Surgical Procedures

/Surgical Procedures
Surgical Procedures 2017-09-01T11:36:16+00:00

Surgery

No matter how minor or major the surgery, the team at Cascade Veterinary approaches it with the same careful preparation and meticulous attention to detail. In every case, we take rigorous precautions to ensure your pet’s safety in the operating room, and give you the peace of mind of knowing your pet is in the hands of a proven professional using advanced surgical procedures.

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Abdominal exploratory surgery, also referred to as laparotomy, is an open surgical procedure to biopsy organs, or to remove previously identified abdominal masses or foreign bodies associated with the digestive tract and abdominal organs. If the procedure is primarily to biopsy an organ of concern, the surgeon typically will explore the entire abdomen to look for any other abnormalities. In the case of abdominal masses, a CT (cat) scan may be recommended prior to surgery to identify the extent of tumor involvement with the organs and to determine if the tumor can be adequately removed. If a foreign body in the abdomen has been identified (usually by radiographs or ultrasound), the surgeon will remove the foreign body material and any surrounding damaged tissue, which may require some reconstruction of the digestive tract.

  • Anal Sacculectomy – for treatment of chronic anal gland infections/impactions or tumors
  • Rectal Polyp/Mass Excision/biopsy
Hernia repair (abdominal, umbilical, inguinal, perineal)
Brachycephalic syndrome encompasses an array of anatomical abnormalities that may require correction in order to improve a dog’s airway and decrease respiratory distress. These abnormalities, which primarily affect short-nosed and flat-faced breeds, include elongated soft palate, stenotic nares (too-narrow nostril openings), abnormal tonsils, larynx or vocal chords, and an underdeveloped trachea. If any of these abnormalities is suspected, an upper airway exam is recommended before proceeding to surgery. The upper airway exam is performed under gradual anesthetic induction prior to intubation, allowing the surgeon to visualize the soft palate, the laryngeal saccules (membranes on the larynx), the tonsils, and the trachea. The nares are visually inspected to determine if they may be impacting the dog’s ability to move air through the nasal passages.

During soft palate resection, a stay suture is placed at one side of the soft palate and left long. Another stay suture is placed on the other side of the soft palate, creating a starting point for suturing. The soft palate is resected with scissors in line with the margin of the tonsils. The surgeon then begins suturing along the palate, finishing by tying on to the first stay suture.
The breathing tube must be removed briefly to allow access to the everted laryngeal saccules (membranes on the larynx which have “popped out”). The surgeon grabs each saccule with forceps and excises them at their base with scissors. No sutures are required for this portion of the surgery. If the tonsils are everted enough to require excision, they are similarly removed, with using cautery to control bleeding.

Finally, the nares are corrected by a vertical wedge resection of the alar folds (bulb in the nostril), and the site is sutured closed. Currently there is no surgical procedure to correct a hypoplastic trachea, a condition in which abnormal growth of cartilage rings forming the trachea narrows the trachea, making it difficult to breathe. If the trachea is severely narrowed, a permanent tracheostomy may be performed to allow air to bypass the trachea and enter the airway directly through the tracheostomy site. Post-operatively, the patient needs to be kept quiet and fed soft food for the first 2 weeks. Any sudden sign of respiratory distress necessitates an immediate evaluation by a veterinarian. A recheck exam and suture removal (if any are present) is recommended at 2 weeks post-op. 

  • Congenital Heart Defects (PDA correction)
  • Pericardial Disease (pericardiectomy/ pericardial window)
  • Heartbase Tumors
  • Diaphragmatic Hernia repair
  • Lung Tumor/Abscess
  • Mediastinal Tumors
  • Chylothorax
  • Spontaneous Pneumothorax
Femoral Head Ostectomy, aka FHO, is a surgical procedure used to manage pain caused by arthritis associated with moderate hip dysplasia, as well as for traumatized or luxated (dislocated) hips that are not repairable by other means.

In this procedure the surgeon removes the femoral head and neck (the “ball and stem” of the ball and socket joint) to abolish contact between the femur (thigh bone) and the pelvis (socket) in an effort to prevent the pain associated with abnormal or diseased contact. Typically a bone saw or bone chisel is used to cut the bone. Careful attention is paid to ensure removal of all the “stem” portion of the femur to reduce the chance of further contact between the two bones.

