Dorsal Lumbotomy Approach for Pediatric Dismembered Pyeloplasty

Abstract

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 1 st 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.

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

“…The average hospital stay duration was 3.9 days, and interestingly analgesia requirements were much lower, with only oral paracetamol given when required. 14 We report a lower average operative time than the literature. The credit goes to the age range at which our patients operated, especially since the back muscles are easier to split, and fewer layers require opening.…”

“…In contrast, many studies report an average range of 1 month-12 year [9][10][11][12][13] with an antenatal diagnosis of as low as 0.09%. 14 Currently, there are two widely used measurement systems: anteroposterior diameter of the renal pelvis (APDRP) and the society of fetal urology (SFU) hydronephrosis grading system. 15,16 Although recent studies call for the improvement of these systems, we found the latter system to be suitable in predicting prognosis and follow up, with most showing significant improvement on follow up (z = -5.654, p < 0.05).…”

“…The credit goes to the age range at which our patients operated, especially since the back muscles are easier to split, and fewer layers require opening. 14 In older age groups, developed musculature can lengthen the procedure, regardless of technique, up to an average of 192.5 min. 9,14,[17][18][19] Moreover, we also had a shorter hospital stay, comparable to patients undergoing the laparoscopic approach, 11,13,[20][21][22][23][24] and our post-operative analgesia requirements were less.…”

“…14 In older age groups, developed musculature can lengthen the procedure, regardless of technique, up to an average of 192.5 min. 9,14,[17][18][19] Moreover, we also had a shorter hospital stay, comparable to patients undergoing the laparoscopic approach, 11,13,[20][21][22][23][24] and our post-operative analgesia requirements were less.…”

A reappraisal of pediatric abdominal surface anatomy

“…Pyeloplasty can be performed through the dorsal lumbotomy approach with an incision below the 12th rib (Mikhail & Hall, 2020;Peters, 2015). Although some studies have recommended mobilization of the 12th rib by dividing the costovertebral ligaments to increase exposure (Gonzalez & Aliabadi, 1987;Orland et al, 1987), most have reported that the operation does not require this technique in the pediatric population (Bajpai et al, 2004;Gonzalez & Aliabadi, 1987;Gupta & Sharma, 2011;Halder et al, 2017). In our study, a minority of right kidneys showed relationships above the 12th rib in all age groups, and a minority of left kidneys in most age groups.…”