Dorsal Lumbotomy Approach Research Articles

Dorsal Lumbotomy Pyeloplasty Via Transverse Incision, A Ten Years’ Experience

The Pelviureteric- junction obstruction (PUJO) is the commonest cause of hydronephrosis in children. Dismembered pyeloplasty is the gold standard procedure for PUJO. Dorsal transverse lumbotomy approach is our preferred approach to get access to Pelviureteric junction. This is a retrospective study of last 10 years of one Hundred and twenty three cases. All the patients were operated via dorsal lumbotomy approach. Pre-operative Investigations hemogram, Ultra sonography and a preoperative diuretic renal scintigraphy with diethyl tri-amino penta acetic acid (DTPA) / Ethylene dicysteine (EC.) and Dimercaptosuccinic acid (DMSA) was performed in every patient to assess the differential function and changes in renogram curve. Indication for pyeloplasty was PUJO with obstructed renogram with non-achievement or delayed excretion of Tracer (T ½). Patient were operated under General anaesthesia in prone position and standard Anderson-Hynes Dismembered pyeloplasty via transverse lumbotomy incision. A Total of 123 patients were operated with the median age of patients was 30 months; the average antero- posterior diameter of the renal pelvis was 24 mm. The Average time for surgery was 99 minutes, The Average days of admission were 4. Six patients had postoperative leak which were managed conservatively. Nine patients required redo surgery.

Evaluation of transverse dorsal lumbotomy in management of PUJ obstruction in patients younger than 6 months

The transverse dorsal lumbotomy approach provides excellent exposure to the PUJ and causes minimal tissue damage. In this study, we assess the efficacy of dorsal lumbotomy in PUJ obstruction in children younger than 6 months. All children less than 6 months who were managed with the dorsal lumbotomy approach between 2009 and 2017 were reviewed prospectively. Data included: demographic data, pre/post-operative renal ultrasound scan with SFU grading and RDS, operative time, post-operative complications, and follow up results. A total of 42 children with a mean age of 4.4 ± 1 months were included. On pre-operative RDS, all patients had an obstructive pattern and a SRF of 30.3 ± 9.3. The mean operative duration was 49 min and analgesia was minimal. Post-operative ultrasound at 6 months showed an improvement in hydronephrosis (p < 0.05) and a mean SRF of 39.3 ± 6.1 (p < 0.001). Transverse dorsal lumbotomy approach is a safe and efficient alternative in patients less than 6 month.

Dorsal lumbotomy for pediatric upper pole hemi-nephrectomy: Back (door) to the future?

Upper pole heminephrectomy (UHN) is performed for two main indications in children: ectopic ureterocele and duplication anomalies with upper pole ectopy, both in the context of a poorly functioning upper pole moiety. Current popular techniques for conducting UHN include laparoscopic (LPN) and robot-assisted laparoscopic (RAPN). To evaluate outcomes following dorsal lumbotomy (DL), an open approach used historically for pyeloplasty and pyelolithotomy, and in which no clinical trials or exclusive case-series have been conducted for upper pole hemi-nephrectomy (UHN) in children. We ultimately aim to compare our outcomes following DL at our centre to that of published outcomes of minimally invasive approaches to UHN. Institutional board review was obtained (H18-03716) for a retrospective review of 50 UHN performed in 49 consecutive pediatric patients using the DL approach by a single surgeon between 2001 and 2019. Clinical variables and indicators included age, sex, weight, skin-to-skin time, total operating room time, duration of hospital stay, post-operative complications, analgesic requirements, and post-operative ultrasound results. Of 50 UHN performed, 23 had a presurgical diagnosis of ectopic ureter, and 27 ureterocele. Mean weight of patients was 12.61kg, and the mean age at surgery was 24.55 months. Mean (range) for time between skin incision and closure was 88.5 (62-132) minutes, and the mean (range) total operating room time was 138.5 (70-180) minutes. There were neither intraoperative complications nor transfusions. The mean (range) post-operative opioid delivered was 0.73 (0.00-2.00) mg/kg/day. Mean (range) post-operative ibuprofen delivered was 5.41 (0.00-37.73) mg/kg/day. Median length of hospital stay was 2 days. No patient received post-operative prescriptions for narcotics at discharge. There were no wound complications. One patient had secondary atrophy of the lower pole. Secondary lower tract surgery, unrelated to surgical approach, was performed in five patients. Ten patients experienced a urinary tract infection at some point after surgery. DL is safe, feasible, and produces operative outcomes and times comparable to that of laparoscopic and robotic techniques. These findings as well as operative costs should be considered when selecting a surgical technique for UHN.