Recovery from this orthopedic surgery is very different from most other orthopedic procedures in that the patient is encouraged to use his or her affected leg immediately. Progressive activity strengthens the muscles and tendons around the hip that support the femur, acting as a new “false” joint that is indeed stable and functional without the ball and socket mechanism.

Complications with this surgery are rare, but can include infection at the surgical site, and unwillingness to use the operated leg. Infection can be avoided by use of an e-collar to prevent licking of the incision. Patients reluctant to use the affected limb can be helped with physical therapy, including range of motion exercises. Controlled activity (progressively lengthening leash walks, short stairs or hills, swimming) can help rehabilitate the patient’s leg and return it to near normal function.

All our surgeons recheck and remove sutures, if present, at two weeks post op. Rechecks past this point are determined on a case-by-case basis

Numerous types of fractures occur in cats and dogs, some being repairable with short splint, and others necessitating surgical intervention. Depending on the type, location and timing of the fracture (recent or not), a properly placed splint (sometimes even molded to fit the patient’s limb) and regular bandage changes are enough to allow the fracture to heal on its own. If this is not the case, the fracture site will require correction for proper bone alignment, with pins or a plate used to stabilize the fracture while it heals. A splint or soft compression bandage may be placed over the limb for extra support during healing. Strict confinement during this time is crucial to the healing process, as the surgical repair can only do so much to protect the fracture.
  • Biopsy
  • Bowel Resection
  • Foreign Body Removal/Obstruction
  • Feline Megacolon (subtotal colectomy)
  • Ear Disease (total ear canal ablation, lateral ear resection, bulla osteotomy)
  • Salivary Mucocele/Cyst excision
  • Oral/Facial Tumors
  • Gallbladder Mucocele
  • Bile Duct disease/biliary diversion
  • Liver biopsy/liver mass excision
  • Portosystemic Shunt (liver shunt) correction
A hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it. Fascia is the soft connective tissue just below the skin that wraps and connects muscles, bones, nerves and blood vessels. Common hernias include umbilical and inguinal, involving the abdominal wall.

An umbilical hernia occurs at the site of the original umbilical cord and is a defect in closure of the abdominal wall with resultant fat herniation if small, but could be intestine if enlarged enough.

An inguinal hernia occurs at the inguinal ring, which allows blood vessels to exit between muscle layers from the abdomen into the inguinal region (the lower lateral region of the abdomen on either side of the pubic region — also called iliac region). It is an enlargement of the ring from weakening that allows fat and possibly intestines to collect in a hernial sac.
Hernias usually enlarge over time. Hernias can occur in the perineum, around the anus, or as a traumatic event anywhere in the abdomen or thorax.

Hernia repair is ideally performed early while they are small to prevent large defect from occurring that can make repair more difficult and recurrence more likely. Typically, local host tissue is used to reconstruct or close the defect. Sometimes a hernia is too large to close without using a mesh material to cover and aid in closing local tissues.

Post-surgery after care is aimed at decreasing pressure on the reconstruction site while the tissues are healing and gaining strength to prevent re-herniation. During this phase, very strict control is required to minimize running, jumping and straining, all of which can result in disruption or failure of the repair. It typically requires 4-6 weeks of healing to gain enough strength to begin reintroduction to normal activities over another 4-6 weeks. 

  • Medial Patellar Luxation Correction (including prosthetic patellar groove replacement)
  • Elbow Dysplasia (fragmented coronoid excision, ununited anconeal process, proximal abducting ulnar osteotomy, sliding humeral osteotomy)
  • Limb Growth Deformities (corrective osteotomies)
  • OCD (shoulder, elbow, knee, ankle)
  • Hip Dysplasia (triple/double pelvic osteotomy, juvenile pubic symphysiodesis, femoral head/neck ostectomy)
Laryngeal paralysis is a condition in which the opening to the windpipe in the back of the throat (the larynx or voicebox) becomes paralyzed. This opening consists of two cartilage structures that act as “doors” that actively open wide during each inhalation. When these structures are paralyzed, the doors are effectively closed, causing varying degrees of increased effort and distress in trying to breathe in. In early stages this may manifest as harsh, raspy panting owing to the turbulent air passing through the small opening in the larynx, and can also change the pitch of a dog’s bark.

