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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 1999  |  Volume : 10  |  Issue : 1  |  Page : 54-58
Synchronous Bilateral Lumbotomy in a Child with Bilateral Stone Disease and Renal Failure: An Old Operation Re-visited

Department of Surgery, North West Armed Forces Hospital, Tabuk, Saudi Arabia

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Keywords: Bilateral renal calculi synchronous lumbotomy operations.

How to cite this article:
Ward J P, Zakaria M, Al Shareef Z. Synchronous Bilateral Lumbotomy in a Child with Bilateral Stone Disease and Renal Failure: An Old Operation Re-visited. Saudi J Kidney Dis Transpl 1999;10:54-8

How to cite this URL:
Ward J P, Zakaria M, Al Shareef Z. Synchronous Bilateral Lumbotomy in a Child with Bilateral Stone Disease and Renal Failure: An Old Operation Re-visited. Saudi J Kidney Dis Transpl [serial online] 1999 [cited 2020 Jun 5];10:54-8. Available from: http://www.sjkdt.org/text.asp?1999/10/1/54/37302

   Introduction Top

Approach to both kidneys at a single operative session was described in 1976 [1],[2] and has been employed for pre-transplant bilateral nephrectomy or bilateral pyelo­lithotomy for stones in urology and transplant units during the lat twenty years. Since the advent of extra corporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCN), the technique is now rarely used. Residents lack training in this procedure, yet it is the operation of choice in selected cases.

This paper reports the cases of an 8-year Saudi female with bilateral renal calculi causing causing bilateral obstruction and bilateral hydronephrosis with incipient renal failure treated with bilateral pyelolithotomy and insertion of double-J stents using the synchronous bilateral lumbotomy technique.

   Case Report Top

An 8-year-old Saudi female presented to the North West Armed forces Hospital in Tabuk with a two year history of vague abdominal pains and dysuria with bouts of fever, malaise, dysuria and vomiting associated with proven urinary infections. Urinalysis revealed 10-20 white blood cells (WBC) per high-power field and a mixed bacterial growth. A repeat urine culture grew Entercoccus faecalis and a further culture three weeks later grew mixed coliforms. An ultrasound examination of the urinary tract revealed bilateral hydronephrosis with considerable distention of all the calyces, the right being worse than the left [Figure - 1].

A plain x-ray of the abdomen demonstrated bilateral large renal calculi [Figure - 2]. An intravenous program revealed non-function of the right kidney and poor function of the left kidney with delay in excretion of the contrast and hydronephrosis due to bilateral obstruction. There was evidence of some remaining renal cortex on the left side [Figure - 3].

The serum creatinine to this stage was 173 mmol/L, the blood urea was 11, the serum potassium 3.8 and the serum sodium 140 mmol/L. The hemoglobin was 107 g/L and the WBC 10, 000/cu ml. a catheter specimen of urine grew klebsiella pneumoniae Scientific Name Search  resistant to penicillin but sensitive to all the common antibiotics. It was decided that bilateral pyelolithotomy, with insertion of bilateral double-J stents to immediately relive the obstruction and to establish drainage of both kidneys, was the best therapeutic option for this child [Figure - 4].

   Surgical Technique Top

General anesthesia was used and the patient was ventilated via an endotracheal tube. She was then placed in the prone position with one arm forward. The skin was prepared and sterile drapes applied exposing both renal areas. A small right transverse skin incision was made over the junction of the erector spine muscle and the oblique muscles of the abdominal wall 3 cm below the 12 th rob. The latissimus dorsi muscle was split and the fine white line of the lumbar fascia was exposed where it was only a single layer before splitting into its three lamellae around the muscles of the lateral abdominal wall. A vertical lumbotomy incision was made in this lumbar fascia exposing the perinephric fat and right renal pelvis. The kidney at this point was very near the surface and a pyelotomy was easily performed between stay sutures. Pus and urine under pressure was immediately released and a specimen was sent for culture and sensitivity. The large pelvic staghorn-type stone was eased out of the renal pelvis using the curved blade of a Macdonald's dissector. The kidney was flushed with sterile saline and a size 5F double-J silicone stent was inserted using a guide wire from the kidney to bladder. Careful examination of the pelvi ureteric junction showed it to be wide open and not obstructive. The pyelotomy was closed with 4-0 Vicryl. As soon as the procedure was satisfactorily concluded on the right side before the wound was closed, the kidney on the left side was synchronously using the same operative technique and a pyelolithotomy and insertion of double-J stent was performed. This operation continued while the right-sided wound was being closed. Both skin wounds were closed with subcuticular Vicryl.

   Post-operation Top

The child made a rapid and uneventful recovery. The pus from the left kidney grew Klebsiella Pneumoniae and streptococcus group D and the pus from the right kidney grew Klebsiella pneumoniae only. The patient was treated with IV amoxicillin/ calvulanate 600 mg 8 hourly for three days and then by oral suspension for a further five days. She was then discharged on prophylactic Septrin pediatric suspension 5 ml at night for three month. On the 8 th post­operative days the serum creatinine had fallen to 145 mmol/L and the creatinine clearance measured at this time was 12 ml/minute.