Dorsal Lumbotomy Approach for Pediatric Dismembered Pyeloplasty

Aim: Recently, the posterior lumbotomy approach has become widely popular for pediatric pyeloplasty. The current study reassesses the approach for pediatric dismembered pyeloplasty considering its advantages and limitations. Materials and methods: We conducted a prospective study with 84 cases of hydronephrosis due to ureteropelvic junction obstruction, over a period of five years. We excluded the cases of hydronephrosis in ectopic or rotated kidney and cases of revision surgery (redo pyeloplasty). All patients were properly evaluated before subjecting them to the surgery. All patients underwent dismembered pyeloplasty through the posterior vertical lumbotomy incision. A transanastomotic double J stent was placed in all cases which were removed within 4-6 weeks of pyeloplasty. Perioperative findings were recorded, tabulated and analyzed carefully. The patients were followed up for 3 years. Results: The mean age of the patient at operation was 43 months. The average length of incision was 3-4 cm and mean operating time was 50.6 minutes. There was no difficulty in gaining the access to the pathology in any of the patients. Intra-operatively, we failed to clear out the distal (ureterovesical junction) obstruction in 4 patients where a nephrostomy was done in addition to pyeloplasty. All patients recovered from anesthesia uneventfully and returned to full oral feeds by 1st postoperative day. There were no major complications related to surgery. The mean duration of hospital stay was 3.9 days. Redo pyeloplasty was needed in two cases. There were no wound related major complications. Conclusion: The dorsal lumbotomy approach for pediatric pyeloplasty is advantageous in the form of small incision, easy and quick access to the pathology, short operating time, early recovery to normal activity and short hospital stay. It could also be practiced in other urological surgeries provided the cases are selected carefully.

Does the surgical approach change the need for a retrograde pyelogram prior to pyeloplasty?

ObjectiveThe opinion on the use of retrograde ureteropyelography (RUPG) prior to routine pyeloplasty for an ureteropelvic (UPJ) obstruction has been divided. This study analyses the efficacy of a preoperative RUPG and determines if a dorsal lumbotomy (DL) approach offers any advantage in this situation. MethodsThis is a retrospective analysis of application of RUPG prior to pyeloplasty in children with ages ranging from 42 days to 16.2 years who underwent surgery at the Children's Hospital at Westmead between 2009 and 2013. ResultsWe identified a total of 95 children with isolated UPJ obstruction, with 59 (62.1%) boys and 36 (37.8%) girls. Overall, open pyeloplasties were performed in 89 (42 DL: 47 loin incision) and the rest (n = 6) laparoscopically. Preoperative RUPG was performed in 58 (61%) and it provided additional information in 11 (18.9%) patients for whom the surgical approach was modified. Hospital stay, operative time, and time to full diet were shorter with the DL approach (p < 0.05). ConclusionsThe current study suggests that RUPG is avoidable if the approach for pyeloplasty is through the conventional loin incision. The short-term advantages might rationalize the use of RUPG if a DL incision is employed.

Transperitoneal laparoscopic repair of a dorsal lumbotomy incisional hernia

Hernias are a rare complication following muscle-splitting dorsal lumbotomy surgery. At our centre, before the introduction of laparoscopic surgery, donor nephrectomy for renal transplantation was performed via a dorsal lumbotomy approach. We present a case of transperitoneal laproscopic repair of a dorsal lumbotomy incisional hernia following donor nephrectomy using a quilted 2-sided expanded polytetrafluoroethylene (ePTFE) mesh. The procedure was uncomplicated and required 2 hours operating time to complete. A 2-day stay in hospital was observed for convalescence and the patient quickly returned to routine activity after discharge. Advantages of the laparoscopic approach include excellent visualization and wide coverage of the hernia defect under direct vision. This case illustrates the benefits of laparoscopic repair of a rare lumbotomy complication.

Revving up our service to Canadian Urology: CUAJ a proud venue.

