Research indicates good outcomes with pyometra and PU surgeries performed in primary care

As new drugs and advanced technology enter the veterinary world, the level of care that can be offered to pets has increased dramatically, but so have associated costs. As financial limitations are the most common barrier to accessing veterinary care for pet owners,¹ most veterinarians practice along a spectrum of care. This is “a continuum of acceptable care that considers available evidence-based medicine while remaining responsive to client expectations and financial limita­tions.”² Yet, barriers to practicing a spectrum of care exist and can include communication challenges, fear of judgement from colleagues or poor outcomes, and lack of evidence for alternative treatment plans.

As part of a movement to improve access to care, some veterinary groups are working to provide scientific evidence that supports treatment plans for common diseases that are not the current gold standard. At the 2022 AVMA Convention in Philadelphia, Pennsylvania, Margaret Slater, DVM, PhD, vice president of research at the ASPCA, presented results from several studies investigating outcomes of perineal urethrostomy (PU) and pyometra surgeries performed in primary care hospitals.

“The reason we picked these health issues is to increase access to care,” said Slater. “Our goal is to help more pets do better for longer.”

Feline perineal urethrostomy surgery

According to Slater, feline urethral obstruction is “a fatal disease that we can fix.” Since the development of therapeutic urinary diets, feline PU has been considered a salvage procedure for cats that repeatedly block. The surgery does not treat the underlying urinary disease, but it does minimize the changes of recurrent urethral obstructions, which are painful, life-threatening, and costly to treat. Gold standard medical management of urethral obstructions includes placement of a urinary catheter, multiple days of hospitalization with fluid therapy, and long-term dietary management, which may cost hundreds to thousands of dollars. Slater noted, “it may not be that much more costly to take them to surgery.”

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A retrospective study of 74 cats that had a PU surgery performed at the ASPCA Animal Hospital, a non-specialty hospital, between September 2015 and July 2017, investigated medical history prior to surgery, postoperative outcomes, and quality of life (QOL).³ According to Slater, the most common reason that cat owners elected surgery was failed medical management, but cost of unblocking treatment was also a consideration for many owners.

Overall, owners reported good quality of life following PU surgery. All owners felt that QOL was at least as good as the preoperative QOL, and 48% of owners felt the postoperative QOL was better. All owners rated QOL at least a 7 on a scale of 1-10, with 75% providing a rating of 10.

“If quality of life is good and cats won’t block again, then we need to offer surgery sooner,” said Slater. Especially for owners who are unable to afford repeated unblocking and hospitalization, considering surgery as an option earlier than the traditional approach of waiting for the third episode of urethral obstruction could save feline lives. Slater notes that PU surgery is not without risks and does require good surgical skills, but it is a procedure that can be successfully performed in general practice, which will reduce associated costs for cat owners.

Canine and feline pyometra

Pyometra is a common emergency presentation in older, unspayed female dogs and cats. The gold standard approach to pyometra includes a full preoperative work-up, same day emergency surgery, and hospitalization for postoperative care. This approach is not financially feasible for some owners, who are then left with the decision to delay treatment while exploring lower cost options or consider euthanasia. “This is a curable disease that people’s pets are being euthanized for,” said Slater. The ASPCA has published multiple studies exploring pyometra outcomes for both dogs and cats in non-specialty settings.^4-7

In a retrospective study comparing outcomes between a referral hospital and outpatient community clinic, the outcomes of 133 dogs were evaluated.⁴ Eighty-three dogs had surgery at a specialty setting and 50 had surgery at a community clinic. Patient presentation, including size, age, and clinical signs, was not significantly different between the two populations. Overall, 97% of pets survived to discharge and 94% remained alive one week following surgery. The location of the surgery did not impact survival. Dogs presenting to the community clinic often had a longer delay prior to surgery (up to 14 days) were treated on an outpatient basis, and had surgery performed by students or interns. These factors did not impact survival to discharge.

A similar survival rate of 97% was found in a retrospective study of 405 dogs treated with ovariohysterectomy at the ASPCA Animal Hospital between January 2017 and February 2019.⁵ In these cases, patients could be hospitalized postoperatively, but there were some delays in treatment as 57% of patients were seen by another veterinarian previously and referred to the ASPCA’s hospital, likely due to cost of the procedure. While data in cats is more limited, 100% of the 134 cats undergoing pyometra surgery at the ASPCA’s hospital survived to discharge.⁶

The findings of these studies support the fact that while it is ideal to perform surgery as quickly as possible, very good outcomes are still seen in dogs with delayed surgical treatment.^4,5 Good outcomes are also seen in non-specialized settings for both dogs and cats.^4-6

Take home points

As the body of literature grows providing evidence-based support for the spectrum of care, veterinarians can feel more comfortable pursuing alternative treatment plans in general practice settings. Patients undergoing pyometra and PU surgery in primary care facilities have good outcomes. PU surgeries could be considered sooner for cats with repeated obstructions, especially if owners have limited finances for continued hospitalization. For dogs and cats diagnosed with pyometra, short delays in surgical treatment and/or outpatient care can still result in good outcomes.

References

1. Access to veterinary care coalition (AVCC). Utk.edu. Accessed August 18, 2022. https://pphe.utk.edu/access-to-veterinary-care-coalition-avcc/
2. Fingland RB, Stone LR, Read EK, and Moore RM. Preparing veterinary students for excellence in general practice: building confidence and competence by focusing on a spectrum of care. J Am Vet Med Assoc 2021;259(5):463-470.
3. Slater MR, Pailler S, Gayle JM, et al. Welfare of cats 5-29 months after perineal urethrostomy: 74 cases (2015-2017). J Feline Med Surg. 2020;22(6):582-588. doi:10.1177/1098612X19867777
4. McCobb E, Dowling-Guyer S, Pailler S, et al. Surgery in a veterinary outpatient community medicine setting has a good outcome for dogs with pyometra. J Am Vet Med Assoc 2022;260(S2). https://doi.org/10.2460/javma.21.06.0320
5. Pailler S, Slater MR, Lesnikowski SM, et al. Findings and prognostic indicators of outcomes for bitches with pyometra treated surgically in a nonspecialized setting. J Am Vet Med Assoc. 2022;260(S2):S49-S56. doi:10.2460/javma.20.12.0713
6. Pallier S, Slater MR, Lesnikowski SM, et al. Findings and prognostic indicators of outcomes for queens with pyometra treated surgically in a nonspecialized setting. J Am Vet Med Assoc 2022;260(S2). https://doi.org/10.2460/javma.20.12.0712
7. Pallier S, Dolan ED, Slater MR, et al. Owner-reported long-term outcomes, quality of life, and longevity after hospital discharge following surgical treatment of pyometra in bitches and queens. J Am Vet Med Assoc 2022;260(S2). https://doi.org/10.2460/javma.20.12.0714

Dr Boatright, a 2013 graduate of the University of Pennsylvania, is a practicing veterinarian and freelance speaker and author in western Pennsylvania. She is passionate about mentorship, education, and addressing common sources of stress for veterinary teams and recent graduates. Outside of clinical practice, Dr Boatright is actively involved in organized veterinary medicine at the local, state, and national levels.