Patients for whom the condition worsens often become intolerant of any sort of exercise — becoming less willing to go on long walks or to run. Hot weather, excitement and exercising in hot weather become dangerous, as patients cannot move enough air over their tongues to cool themselves (dogs do not sweat, and rely on evaporation of saliva over their tongues to regulate their body temperature). In the most severe cases, dogs can present to an emergency room hyperthermic and gasping for air. Left untreated, the condition can be fatal.

In certain breeds, puppies can be born with the disease (i.e., a congenital form). There are also specific problems that can cause laryngeal paralysis, such as trauma or a tumor affecting the nerves supplying the larynx, or neuromuscular disease such as myasthenia gravis. However, far and away the most common form of laryngeal paralysis is a syndrome in older sporting breeds (a classic case would be a 12-year-old Lab) in which the specific cause is unknown.

Treatment involves a surgical procedure to widen the opening to the larynx to allow more air flow. In most cases, this is done by means of a laryngeal “tieback” in which a suture or sutures hold one of the cartilage doors open permanently so as to allow for ease of breathing at rest or during mild activity. It is not, however, a “normal” opening, and pet owners must take care not to allow strenuous activity, especially in hot weather.

Most patients are markedly improved immediately after surgery, and live out their lives relatively asymptomatic. However, the procedure is not without risk; among potential complications, the most significant is pneumonia resulting from aspiration of food or water into the lungs through the enlarged opening to the larynx. The risk of aspiration pneumonia is minimized by feeding wet food in bite-sized portions in a head-down position, such as from a bowl on the floor. In cases in which pneumonia does develop, it is usually mild and resolved with antibiotics.

A liver shunt is an abnormal vessel that bypasses the normal transport of blood through the liver. Normally, there are two distinct and separate types of venous blood circulation in the body — the “portal” circulation and the “systemic” circulation, separated from each other by the liver. Blood from the gastrointestinal tract, rich in nutrients and ammonia, is transported via the portal vein to the liver, where these compounds are metabolized and detoxified before passing into the “systemic” circulation (via the vena cava, the main vessel returning blood to the heart), where it is pumped out by the heart to the rest of the body and brain. In patients with liver shunts, an abnormal vessel allows portal blood to bypass the liver and flow directly into the “systemic” bloodstream where the toxins can adversely affect the brain and other organ systems, causing generally poor health and sometimes seizures or other neurologic signs. Hence, these are called “portosystemic shunts” (PSS).

Surgically treatable forms of PSS are congenital – a defect at birth – so most of these patients’ problems are recognized at a relatively young age, through symptoms such as failure to grow, develop and/or thrive, showing neurologic signs, or having elevated liver enzymes or abnormal liver function (“bile acids”). In the patients, because the liver has never received the normal blood flow to sustain it, it is usually smaller than normal. The shunt can be located either outside the liver (“extrahepatic” — usually small breed dogs and cats), or within the liver itself (“intrahepatic” — usually larger breed dogs). To make matters more complicated, there can also be a congenital form in which the shunting occurs at a microscopic level within the liver substance, called “microvascular dysplasia, which is not treatable surgically. Finally, some dogs with severe liver disease can develop multiple “acquired shunts” as adults, secondary to increased portal blood pressure from the liver disease.

Patients suspected of having a congenital PSS usually have an abdominal ultrasound as part of the diagnostic workup to attempt to identify the shunt. Failure to find the shunt on ultrasound does not necessarily rule it out, however, and surgical exploration of the abdomen is often still recommended if all other factors point to a shunt being present. If a shunt vessel is found at surgery, an “ameroid ring constrictor” is placed around the shunt near its confluence with the systemic circulation (usually the vena cava). A liver biopsy is taken, and if the patient is not yet spayed or neutered, this is performed at that time. The bladder is also checked for stones that sometimes occur in these patients. The ring constrictor gradually closes off the shunt over a 4-6 week period after the surgery. This allows the liver to adjust gradually to the additional new blood flow being redirected through it, preventing excess pressure from building up on the portal side of the circulation. The most significant potential complication is the development of seizures in the first few days post-op, which can be life threatening. Fortunately, this is relatively rare, and is minimized by preemptively placing the patient on an antiseizure medication prior to surgery and for two weeks postoperatively.

