Dorsal Lumbotomy Incision for Partial Nephrectomy in Patients With Small Posterior Renal Masses

A Helpful Tool in the Renal Surgery Armamentarium: Dorsal Lumbotomy nephrectomy for Tumor in Patients with End-Stage Renal Disease

OBJECTIVE

To compare operative outcomes between the dorsal lumbotomy (DL) and laparoscopic nephrectomy (LN) approaches for patients with end stage renal disease (ESRD) undergoing nephrectomy. DL operative technique is also described.

MATERIALS AND METHODS

We performed a retrospective review of all patients undergoing DL nephrectomy at Emory University from 2008-2020. Cases were matched with control patients with ESRD who had undergone LN. Parameters evaluated included operative time, estimated blood loss, length of stay, postoperative narcotic requirements, and complication rates. Statistical analysis performed with SPSS.

RESULTS

43 DL patients and 86 LN patients were assessed. DL had shorter total OR time (173min vs 198min; P = 0.001) and surgery time (101min vs 135min; P<0.001) compared to LN. There was a trend towards decreased mean length of stay among the DL group (2.65d vs 3.14d; P = 0.069) as well as daily narcotic requirement measured in oral morphine equivalents (54.8mg/day vs 73.6mg/day, P = 0.051). There were no differences in estimated blood loss, perioperative complication rates, ICU admissions, or 30-day readmissions. Limitations include retrospective design and small sample size.

CONCLUSION

Among patients with ESRD, DL was found to be safe and effective compared to LN, with shorter operative times, a trend towards decreased length of stay and post-operative narcotic requirements, and similar perioperative complication rates. DL should be considered as an approach for nephrectomy in this patient population.

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

INTRODUCTION

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).

OBJECTIVE

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.

STUDY DESIGN

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.

RESULTS

Of 50 UHN performed, 23 had a presurgical diagnosis of ectopic ureter, and 27 ureterocele. Mean weight of patients was 12.61 kg, 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.

CONCLUSION

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.

Transverse Lumbotomy for Open Partial/Radical Nephrectomy: How I Do It

INTRODUCTION

Conventional open surgical techniques allow proper surgical management for renal malignancies but have their intrinsic drawbacks. The aim of this paper is to present our technique in minimal renal exposure while avoiding the intrinsic complications of conventional techniques.

METHODS

We described our technique, which can be easily understood and replicated by urologists performing open kidney surgery.

RESULTS

Ninety-five patients had this technique done safely over the last 4 years, and 3 patients had this exposure changed into intraperitoneal extended wound for very large upper pole tumours. The median operating time was 70 min. No single patient required intraoperative blood transfusion. Median warm ischemic time was 9 min.

CONCLUSION

Transverse lumbotomy is a safe reproducible technique that allows proper kidney exposure through a relatively smaller wound and avoiding unnecessary auxiliary techniques as rib resection, pleural tear management, and intraperitoneal exposure.