Tortoise Bladder Stone

Introduction
Symptoms
Diagnosis
Treatment

Introduction

One of the more interesting and unique surgeries we perform is the removal of a bladder stone from California Desert Tortoises. Some of these stones grow to tremendous size, and it is a wonder that these animals can survive with such a problem. Other animal species get bladder stones, but none of them are anywhere near as large as tortoise bladder stones.

This page has 2 short Quicktime videos that will take a few extra minutes to download. If you do not have Quicktime it has available at apples web site. (www.apple.com).

Symptoms

There are no specific symptoms that tell us a tortoise has a bladder stone, some of them don't show any symptoms at all. The more common symptoms are nasal discharge, poor appetite, and lethargy. Some of these stones are diagnosed as incidental findings when we take an x-ray or perform an exam for an unrelated problem. The tremendous size of some of the stones indicates they may have been present for years before being diagnosed. Anybody that has ever had a kidney stone can sympathize with what these animals feel like with such large stones.

Diagnosis

There are two methods utilized to diagnose bladder stones. During an examination we can sometimes palpate a stone by gently rolling the tortoise back and forth while we feel in the soft spot by its rear leg. To perform the palpation technique you need to understand tortoise anatomy and be experienced at palpation.

Not every stone can be found on palpation. The other method to make a diagnosis, and usually more reliable method, is to take an x-ray. Even though the stone in this x-ray is large, this is not an unusual finding. Some of the stones are so large that we have to break them into pieces to get them out of the opening in the shell.

Surgical Procedure

The usual treatment for a bladder stone in tortoises is to perform surgery to completely remove the stone. In this surgery we literally cut a hole in the bottom of the shell and remove the stone from the bladder. Most tortoises do fine postoperatively, and after a few days in the hospital and a few weeks of recuperation at home, they are back to normal. We tend not to perform this surgery when hibernation is near.

The following area contains graphic pictures of an actual surgical procedure performed at the hospital. It may not be suitable for some children (and some adults also!).

Prior to surgery our patient is prepared to minimize anesthetic risk. In some patients we place a feeding tube to insure adequate hydration and nutrition, both before and after the surgery. In other patients we insert an intravenous catheter (IV) to maintain blood pressure during surgery.

This tortoise has an IV catheter in its jugulare vein. We use this vein because it is relatively easy to insert the catheter and it is large enough to take the volume of fluid we need to give.

Once the tortoise is stable and ready for surgery we gently induce anesthesia with a mask.

When fully relaxed we gently inserted a breathing tub called an endotracheal tube (ET). This facilitates the administration of oxygen and anesthesia in a much more efficient manner.

While our patient is being prepared Dr. Ridgeway is preparing his instruments

After the tortoise is anesthetized the bottom of the shell (called the plastron) is cleansed thoroughly. This may take several scrubbings with the use of a gentle brush to get clean enough for surgery. The black rectangle outlines where the shell will eventually be cut to gain access to the bladder.

When the shell is clean our surgeon carefully commences the draping process. This is important to prevent contamination and infection.

Infection is especially critical in this surgery because once the cut piece of shell is resealed to the bottom of the shell, an infection can fester on the inside without our knowing about it.

The rest of the surgical team is preparing at the same time. These assistants are students in our externship program. They will be assisting the surgeon with flushing and suctioning of fluids, along with the administration of anesthesia.

Even though it is living tissue, which means it has feeling and bleeds, tortoise shells are tough. We use a special drill called a dremel to cut the shell. This close up view shows the serrated edge.

Dr. Ridgeway starts his cut with his safety glasses on to protect him from particles brought on by the drill used to cut into the shell.

The blade spins at a high speed so sterile water needs to be constantly applied to the cut surface to minimize burning. The blade cuts at an angle facilitating replacement of the shell when the surgery is complete. If this angled cut is not made, the shell will just fall back into the abdominal cavity (it is called the coelomic cavity in a reptile) and the incision site will never heal.

We have a short Quicktime video of this part of the surgery. Double click on the picture below to start it.