Post-op, patients are typically placed on a prescription diet intended to minimize the toxins available to be absorbed into the portal circulation while the constrictor is closing off the shunt, and to promote healing of the liver. At three months post-op, liver function tests are repeated. If the results are normal, then the patient is deemed cured, and can be switched gradually back to a normal diet. If the values are improved but still not normal, the prescription diet is continued and rechecked again in three more months. In some dogs, the liver does not fully normalize, and these patients may need to continue the special diet indefinitely, although they are typically asymptomatic for liver disease. 

Many different types of tumors can be surgically excised, either through debulking in preparation for chemotherapy or radiation, or as a means to improve comfort if follow-up treatment will not be pursued. Prior to surgery, the mass is typically aspirated and the sample is sent to the lab to determine the type of tumor cells present. Based on these results, a CT (cat) scan of the mass and surrounding area may be recommended to determine if removal with clean margins is possible. These tumors are generally excised with an elliptical incision around the majority of the mass, with a margin of several millimeters of tissue or muscle, if possible, depending on the location of the mass. The mass is sent to a pathologist to confirm the type of tumor and whether the margins taken around it were adequate and clean. This diagnosis aids in generating a treatment plan for the patient in the future.
Patellar luxation is a common orthopedic disorder in which the kneecap (patella) dislocates out of the groove in the upper knee joint where it resides. It can occur as a result of traumatic injury, but is far more commonly congenital – that is, a conformation that predisposes a patient to developing the condition. The condition most often becomes evident as a problem at age 1 to 2 years, and often involves both knees. The patella can luxate either to the outside or the inside of the knee, but most often dislocates to the inside, or “medially.”

Early on, owners may notice their pets “skipping” or lifting one leg for a few steps when the patella luxates, abruptly returning to his/her normal gait once the patella has popped back into place. Sometimes the patella can be felt popping back and forth. Eventually lameness becomes more frequent or even constant, and the knee may become very painful if the cartilage is damaged.

Treatment is by surgical correction of the contributing abnormalities. This may involve deepening the groove in which the patella rides, freeing up tightened or scarred tissues that are pulling the patella out of the groove, and also tightening the tissues on the opposite side to anchor the patella in its proper position, to prevent luxation. In some cases, the attachment of the patellar tendon is relocated to better align with the groove. In the most severe cases, it may be necessary to cut the femur (thighbone) or tibia (shinbone) and apply a plate to align the bone with the patella.

Regardless of the techniques used for correction, recovery generally involves at least six weeks of absolute confinement and restricted activity to protect the repair. Physical therapy during this time is also important. Prognosis is excellent, and in most cases, patients return either to normal or markedly improved leg function.

  • Fracture/Luxation (dislocation) Repair
  • Plate Fixation
  • External Skeletal Fixation/Circular ExFix
  • Intramedullary pinning/cerclage wire
  • Toggle-rod Fixation for hip luxation
  • Cruciate Ligament Injury/Disease
  • Tibial Plateau Leveling Osteotomy (TPLO)
  • TTA
  • Lateral Fabellar Suture
  • Fibular Head Transposition
  • Juvenile Orthopedic Diseases
  • Medial Patellar Luxation Correction (including prosthetic patellar groove replacement)
  • Elbow Dysplasia (fragmented coronoid excision, ununited anconeal process, proximal abducting ulnar osteotomy, sliding humeral osteotomy)
  • Limb Growth Deformities (corrective osteotomies)
  • OCD (shoulder, elbow, knee, ankle)
  • Hip Dysplasia (triple/double pelvic osteotomy, juvenile pubic symphysiodesis, femoral head/neck ostectomy)
  • Traumatic Wound Reconstruction (skin flaps/grafts)
  • Reconstructive closure of defects from large tumor removal
  • Lip fold, nasal fold, vulvar fold resection
  • Oncologic (cancer) Surgery – curative intent and palliative removal of tumors
  • Skin and Soft-Tissue Tumors (mast cell tumor, soft-tissue sarcoma, etc)
  • Bone Tumors (osteosarcoma, etc; limb/digit amputation)
  • Oral Tumors (upper/lower jaw, tongue, lip, skull, face; mandibulectomy, maxillectomy, orbitectomy, etc)
  • Nasal Tumors (biopsy, laser ablation)
  • Neck Tumors
  • Thoracic Tumors (lung lobectomy, mediastinal tumors, heartbase tumors)
  • Body Wall tumors (chest/abdominal wall resection and reconstruction)
  • Abdominal Tumors (splenectomy, bowel resection, liver lobectomy, nephrectomy, uterine tumors)
  • Endocrine/Glandular Tumors – thyroid/parathyroid, pancreas, adrenal, salivary, prostate, anal sac
  • Urogenital (bladder/urethra, penis, vagina) – partial cystectomy, laser ablation, urethral stenting, perineal urethrostomy, scrotal urethrostomy
A spinal fracture is different than a broken arm or leg. A fracture or dislocation of a vertebra can cause bone fragments to pinch and/or damage the spinal nerves or spinal cord. Most spinal fractures occur from car accidents, falls, or gunshot injuries. Fractures and dislocations of the bony vertebrae can result in debilitating spinal cord damage. Depending on the severity of the injury, your pet may experience pain, difficulty walking, or be unable to move their legs (paralysis). Severe fractures may require surgery to realign the bones and stabilize them for proper healing of nerve or spinal cord injury.