   Discussion Top

Bilateral obstructive uropathy in a child in association with stone disease and infection is best treated by immediate urinary drainage of the kidneys. The drainage should be continued for a minimum of six weeks, but preferably three months while the renal function recovers. It has been demonstrated in open nephrolithotomy that renal function takes this length of time to cover. [3] The options for treatment in this case were

a) insertion of bilateral percutaneous nephrostomy tubes and continuous drainage,

b) the endoscopic insertion of double-J stents,

c) open surgical removal of the stones by staged individual operations of d) a synchronous combined single operation

In general, it is unsatisfactory to have a child with bilateral nephrostomy tubes out in the community as management of the tubes is difficult and the tubes must drain freely and remain in the kidney without risk of displacement. Even under hospital supervision one would be reluctant to have nephrostomy tubes in situ for more than two weeks. We therefore, ruled this option out as a satisfactory form of treatment in this child.

The endoscopic insertion of bilateral double-J stents could have been performed, but it is not always possible to manipulate a guide wire past the stone in the renal pelvis to get the double-J stent sited correctly. Provided adequate drainage of the kidney is established and there is antibiotic cover, this form of treatment is permissible. If drainage is not properly established bacteremia and septicemia may easily occur. Following renal functional recovery, however, a second or third procedure of pyelolithotomy will be required.

The stones were large and unsuitable for ESWL, but debulking using the technique of percutaneous nephrolithotomy could be performed. However, it is unlikely that complete stone clearance would be achieved at one sitting as some form of intrarenal lithotripsy would have to be employed. [4] Lithotripsy of infected stones has increased risk of bacteremia and septicemia and associated morbidity. [5] However, ESWL monotherapy in children has been surprisingly successful, [6] an option which would have been difficult in this child with bilateral staghorn stones.

The third option of performing an open pyelolithotomy on the kidney with the poorest function and the establishment of urinary drainage was probably the safest option, but a second operation on the contralateral kidney would be required after one to three months. In the interim period it would be very difficult to eradicate the urinary infection in the presence of a stone in the remaining kidney.

The last option of open bilateral pyelo­lithotomy with the establishment of urinary drainage at a single operative sitting, seemed to be the best option with the least problems for the patients, provided that the duration of the operation was not too long and the technique minimally invasive. The posterior vertical lumbotomy technique is very non-traumatic, can be performed through tiny incision, does not involve massive muscle cutting and is very well tolerated by both adults and children alike [7] . Of course, with such precarious renal function, the renal dialysis unit should be alerted and warned that pot-operative dialysis may be required in the recovery period. Fortunately, in this child, a creatinine clearance of 12 ml/minute was sufficient to avoid this complication.

The posterior lumbotomy approach to the kidneys is an anatomically correct one, causing minimal disruption of the abdominal musculature and provides easy access to the kidney. Complete stone clearance can always be achieved whereas in the technique of PCN and lithotripsy retained fragments within the kidney can often be a problem. Post-operative mobilization is more rapid and the convalescent period is shorter than using the conventional muscle­cutting kidney approach.

The technique of posterior vertical lumbotomy should be encouraged in selected cases needing renal surgery, particularly when synchronous bilateral operations are necessary.

   References Top

1.Ward JP, Smart DJ, O;Donogheu EP, Wickham JE. Synchronous bilateral lumbotomy. Eur Urol 1976;2(2):102-4.  Back to cited text no. 1    
2.Ward JP. Lumbotomy advanced as best surgical approach. Clin Trends Urol 1976;5:2.  Back to cited text no. 2    
3.Wickham JE, Coe N, Ward JP. One hundred cases of nephrolithotomy under hypothermia. J Urol 1976;112:702.  Back to cited text no. 3    
4.Di-selverio F, Gallucci M, Alpi G. Staghorn calculi of the kidney classification and therapy. Br J Urol 1990;65:449-52.  Back to cited text no. 4    
5.Michaels EK, fowler JE, Mariano M. Bacteriuria following extracorporeal shock wave lithotripsy of infection stones. J Urol 1988;140:254-6.  Back to cited text no. 5    
6.Thornhill JA, Moran K, Mooney EE, Sheehan S, Smith JM, Fitzpatrick JM. Extra-corporeal shockwave lithotripsy monotherapy for pediatric urinary tact calculi. Br J Urol 1990;65:638-40.  Back to cited text no. 6  [PUBMED]  
7.Cheema MA. Merit of posterior lumbotomy approach to the upper urinary tract. J Pak Med Assoc 1993;43(1):6-8.  Back to cited text no. 7    

Correspondence Address:
M Zakaria
Department of Surgery, North West Armed Forces Hospital, P.O. Box 100, Tabuk
Saudi Arabia
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PMID: 18212414

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