Imagine your pet suffers from an insidious disease she’ll have to suffer with for the rest of her life. Next, picture a simple surgery that can fix it. No more drugs. No more side effects. No more constant testing.
Not that you general practitioner or internal medicine specialist doesn’t deserve a shot at treating your pet’s ills. And trust me, you’ll not yet want to go running off to the veterinary surgeon with Dolittler post in hand expecting miracles. Nevertheless, a couple new surgeries may render some hard-to-manage diseases eminently treatable––without the benefit of side effect-ridden drugs.
Today’s two ills in question are common. One is considered just plain annoying, and because it’s often unresponsive to medical therapy, the surgical option may provide some very welcome relief. The other falls under the category of “fundamentally difficult to treat” by anyone’s standards. The possibility of a surgical treatment, though admittedly a tricky one, may well save lives for pets who don’t respond well to drug the complex drug therapies involved.
The conditions? Spay-related, hormone-responsive urinary sphincter incontinence and the dreaded Cushing's disease.
For dogs who suffer incontinence as a result of hormonal changes, medical management can be fraught with side effects and incomplete remission of symptoms. Then there are dogs whose concurrent conditions and non-urinary drug regimens may make medical treatment not so attemptable. In all these cases, surgery is an option. Here’s what it looks like according to a recent conference proceeding:
“Colposuspension is the most common surgery used to address USMI (urinary sphincter mechanism incompetence) in female dogs. This procedure involves placement of sutures from the cranial vagina to the prepubic tendon on either side of the proximal urethra, thereby positioning the proximal urethra within the abdomen and placing pressure on the urethra as it crosses the pubic brim. Several studies have looked the long-term outcome following colposuspension. One of the most recent studies reported a response rate of 82% with half of those animals completely continent without medication. These results are in contrast to a separate study which reported only a 54% response rate, although a client satisfaction rate of 86% was also found.”
Pretty good stuff, I’d say. And before I read this, I’d never once thought to refer one of my patients to the surgeons across the street for this condition––all of whom can handle this surgery in their sleep (OK, maybe not, but close).
Next up, hypophysectomy. It’s nowhere near so easy as the colposuspension, but medical treatment of pituitary-dependent canine hyperadrenocortisism (Cushing's disease) can be so complex, demanding and tricky that euthanasia is often elected in lieu of continued attempts at drug therapy. For this reason, European vets have been treating the source of the problem with brain surgery. Again, according to a conference proceeding from earlier this month:
“Hypophysectomy surgery [removal of the hypophysis (in the brain)] is performed for dogs with pituitary and adrenal-dependent [Cushing's] disease. In the United States there is limited experience with hypophysectomy for pituitary tumors but outside the United States this surgery has been performed with good results. The mortality rate can approach 10% but most dogs obtain a complete remission for several years. In addition to perioperative mortality, diabetes insipidus may occur [an easily treated side-effect that results in excessive water drinking] but is usually transient.”
The full range of risks and stats are not immediately at my command, but I’m happy to say I’ll be hearing more now that my intrepid boyfriend-the-vet-surgeon is revving up his CT scanner in anticipation of some cases.
But let’s not get too excited just yet. In the case of both these diseases, it’s clear the old ways still come first. Treating both pituitary-dependent Cushingss disease and hormone-responsive urinary incontinence will perhaps always require drugs as a first line of defense, but new treatment options are always welcome for those who can’t be treated the old way.
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Huh. Urinary incontinence and Cushing's...and yesterday's arthritis post...that's my Tessa. She's pretty well controlled by meds, though, which is nice.
Do you have any obviously-very-ballpark numbers on the possible costs of these surgeries?
Galadriel August 29th, 2009 11:56:12 AM
Anything that will have a good possibility to make dealing with a medical problem of any kind of complexity easier, sounds good to me. I've seen many cases of "I just can't handle all the ....." different compications (diabetes being the #1 issue even though many vet staff don't think it's complicated, many clients do). so the animal gets put down. Even when it's an elderly animal, if a better quality of life was available for those last months or year, the idea of giving up and getting a new pet is sad.
The new injectable AB Convenia is, in a smaller way, the same kind of valuable improvement. Cats (and dogs) who are hard to impossible to pill can now have a better outcome from wounds and some infections because of a simpler treatment. It's saved me trouble twice this year alone.
