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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2013  |  Volume : 24  |  Issue : 2  |  Page : 330-332
Rhabdomyolysis and acute renal failure following prolonged surgery in the lithotomy position

1 Department of Nephrology, Fahd Military Medical Complex, Dhahran, Saudi Arabia
2 Department of Urology, Fahd Military Medical Complex, Dhahran, Saudi Arabia

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Date of Web Publication26-Mar-2013


Operative positions commonly used in urogenital surgeries when perineal exposure is required include the lithotomy and the exaggerated lithotomy positions (LPs), which expose patients to the risk of rhabdomyolysis. We report a patient with bladder outflow obstruction, benign prostatic hypertrophy and a very large bladder stone, which was removed with cystoscopy and cystolitholapaxy in the LP. The procedure was complicated by posterior bladder perforation and abdominal distention leading to prolonged surgery duration (5.5 h). The patient developed rhabdomyolysis and acute renal failure (ARF) without compartmental syndrome. On the other hand, there was a potential role of glycine solution, used for bladder irrigation, in the appearance of ARF. Overall, our case shows that rhabdomyolysis and ARF can develop in operative positions, and duration of surgery is the most important risk factor for such complications.

How to cite this article:
Guella A, Al Oraifi I. Rhabdomyolysis and acute renal failure following prolonged surgery in the lithotomy position. Saudi J Kidney Dis Transpl 2013;24:330-2

How to cite this URL:
Guella A, Al Oraifi I. Rhabdomyolysis and acute renal failure following prolonged surgery in the lithotomy position. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2022 Jun 25];24:330-2. Available from: https://www.sjkdt.org/text.asp?2013/24/2/330/109597

   Introduction Top

Rhabdomyolysis, with secondary acute renal failure (ARF), may occur following urogenital surgery as a complication of operative positions. [1] These complications are mainly reported in the exaggerated lithotomy position (ELP) and less frequently in the lithotomy position (LP). [2],[3],[4],[5],[6]

We report a patient who was operated on in the LP and developed rhabdomyolysis and ARF without compartmental syndrome or muscle injury. There was a potential role of glycine used in bladder irrigation as an additive cause of ARF.

   Case Report Top

An 80-year-old man was diagnosed with bladder outflow obstruction, benign prostatic hypertrophy and very large bladder stone. His physical examination was unremarkable, with a weight of 74 kg and a height of 1.68 m. He underwent cystoscopy and cystolitholapaxy, performed in the LP.

Laboratory results prior to the procedure revealed blood urea nitrogen (BUN) 6.2 mmol/L, serum creatinine 101 μmol/L, hemoglobin 14.2 g/dL and WBC 8000 mm³. An epidural catheter was placed and general anesthesia was administered. One dose of Ceftriaxone (1 g intravenous) was given pre-operatively and two doses post-operatively. During the procedure, electrohydrolic lithotripsy and crushing forceps were used for disintegration of the bladder stone. This was complicated by posterior bladder perforation and abdominal distention. Then, the abdomen was opened and large amounts of 1.5% glycine irrigation solution were evacuated from the intraperitoneum.

A posterior bladder injury was noticed. The bladder was opened vertically and the perforation was repaired. During the procedure, which lasted 5.5 h, there were no hypotensive episodes but the patient developed sinus bradycardia (50 bpm). The central venous pressure (CVP) remained between 7 and 10 cm H 2 0 during the whole procedure.

Post-operatively, the patient was transferred to the recovery room in a stable condition. In the next 12 h, the patient became oligoanuric (160 mL of urine in 12 h), CVP did not decrease (7-8 cmH 2 0), blood pressure remained stable (145/65) and bradycardia (50 bpm) persisted. Abdominal ultrasound was unremarkable. BUN increased to 8 mmol/L and serum creatinine to 136 μmol/L compared with the immediate post-operative values of 7.2 mmol/ L and 126 μmol/L, respectively. Sodium level decreased from 139 mmol/L pre-operatively to 126 mmol/L post-operatively.

On the next day, Na + was 127 mmol/L, BUN was 10.8 mmol/L, serum creatinine was 175 μmol/L, K + was 6.4 mmol/L and CPK was 3677 IU/L. Prothrombin and partial thromboplastin times were within normal limits. The patient received fluid challenge and intravenous furosemide, and alkalization of the urine with no effect on his oliguria. The following day, his CPK was lower (1533 IU/L), and continued to decrease gradually afterwards.

Hemodialysis was started 72 h post-operatively as the patient remained oliguric with a high creatinine level (445 μmol/L) and features of pulmonary congestion. He required four more dialysis sessions until he started to show improvement in urine output and renal function. Eventually, the patient was discharged with serum creatinine of 72 μmol/L and BUN 6 mmol/L.

   Discussion Top

Operation positions expose patients to rhabdomyolysis, particularly following prolonged surgeries, due to constant and prolonged pressure of the muscle beds with elongation of muscles and arterial blood supply, which can result in decreased blood flow and ischemia. [7] The mechanism of renal injury in this condition is multifactorial and includes relative hypovolemia secondary to redistribution of intravascular volume into the edematous muscle tissue, intratubular cast formation with resultant obstruction and direct hememediated proximal toxicity. [8] Myoglobin as well is intrinsically nephrotoxic and can precipitate acute tubular necrosis. [9]

Targa et al, [1] showed in their prospective study that rhabdomyolysis was directly related to the duration of surgery, and that for a mean time of surgery duration of 3.5 h, ARF did not occur. In almost all reported cases where ARF was involved, duration of surgery was above 5 h. [2],[3],[4],[5],[6] Our case, with a 5.5-h duration of surgery complies with this finding. However, the other known potential risk factors, including hypertension, diabetes, obesity, pre-existing renal failure and extra-cellular volume depletion, were all absent in our patient. [3] Kikuno et al advocated duration time of an operation above 5 h as the most important risk factor for rhabdomyolysis and subsequent ARF. [10] We believe that it is also the most important factor to consider in the prevention of such complications.