It is an honour and privilege to be writing this editorial as the newly installed CUAJ Editor-in-Chief. This position is vetted and recommended by an ad hoc committee of the CUA and subsequently confirmed by its executive. I am extraordinarily grateful, and at the same time humbled, by this opportunity to lead our journal over the next few years. If you will excuse the indulgence, it does seem fitting at this time to thank those members of the CUA executive, as well as CUAJ editorial board members and especially Dr. Laurence Klotz, our founding editor, for their ongoing support and tutelage. Dr. Klotz was of course essential in the CUAJ’s development in 2007 and has led the journal to a point of undeniable success and sustainability – impressive after only 5 years. CUAJ’s editorial board recently voted to publicly acknowledge Dr. Klotz’s tireless work for the Journal by creating the title of Editor Emeritus. Given the time and sweat he has donated to the Journal and the CUA as a whole, this title is fitting, however, one can only expect that his service will be remembered and appropriately feted in the near future by our association. Although CUAJ’s Editor reports to the CUA executive, it is important for readers to understand that the CUA as an organization has had a remarkable history of an “arms length” stance with respect to editorial freedom and direction of the Journal. This is perhaps of significant import given the small community that is Canadian Urology. However, it goes without saying that maintaining a venue proud to publish and advertise Canadian endeavours in urological health advocacy, education and research will continue to be a priority for the Journal. These are exciting times for CUAJ. We are soon going to unveil our online journal service, a new look online which will be easier for reviewers and authors alike. We are also looking forward to providing a monthly publication, a step that is born out of the increasing number and quality of original submissions. The editorial board is busy tackling several other issues experienced by all medical journals today, including concerns around publishing ethics (role of reviewers, self-plagiarism) and journal format (electronic versions, electronic only, IPAD/Smartphone applications, dual format). We are interested in engaging all readers in discussing these issues and look forward to your thoughts. In this issue, several articles are excellent examples of “quality assurance.” Cloutier and colleagues describe their experience using the dorsal lumbotomy approach to open UPJO repair in older children, describing comparable results using this under-utilized surgical approach.1 Similarly, Webster and colleagues epitomize the goals of Cancer Care Ontario (CCO) by collating and publishing their results of two years of prostatectomies with the CCO guidelines for surgical optimization in mind.2 Although the authors acknowledge the need for more work to improve their own quality and one could argue the rationale and external validity of our putative “quality” indicators of care, every individual or team who manages men with prostate cancer should take a lesson from this article when contemplating and measuring their own practice outcomes. Finally, our review article by So and colleagues is required reading for all trainees and practicing urologists with respect to the use of bone-targeted therapies in men with castration resistant prostate cancer.3 With the increasingly crowded world of CRPC therapeutics, timely articles such as these help ensure we can “achieve the achievable,” translating the benefits and potential harms to routine clinical practice.

Unilateral ureteric obstruction: Role of renin angiotensin system blockade on renal recovery: An experimental study

Aims:To study and compare the effects of angiotensin II antagonist (Losartan) and angiotensin converting enzyme (ACE) inhibitor (Enalapril) on renal recovery following reversal of iatrogenic unilateral upper ureteric obstruction.Materials and Methods:Unilateral upper ureteric obstruction was created in 96 adult Wistar rats that were reversed after predetermined intervals. Losartan and Enalapril were given to different subgroups of rats following relief of obstruction. Rats were sacrificed and kidneys were subjected to planimetric and histopathological analysis.Results:Dorsal lumbotomy approach provided a rapid and safe approach to kidneys in rats. The planimetric and histopathological changes were most severe in the group of rats in whom obstruction was not relieved before sacrifice. Addition of Enalapril and Losartan significantly hastened the reversal of renal changes following relief of obstruction as compared with the group in which no treatment was given following reversal of blockade.Conclusions:Renin angiotensin system (RAS) is the major pathway responsible for renal damage following outflow obstruction. However, this damage can be reversed with the use of drugs acting on the RAS.

Laparoscopy Versus Dorsal Lumbotomy for Ureteropelvic Junction Obstruction Repair

Laparoscopic pyeloplasty offers similar success rates compared to open surgery. However, the advanced laparoscopic skills required may limit its widespread application. In select patients the dorsal lumbotomy approach can provide similar postoperative advantages to minimally invasive surgery. We analyze the perioperative management of laparoscopy vs dorsal lumbotomy for the repair of ureteropelvic junction obstruction. In a retrospective review 13 patients who underwent dorsal lumbotomy pyeloplasty were compared to 19 patients who underwent laparoscopic pyeloplasty between 1998 and 2003. Preoperative confirmation of obstruction was obtained through excretory urogram or renal Lasix scan. All 13 patients undergoing dorsal lumbotomy had a dismembered pyeloplasty. Of the 19 laparoscopic cases 16 had a dismembered pyeloplasty and 3 had a Fenger procedure. Average followup was 12 months for the open group and 13.3 months for the laparoscopic group. Postoperative results were evaluated with excretory urogram or renal Lasix scan as well as subjective outcomes by the patients. Operative time was slightly longer for the laparoscopy group at 231 minutes vs 200 minutes. Estimated blood loss and postoperative morphine requirements were also similar. Hospital stay was 3.3 days for the dorsal lumbotomy group compared to 2.4 for the laparoscopy group. The overall success rate for the laparoscopic group was 94.7% compared to 100% for the dorsal lumbotomy group. Each group had 1 complication, paresthesia of anterior/medial thigh that resolved by 6 months. Our preliminary results show that a dismembered dorsal lumbotomy pyeloplasty is comparable to laparoscopic dismembered pyeloplasty with regard to intraoperative and postoperative hospital course.