KateH August 29th, 2009 12:01:40 PM
Galadriel: In Miami, the hypophysectomy would cost about $2,500 plus the cost of the CT for proper mapping (another $750). About the same price of intervertebral disc surgery––though my source confirms that he can't speak to the price of follow-up costs. They may add up to $500-$1,000 more––or none at all. The added beenfit is that, although benefits may not last for more than 3-4 years (depending on the cleanliness of the margins at the time of surgery––surgeon skill, etc.), and the mortalty rate (as of a study 10 years ago) is at about 10%, it's a given that most dogs with Cushing's, even well-controlled ones, experience a much higher mortality rate than that within two years (50%?).
I'd love for you to add up your Lysodren or Trilostane costs so we can compare the two options' prices.
Dr. Patty Khuly August 29th, 2009 12:48:46 PM
KateH: Diabetes insipitus is infinitely easier to treat than diabetes mellitus (should've been clearer on that). In fact, it doesn't even need to be treated is the owner can put up with the excessive drinking and urination. And it's transient. KCS is another possible problem (dry eye) with this procedure. But again, it's easily managed and transient. The truth is, however, these are not animals that come attached to owners unwilling to shoulder the stress of complications like these. They're usually among the most dedicated and willing.
Dr. Patty Khuly August 29th, 2009 12:53:14 PM
I wrote an article on incontinence in 2006 that briefly mentioned colposuspension, along with a newer technique involving collagen injections for control of incontinence (http://www.dogaware.com/wdjincontinence.html). The studies that I found showed that many dogs relapse during the first year.
The study mentioned above with 82% response rate is available here: http://d.wanfangdata.com.cn/NSTLQK_NSTL_QK3779791.aspx -- it reports that 40% of dogs became totally continent and another 42% were markedly improved or totally continent with added medication, but it doesn't say how long those dogs were followed. Note this study was published in 1999; it is not "one of the most recent studies."
The second study she mentions with 54% response rate but 86% client satisfaction I found at http://avmajournals.avma.org/doi/abs/10.2460/javma.2001.219.770. It is not clear whether the satisfaction was with initial results only, as the study said that, while 12 out of 22 dogs had complete urinary control after two months, only 3 retained that control for one year. Nine of the 22 dogs had either complete urinary control (8) or great improvement (1) after one year when medical treatment was added.
Another article cites the first study above, along with a second study, but concludes, "Despite these encouraging results long-term follow-up has revealed continence rates of only 14% one year after surgery with another 33% described as "greatly improved" (Rawlings et al. 2001). An improved response to medical management was noted with 38% of bitches considered continent and a further 43% greatly improved when surgical and medical therapies were combined."(http://www.irishveterinaryjournal.com/Links/PDFs/CE-Small/CESA_December_2008.pdf).
I do think that surgery is a viable option when incontinence cannot be controlled in any other way, but I think claiming an 82% success rate is misleading.
Mary Straus August 29th, 2009 01:16:48 PM
What about using Lysodren or Trilostane to intentionally destroy the adrenal glands and create an Addisonian? Addisonian's can live a normal life with hormone replacement. From everything I have read about Cushing's I would rather have an Addisonian.
Elizabeth - from Nova Scotia August 29th, 2009 02:28:03 PM
Tessa gets a 500 mg Lysodren tab, twice a week. It's about $130 for 30 tablets (from a compounding pharmacy, so I'd guess that's about as good as the price gets around here). So, looks like about $450/yr. There's also about $150 twice a year for ACTH stim tests to check how she's doing, so perhaps $750 a year as long as everything stays on an even keel.
Elizabeth, my Tessa is doing great as a Cushing's dog. As long as she gets her meds she's peppy (for a 12-yr-old) and happy, and doesn't have any of the major Cushing's symptoms. I'd rather maintain her as she is now than deal with the see-saw of a dog who may go into Addisonian crisis due to stress or unpredictable life events. It was worrisome enough when Tessa was going through her "loading" phase (getting Lysodren daily to get her back to something like normal, which might have caused an Addisonian crisis if she responded strangely). I have a friend with an Addisonian dog, and Tessa's condition is *much* more easily manageable, much less stress.
I know there are dogs whose Cushing's is a lot more hassle, but that's not all of them. Tess was diagnosed about this time last year, and treatment turned back the clock for her; I now expect her to be with me for many years yet, even though she's a 12-yr-old 50-lb dog with some hefty arthritis. She gets her Lysodren, her diethylstilbetrol, and her Adequan and she's a happy girl. She's over there wagging in her sleep right now.