When the shell has been cut in a rectangular piece it is gently pried up with an instrument called an elevator. There are muscular attachments that are gently separated from the shell to allow the shell to become completely free. The cut shell is living tissue and needs careful handling. After it is removed it is kept moist with sterile saline until it is replaced at the end of the surgery.

The rectangular piece of cut shell is removed and placed inside saline soaked gauze until it is put back at the end of the surgery

The next layer encountered is the lining of the coelomic cavity. It is gently cut to give full exposure to the organs in the cavity. The reddish areas are the muscular attachments to the piece of shell that was removed.

Internal organs can be visualized easily through this large opening. These are egg follicles.

Before we proceed further fluids in the coelomic cavity are suctioned out for better visualization

The bladder is gently exteriorized through the hole in the shell

This stone was too large to fit the opening so the lining of the coelomic cavity had to be enlarged. For faster healing me make this opening just large enough to gently squeeze the bladder out of the cavity with the stone still inside the bladder.

Using instruments and gently traction the offending bladder finally gives up and out it comes

When fully exteriorized it is packed off so no debris falls back into the coelomic cavity

Before actual stone removal a "stay" suture is placed in the bladder at two locations. The suture is then attached to a hemostat and clamped to the towels. This prevents the bladder from falling back into the coelomic cavity when the stone is removed.

Dr. Ridgeway has made an incision into the bladder and the stone is starting to bulge out

Here is the culprit as it is being removed from the bladder

The bladder is usually filled with a sludge like material. If the sludge is not removed healing will be delayed and the potential for recurrence of the stone increases. The larger clumps of sludge are removed with a special instrument called an angle spoon. This high tech instrument is made special in our lab by taking a regular tablespoon and bending it.

The smaller pieces are suctioned after the bladder has been flushed. This usually takes many flushings with sterile saline. Only when the bladder has been thoroughly flushed is it sutured back together. Notice how inflamed the inner lining of the bladder has become from the tremendous irritation from the stone. This bladder is also thickened for the same reason. A normal bladder is very thin walled, almost like tissue paper.

A special suture material is used to close the opening in the bladder. This suture is very strong yet causes minimal tissue reaction, and will slowly dissolve over several months.

The coelomic cavity is also flushed copiously with warm sterile saline, then the fluid is suctioned out. This process helps prevent an infection and aids in the healing process. If an infection is sealed into the coelomic cavity the outcome could be catastrophic.

The incision made in the tissue lining the cavity is sutured next, using the same type of suture material as the bladder. The muscular attachments to the cut piece of shell will gradually reestablish themselves to the underside of the cut piece.

While all of this was going on the piece of shell that was removed at the beginning of the surgery was kept moist by wrapping it with sterile gauze soaked with saline. Doctor R is removing the gauze before putting the cut piece of shell back in place.

When the shell is back in place bone wax is used to help seal the edges

Now the fun of putting the shell back together begins. The previously removed piece of shell is put back into position and a piece of fiberglass is measured and cut so that it just covers the cut piece of shell.

A special quick drying epoxy is poured on the shell. Once this epoxy hardens it can not be removed or reshaped, so we have to move fast. The first layer of epoxy is put directly on the shell.  When it gets tacky we are ready for the next step.

Before this first layer dries the fiberglass is placed on the shell and another layer of epoxy is layered.

When completed this is what the final result looks like

The epoxy becomes firm within a few minutes. During this time it is important that the tortoise does not wake up or breathe deeply because the pressure in the lungs will push the patch out. Cellophane is put over the patch for cleanliness. 

Here is our friend just waking up from anesthesia. At this point we will give her a pain injection and place her in a special room that maintains a temperature of 85 degrees. She will stay in the hospital for a few days until she is eating and active.

We have a short Quicktime video of the beating heart of a tortoise during this procedure. You can see the heart beating under a membrane because reptiles do not have a diaphragm, the muscle that separates the chest from the abdomen. If you have Quicktime double click on the picture below to watch it beat.