There are a number of ways to stabilize a vertebral injury, including the use of bone plates and screws and external skeletal fixators (ESF). With ESF, pins are drilled into the vertebral bodies of the unaffected vertebra in front of and behind the fractured vertebrae with distraction of the fracture segment and connection of pins w/ bars and clamps outside the body. The ESF stays on while the bones heal, and are removed once they have healed, usually 6-10 weeks later.

During the fracture healing period, your pet must be strictly confined and assisted as needed for eliminations. This is to protect the fracture repair from prematurely loosening or failure of the implants or bones the implants are placed into. The outcome of spinal fracture repair is dictated by many variables, but most strongly by the degree of injury prior to repair, how well the implants purchase and stabilize the involved area, and by how well the individual is protected/ confined and assisted during the bone healing period.

Lung lobe and heart base masses are particularly difficult to access and remove. When any type of chest mass has been identified on radiographs, a CT (cat) scan is recommended to define the tumor’s extent for surgical planning. Ideally, if the mass is located in an area that is accessible with the laparoscope, a thoracoscopy can be performed. If a heart base mass is present, it often causes pericardial effusion (fluid buildup in the sac surrounding the heart). Unfortunately, heart base masses generally cannot be excised, but a window can be made (pericardiectomy) in the pericardium (the sac surrounding the heart) to prevent further fluid buildup around the heart and lessen the strain on the heart’s everyday function.

To perform a thoracoscopy, the surgeon makes a portal incision between the ribs. Air is then allowed to enter the space between the lungs and the chest wall, causing the lung to partially collapse and increasing visibility of the surrounding structures. The scope is inserted into the chest cavity, and the contents of the chest are explored. Additional portal incisions are then made to allow the insertion of instruments to aid in removal of tumor tissue or diseased lung, or to perform a pericardiectomy (removal of part or the entire sac around the heart). Depending on the amount of diseased tissue to be removed, a tissue retrieval bag may used to pull the tumor tissue from the chest cavity. If a pericardiectomy is being performed, then the pericardium is elevated away from the heart with forceps, and an approximately 2 x 2-cm segment of tissue is cut with a vessel sealing device and the tissue is removed from the chest.

Once the surgery is complete, a chest tube is inserted through the portal incision site and sutured to the chest wall. The remainder of the incision is closed around the tube with a combination of sutures and staples. The chest tube is attached to a drain that continuously pulls any accumulated fluid out of the chest to prevent buildup and to help any tissue irritation resolve quickly. The drain usually remains in place one to two days after surgery, or until drainage has adequately slowed.

A thoracotomy is performed when a mass is not completely accessible with the laparoscope. If entrance into the chest began with a thoracoscopy, the same portal incision is made larger, and the ribs are spread apart with instruments. In rare cases, the sternum is split with a surgical saw and held open with rib spreaders. This procedure, called a sternotomy, is used when the diseased area is not accessible from the side of the chest or the mass is too large to fit through the rib cage. Surgical wire is used to close the sternotomy site in these cases. A chest tube drain is placed in similar fashion as with a thoracoscopy. 