Galadriel August 29th, 2009 03:04:21 PM
Galadriel : It sounds to me like we may both have the wrong idea both about Addison's and Cushing's. Addisonian's who are properly managed on a drug like percorten do not see-saw in and out of crisis at all actually. Now it is harder to manage an Addison's dog on Florinef. Once you find the LED ( lowest effective dose ) of percorten and prednisone for an Addisonian there should never be a crisis again. If your friends dog is having problems she might want to check out the Yahoo support groups for AD Dogs, awesome group! http://pets.groups.yahoo.com/group/AddisonDogs_/
Elizabeth - from Nova Scotia August 29th, 2009 04:03:12 PM
"Huh. Urinary incontinence and Cushing's...and yesterday's arthritis post...that's my Tessa. She's pretty well controlled by meds, though, which is nice. Do you have any obviously-very-ballpark numbers on the possible costs of these surgeries?"
Yes this is a very good question, I have my cat controlled with Lysodren http://www.entirelypets.com/lys500mgpert.html if that helps
Davendra August 29th, 2009 05:37:32 PM
Great info Dr Patty, thank you!
I've got a 7 year old bitch who has had spay incontinence for about 5 years now. She has an unrelated neurological disorder, and for some reason both DES and PPA increase her ataxia. Finding a balance point between soaking everything she sleeps on (I long ago covered practically everything in the house with waterproof covers, but it still means doing a LOT of laundry) and her not being able to walk has been frustrating to say the least! I hadn't heard of any surgical options, it is possible she's not a candidate but I'm sure going to check it out. No lie - we are hardly rich but I've gotten to the point that it would be worth several thousand to me to be able to solve the problem!! (She had a BAD night last night, can you tell I'm nearly at my wit's end?<g>)
Barb August 29th, 2009 06:52:00 PM
Oh, Dr. K. that photo of the puppy 'waving' is too cute! Is that one of your happy patients?
KateH August 29th, 2009 09:03:01 PM
Well, being on the third dog with Urinary incontinence and being totally tired of having to give pills everyday. This is an excellent option. May have to ask my vet about it. Oh, but wait, Chloe is a bleeder so may not be the best for her. But my next dog??? What does your source cost this out at?
Sharon August 29th, 2009 10:42:37 PM
Sharon: This surgery's much easier than a hypophysectomy. But you're still looking at $1,500-$2,000 in my 'hood. But then, even a soft palate resection goes for $1,200-$1,500 at a specialist's.
Sounds like the note of caution Mary Strauss sounded above is worth looking into, though, before proceeding. Thanks for that, Mary, I'll be checking into it.
Dr. Patty Khuly August 30th, 2009 07:36:04 AM
Dr. Khuly:
In our CanineCushings-AutoimmuneCare Group, we have a number of dogs who have undergone transsphenoidal surgery for the treatment of functional pituitary macroadenomas. One of our list members, David Bruyette, DVM, DACVIM, who is the Medical Director of VCA West Los Angeles Animal Hospital (USA), recently posted an invitation to participate in a pituitary tumor clinical trial (hypophysectomy). You can read about it on our CCAC home page:http://s94250755.onlinehome.us/CCAC/CCAC_News.pdf
Cheers,
Heidi Schmeck
CCAC Group Owner (http://profiles.yahoo.com/owner_ccac)
Heidi Schmeck August 30th, 2009 06:44:10 PM
Great, Heidi! I will have Dr. Wosar contact him directly for more information. This is potentially an invaluable connection. I can't thank you enough.
Dr. Patty Khuly August 30th, 2009 07:10:26 PM
Dr. Khuly,
You're welcome. :) Feel free to mention my name when making contact.
VCA West Los Angeles Animal Hospital
http://www.vcapets.com/Talent/h00101.asp
Dr. Bruyette can also be reached through V.I.N., where he is a Featured Consultant.
Kind regards,
Heidi Schmeck (CT, USA)
Heidi Schmeck August 30th, 2009 07:23:00 PM
Elizabeth from Nova Scotia wrote:
"What about using Lysodren or Trilostane to intentionally destroy the adrenal glands and create an Addisonian?"