Blockade of Rennin-Angiotensin system blunts the fibrotic response in experimental acute pyelonephritis

<b>Aim</b>: To study the impact of Renin-Angiotensin system blockade in experimental acute pyelonephritis, induced by a novel surgical approach via dorsal lumbotomy incision. <br><b>Materials and Methods</b> : 45 Adult female WISTAR rats aged 8-12 weeks, underwent direct inoculation of 0.1 ml of E.coli suspension into the parenchyma of the surgically exposed kidney. 3 groups of rats were studied: Group A - treated with antibiotics only; Group B- Captopril and antibiotics and Group C- Losartan and antibiotics. Changes of acute inflammation, parenchymal destruction and scarring were compared between the groups on histopathological sections. Kruskal-Wallis test<b> </b> was used for statistical analysis.<br><b>Results</b> : Changes consistent with acute pyelonephritis were seen in all the kidneys. Mean% scar area in Group A, Group B and Group C was 37.08±1.79, 24.40±1.88 and 24.68±1.32% respectively at end of six weeks. Mean tubular density in Group A, B and C was 17.26±1.92, 47.18±3.00 and 47.00±5.08-tubules/lac mm2 respectively. The differences between the control and the treated animals were significant, though the results did not differ between the losartan and captopril treated rats.<br><b>Conclusions</b> : Dorsal lumbotomy approach to the kidney provides a good exposure of the kidney. Induction of acute pyelonephritis by direct inoculation of bacteria into renal cortex produced a consistent scar at 6 weeks. Blockade of renin angiotensin system by either captopril or losartan decreased the renal scar area by almost 1/3 at 6 weeks.<br>

Surgical correction of pelviureteric junction obstruction in childhood--dorsal lumbotomy approach and selective internal ureteric stenting.

Ninety-four children (average age 3.6 years) underwent surgery for pelviureteric junction (PUJ) obstruction between 1994 and 1999. There were 96 operations: 94 dismemberment pyeloplasties (2 bilateral) and 2 ureterocalycostomies. The surgical approach in all cases was by a dorsal lumbotomy incision. Internal ureteric stenting was employed selectively for solitary kidneys, inflamed renal pelves, long strictures, and ureterocalycostomies. The average operative time was 57 min and the average postoperative stay in hospital was 2.5 days. Of the 94 patients, 93 had a good outcome. Of the 78 pyeloplasties that were unstented, 7 (9%) required stenting in the early postoperative period for urinary leak or obstruction. There were no wound-related complications. PUJ surgery via a dorsal lumbotomy approach with selective internal ureteric stenting is recommended as a safe and effective approach to PUJ obstruction in childhood.

Evolution in the management of infant pyeloplasty

Improving diagnostic modalities, evolving concepts regarding perinatal renal physiology, and advances in surgical technique have contributed to an evolution in the management of infant pyeloplasties. Currently, the majority of patients present with a prenatal diagnosis of ureteropelvic junction obstruction and do not require surgical intervention prior to 4 weeks of age. Postnatal ultrasound, voiding cystourethrography, and nuclear renography complete the diagnostic evaluation, with intravenous urography and retrograde pyelography being unnecessary in the majority of infants. A decreasing incidence of complications and a shortening of hospital stay has been documented. We presently prefer a dismembered, nonintubated technique performed through a dorsal lumbotomy approach.

Dorsal Lumbotomy for Surgery of the Upper Urinary Tract

Between July 1978 and December 1985, 100 patients underwent an operation on the kidneys and ureter through the dorsal lumbotomy approach. A total of 12 patients underwent dismembered pyeloplasty for ureteropelvic junction obstruction. Compared to patients who underwent an operation via the standard flank incision, these 12 patients had significantly shorter hospitalization and fewer doses of analgesics. The treatment demonstrated improved cost-effectiveness. Similar advantages were noted in the remaining patients in whom removal of calculi (78), open renal biopsy (5), simple nephrectomy (4) and removal of a foreign body in the ureter (1) were done through the dorsal lumbotomy approach. We appeal for a renaissance of the dorsal lumbotomy approach in urological teaching and practice.