ibial plateau leveling osteotomy is a surgical procedure used to stabilize the instability in the dog’s knee (stifle) caused by cranial cruciate ligament (CCL) injuries. CCL injuries are increasingly diagnosed and treated in dogs. To understand the procedure, a discussion of the mechanics of the stifle is needed. Weight-bearing forces in the rear limb are transferred from the ground to the hip through the stifle. The CCL (anterior, or ACL, in people) stabilizes the tibia from sliding forward relative to the femur (thigh bone). The top of the dog’s tibia, termed the tibial plateau, is angled backward relative to the weight-bearing forces as compared to humans. In humans the tibial plateau is perpendicular to the weight-bearing forces. The primary difference between dogs and humans is that when the dog bears weight and the stifle joint is loaded, there is a forward thrust that is generated and counteracted by the CCL. In humans there is no cranial thrust when the knee is normally loaded, and the ACL is therefore less “challenged” than the CCL in the dog’s knee.

ACL injuries in humans are almost always sports related traumas, but for dogs, the cause is rarely a traumatic event. The cause for the increasing frequency of CCL injuries in dogs is not well understood; however, it is understood that causes vary, including genetics, inflammatory conditions, and conformation. We do know that repetitive explosive activities, such as chasing balls, Frisbees, squirrels, etc. put the ligament under abrupt heavy loading and too much thrust can cause the ligament to tear. The ligament can acutely fail, tearing completely with resultant significant pain and lameness, or tear fibers in multiple events over time with a complete tear as a later event. In the later scenario of partial tears, lameness is less dramatic with partial recovery, and presents as chronic progressive lameness until a complete tear occurs. As in all species, the CCL does not heal, and as the ligament weakens with progressive injury, it is destined to fail completely. For this reason surgery is the mode of choice for management of CCL injuries in dogs, whether they are partial or complete.
The meniscus, a cartilaginous C-shaped tissue that acts as a cushion and stabilizer between the femur and tibia, can also become injured and if injured will need to be removed ( partial meniscectomy) in conjunction with stabilization of the stifle.

Surgery to manage CCL injury falls into two broad categories: replacement/substitution vs. proximal tibial osteotomy methods. The later does not attempt to replace the ligament/function but rather changes the mechanics of the stifle to abolish the thrust that creates the instability. The later is often selected over replacement/substitution methods, because historically replacement/substitution methods have had a high failure rate.

TPLO is performed to lower the tibial plateau slope to abolish the thrust, eliminating the need for the cruciate ligament. Prior to surgery, x-rays of the knee measure the tibial plateau slope angle, which determines the amount of rotation needed to level the plateau to an ideal 5 degrees. Prior to making the osteotomy (cutting the tibia), the joint is explored to confirm the damaged CCL and to inspect the meniscus. Any damaged ligament and/or meniscus are removed prior to making the osteotomy. The top of the tibia is cut with a circular saw blade, allowing the plateau to be rotated to the desired slope. Once the plateau has been rotated to the desired degree, the osteotomy is stabilized with a bone plate and screws to maintain the new position while the bone heals. Postoperative x-rays confirm the tibial slope and implant position.

Complications with TPLO surgery are infrequent with appropriate surgical technique and aftercare, but can include fracture of the fibula, breakdown of the TPLO fixation, or infection at the surgical site. Complications can be minimized by following appropriate aftercare instructions, which include a strictly controlled environment which does not allow explosive movements during the healing period, such as running or jumping, and the use of an e-collar to prevent licking of the incision.

All our surgeons recheck at two weeks post-op, and take follow-up x-rays at 6-8 weeks to assess bone healing prior to beginning a plan for rehabilitation/reintroduction to activity. At this point, a third recheck may or may not be needed and is determined by the doctors follow-up protocol and healing of the bone at the TPLO site.

  • Laryngeal Paralysis
  • Brachycephalic (“bulldog”) Airway Correction
  • Larygeal Collapse
  • Tracheal Collapse/Tracheal Stenting
  • Stone removal (bladder/urethra/ureter/kidney)
  • Perineal Urethrostomy (cats)
  • Scrotal Urethrostomy (dogs)
  • Subpubic Urethrostomy (dog or cat)
  • Ectopic Ureter Correction
  • Urinary Incontinence (urethral sphincter augmentation, colposuspension)
  • Prostatic Abscess drainage
  • Urinary Diversion (cystostomy tube)
  • Uterine/Vaginal Tumors