Elizabeth,
Just for clarification. :)
Planned induction of permanent hypoadrenocorticism (medical adrenalectomy) with high doses of Lysodren is very risky, particularly in a geriatric or debilitated patient. Here in the USA, it is usually reserved as a last resort for Cushing's patients for whom all else had failed.
According to the literature, severe adverse effects and death occurred in 40% of dogs treated with a planned medical adrenalectomy (Den Hertog et al, 1999). Furthermore, approximately 40% of dogs so treated relapse with Cushing's syndrome within the first 12 to 18 months. In the Third edition of "Canine and Feline Endocrinology and Reproduction", Drs. Feldman and Nelson do not recommend use of this protocol. The authors also point out that "A dog with well-controlled Cushing's syndrome that receives o.p'-DDD (Lysodren) several times a week or month is not in danger if the medication is not given; however, it is crucial to treat a dog with hypoadrenocorticism."
HTH.
Kind regards,
Heidi Schmeck
Heidi Schmeck August 30th, 2009 08:34:31 PM
Thanks Heidi,
I see new dogs weekly on the Addison Dogs yahoo Group who were cushings dogs and now are Addisonian. In three years I have only seen one dog that reverted back to cushings. It's funny but everyone when asked say they much prefer the Addison's to Cushings.. Maybe these are the difficult to control cushings dogs in the first place.
Elizabeth - from Nova Scotia August 31st, 2009 06:52:07 PM
I have the impression (in part from the dear departed TV series, "Vets in Practice") that surgical treatment of hyperthyroidism in cats is more often used in the UK than here in the US. The surgery looks less iinvasive than hypophysectomy and more in the "home territory" of general practice veterinarians. I see quite a few clients with hyperthyroid cats that are difficult to pill, unstable on transdermal and owners that are disinclined to do I135 for reason of cost etc. What about more frequent use of partial thyroidectomy to get a permanent (long term?) amelioration of hyperthyroidism in cats?
Dr. Steve Dubin September 1st, 2009 12:47:59 PM
Dr. D: My in-office colleagues are still willing to perform partial thyroidectomies for some patients. The problem is that remissions are often incomplete and sometimes very short-lived. I take the tack that the $1,200 it costs to have the radioactive iodide treatments is too close to the cost of the drugs (after a year or two of treatment) to pass on. Most eventually relent and go that route. Never seen anyone unhappy with that decision relative to frustration over thyroidectomy.
Dr. Patty Khuly September 2nd, 2009 07:04:21 AM
Elizabeth - from Nova Scotia wrote:
> I see new dogs weekly on the Addison Dogs yahoo Group who were cushings dogs and now are Addisonian. In three years I have only seen one dog that reverted back to cushings.<
Elizabeth,
We have many dogs in our CanineCushings-AutoimmuneCare group who have iatrogenic hypoadrenocorticism (drug-induced Addison's disease). Several of our CCAC moderators have Addisonian dogs (primary, atypical, secondary) and are quite knowledgeable in this area. In fact, they're also members of the Addison's groups and usually answer the questions about iatrogenic hypoadrenocorticism on those lists. <g>
Iatrogenic hypoadrenocorticism is a potential complication of Lysodren and Trilostane therapy (overdosage) used in the treatment of hyperadrenocorticism. An Addisonian crisis, or acute adrenal insufficiency, can also occur after an adrenalectomy in Cushing's syndrome. The majority of Cushingoid-turned-Addisonian dogs eventually rebound back to a Cushingoid state. However, a minority of dogs (2% to 5% in the literature) develop permanent hypoadrenocorticism (concomitant glucocorticoid and mineralocorticoid deficiency) and usually require both mineralocorticoid (fludrocortisone or DOCP) and glucocorticoid (prednisolone) treatment for life.
Permanent (irreversible) iatrogenic Addison's disease occurs when there is necrosis of the cells of the zona glomerulosa. This is because the zona glomerulosa serves as the regenerative layer for the entire adrenal cortex (all three layers). If enough zona glomerulosa cells are killed to cause electrolyte abnormalities (low sodium and high potassium), then the adrenal gland does not usually recover, despite ongoing elevated ACTH secretion from the pituitary gland. There are numerous cases of dogs with secondary iatrogenic hypoadrenocorticism in our group; some of whom rebounded after a year or more, and others who remained permanently Addisonian.
Kind regards,
Heidi Schmeck
Heidi Schmeck September 6th, 2009 03:46:40 PM
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