The usual symptoms of compartmental syndrome or direct muscle injury including the lower back and extremity pain or swelling on the buttocks were not present in our patient. His old age with low muscular mass may explain why blood levels of CK and myoglobine were not excessively elevated, and raise the point that higher levels and large muscular frame may not be mandatory for rhabdomyolysis to occur. [4] In this condition, the rapid increase in serum creatinine greater than 1 mg/dL per 24 h, which is highly suggestive of the diagnosis of rhabdomyolysis and noticed in our patient, should be given prime importance in order to reach an early diagnosis. [11]

On the other hand, cases in the LP are very seldom reported, [10] probably because ELP is more frequently used. Cases of rhabdomyolysis due to the LP and without compartmental syndrome, as in our case, are even rarer, and as far as we know, only a handful of cases are reported combining both conditions. [3],[5],[10] Consequently, it shows that the LP is not safer than the ELP, and that, in fact, duration of surgery is a main trigger for rhabdomyolysis.

Finally, this condition remains widely unrecognized and more awareness by anesthetists, surgeons and nephrologists will definitely improve early diagnosis and prevention of this morbid condition.

The use of 1.5% glycine irrigation solution may lead to toxicity of glycine, which is known to occur in urologic surgery following transurethral resection of the prostate (TURP) causing post-TURP syndrome. In our patient, bladder perforation led to the leak of glycine solution into the peritoneum. Although big amounts of fluids were evacuated from the intraperitoneum, post-TURP syndrome was suspected based on the appearance of bradycardia and hyponatremia. The latter, however, was asymptomatic and was not severe enough to be suspected as a cause of rhabdomyolysis in our patient. [12],[13]

The other possibility following important resorption of glycine, which is catabolized into oxalate, may be acute oxalate deposit in the tubules causing ARF and anuria.

This possibility as well, was unlikely in our patient as the oxalate level was normal. Moreover, in such cases, one single dialysis session was shown to be sufficient to restore renal function, [14] and that was not the case in our patient who needed five dialysis sessions.

Conflict of interest: None

   References Top

1.Targa L, Droghetti L, Caggese G, Zatelli R, Roccela P. Rhabdomyolysis and operating position. Anesthesia 1991;46:141-3.  Back to cited text no. 1
2.Ali H, Nieto JG, Rhamy RK, Chandralapaty SK, Vaamonde CA. Acute renal failure due to rhabdomyolysis associated with the extreme lithotomy position. Case report. Am J Kidney Dis 1993;22:865-9.  Back to cited text no. 2
3.Biswas S, Gnanasekaran I, Ivatury RR, Simon R, Patel AN. Exaggerated lithotomy position related rhabdomyolysis. Am Surg 1997;63: 361-4.  Back to cited text no. 3
4.Gabrielli A, Caruso L. Post-operative acute renal failure secondary to rhabdomyolysis from exaggerated lithotomy position. J Clin Anesth 1999;11:257-63.  Back to cited text no. 4
5.Anema JG, Morey AF, Mc Aninch JW, Mario LA, Wessels H. Complications related to the high lithotomy position during urethral recons-truction. J Urol 2000;164:360-3.  Back to cited text no. 5
6.Orihuela E, Nazemi T, Shu T. Acute renal failure due to rhabdomyolysis associated with radical perineal prostatectomy. Eur Urol 2001; 39:606-9.  Back to cited text no. 6
7.Angermeier KW, Jordan GH. Complications of the exaggerated lithotomy position: A review of 177 cases. J Urol 1994;151:866-8.  Back to cited text no. 7
8.Zager RA. Rhabdomyolysis and myohemogloginuric acute renal failure. Kidney Int 1996; 49:314-26.  Back to cited text no. 8
9.Minigh JL, Valentovic MA. Characterisation of myoglobin toxicity in renal cortical slices from Fischer 344 rats. Toxicology 2003;184: 113-23.  Back to cited text no. 9
10.Kikuno N, Urakami S, Shigeno K, Kishi H, Shiina H, Igawa M. Traumatic rhabdomyolysis resulting from continuous compression in the exaggerated lithotomy position for radical perineal prostatectomy. Int J Urol 2002;9:521-4.  Back to cited text no. 10
11.Koffler A, Friedler RM, Massry SG. Acute renal failure due to non traumatic rhabdomyolysis. Ann Intern Med 1976;85:23-8.  Back to cited text no. 11
12.Ayus JC, Arieff AI. Glycine-induced hypo-osmolar hyponatremia. Arch Int Med 1997; 157:223-6.  Back to cited text no. 12
13.Mitnick PD, Bell S. Rhabdomyolysis associated with severe hyponatremia after prostatic surgery. Am J Kidney Dis 1990;16:73-5.  Back to cited text no. 13
14.Arvieux C, Peyrin JC, Dechelette E, Davin JL, Naud G, Faure G. Acute renal failure insufficiency following endourethral surgery with glycin irrigation. J Urol 1984;90:107-10.  Back to cited text no. 14

Correspondence Address:
Adnane Guella
Department of Nephrology, Fahd Military Medical Complex, P. O. Box 946, 31932 Dhahran
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.109597

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