pre-surgical value within 18 days post surgery were apparently, due to increased fluid intake through both oral and intravenous administrations of physiological saline solution, leading to production of diluted urine with relative normal urine pH and decreased SG. Upon withdrawal of the intravenous fluid and complete return to pre-surgical feeding of meal per os, the urine pH decreased, but thereafter stabilized within the base line. Traces of protein in the urine were attributed to hemorrhage and inflammatory responses, caused by irritation of the surgical site in contact with urine, surgical trauma, leading to gross and occult hemorrhages, and inflammatory exudation of plasma protein (secretory protenuria). The persistent hematuria observed could be due to extravasations of erythrocytes into the urinary bladder as a result of hemorrhages, caused by the surgical trauma on the bladder, inflammatory process, and the corrosive nature of the urine on the anastomotic site. Leukocyturia is an indicator of inflammatory response by the urinary tract following surgical trauma. High opacification revealed within the urinary bladder was clear indication of distinctive urinary bladder silhouettes and indicated near perfectly preserved urinary bladder devoid of leaks. It was also evidence of adaptation between the neocystic (composite colo-peritoneal portion) and the transitional tissues of the urinary bladder. The result was in agreement with the findings of Muhammad et al. and Probst et al., who reported uniform and smooth urinary bladder topography in dogs following colocystoplasty. The cystograms were also similar to the illustration recorded by Muhammad et al., who employed contrast cystography (using 20% solution of Urografin) to evaluate the urinary bladder following ileocystoplasty. It was deduced that the defect created on the urinary bladder mimicked conditions resulting in loss (due to disease or surgery) of significant portion of the bladder, which necessitated surgical repair by grafting technique. The decision to undertake this technique of reconstruction was based on the concept of “composite” cystoplasty, required to achieve adequate compliance, configuration of the segment on the native bladder, and assessment of the patient for the colo-peritoneo-cystoplastic procedure, as a quality-of-life intervention. Successful grafting of autologous composite colo-peritoneal tissue in the reconstruction of defective urinary bladder in dogs by means of colo-peritoneo-cystoplasty is possible through harvesting and transplanting autologous peritoneal sheath onto harvested vascularized, sero-muscular colonic pedicle segment to form “a pediculated composite colo-peritoneal tissue,” and grafting of the pediculated autologous composite colo-peritoneal tissue onto the partially cystectomized urinary bladder. Hematuria, proteinuria, and (pyuria) were the commonest early findings from the urinalysis post-colo-peritoneo-cystoplasty. Cystographs revealed engorged and well-preserved urinary bladder architecture with no evidence of leaks, indicative of advanced healing and adaptation between composite colo-peritoneal portion and the urinary bladder.
It was concluded that autologous composite colo-peritoneal tissue graft successfully formed was effective in the repair of urinary bladder defects in the dogs. This management intervention could be evaluated in human subjects.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]