Nephroptosis have to be treated just in the rarely patients who existing with a full range of symptoms and also confirmation that the diagnosis with among the imaging researches described over (see Imaging Studies).

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Owing come hypochondriac actions that regularly accompany symptomatic nephroptosis, nonsurgical treatments room recommended together a first-line intervention. Part such treatments incorporate weight gain, therapy with cradle medications, abdominal wall–strengthening exercises, abdominal wall binders (eg, corsets), and frequent rests in the supine position. Extracorporeal assistance of the ptotic kidney shows up to it is in the most efficient nonsurgical treatment, and ab binders and also corsets were in typical use transparent the 1900s. <3> similar to a truss for treating a hernia, these philosophies are every temporizing maneuvers.



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Surgical Therapy


All surgical therapies for nephroptosis are based on the principle the the ptotic kidney should be irreversibly fixed right into its normal position by securing the kidney or perinephric organization (renal capsule, perirenal fat, Gerota fascia) to the body wall high in the retroperitoneum via one of two people suture or subsequent adhesion formation. A few of the significant surgical measures are questioned below.


Nephropexy

This procedure is offered to affix the kidney to the retroperitoneal tissues via open or laparoscopic surgery. The renal capsule is attached to the psoas or quadratus lumborum muscle with nonabsorbable sutures, fascial or muscle bands, and/or polyglactin mesh. <1> This procedure to be pioneered by Bassini and is currently the most generally used open surgical nephropexy technique. Making use of the 12th rib together a sling or skewer has normally fallen the end of favor.


Endourological procedures

In the critical 20 years, the endourological procedures laparoscopic nephropexy and circle (U) nephrostomy pipe insertion have got favor as surgical therapies for nephroptosis. <3>


Laparoscopic nephropexy


This is a laparoscopic procedure that closely duplicates the open up nephropexy described over but that outcomes in considerably lower morbidity. Laparoscopic nephropexy confers a far-ranging and durable development in top quality of life in roughly 70%-90% that patients who undergo the procedure. <20, 8, 21, 22> The method is practiced at many centers with considerable laparoscopic experience.


In 1997, Fornara and also colleagues contrasted open with laparoscopic nephropexy. The average operative time to be 49 minutes and also 61 minutes, respectively. Postoperative analgesic control was measure to be an average of 15 mg morphine equivalents in the laparoscopic group and also 38 mg in the open up group. In the laparoscopic group, the median hospital stay was 3.7 days, matches 16 work in the open surgery group. In addition, break-up renal role improved native 38% come 47% postoperatively in the laparoscopic group. <20>


Multiple laparoscopic procedural methods exist, including the usage of absorbable mesh, continuous staples, and/or sutures put through Gerota fascia and also sutures with the renal capsule. Countless studies have presented that organization adhesives (eg, butyl cyanoacrylate) and also medical devices (eg, tension-free vaginal tape) can likewise be offered to certain the kidney high in the retroperitoneum. <23, 24, 25> effective kidney fixation has actually been reported through the slide cup techniqueutilizing suture and nonabsorbable polymer clips. <26>


Multiple irreversible outcome studies have actually proven the efficacy of laparoscopic nephropexy. <8, 9, 21, 27> this reports, with follow-up times varying from 3.3-8.2 years, showed that, postprocedure, 71% of patient reported an development in quality of life and also showed one 80%-91% reduction in pain.


The initial laparoscopic procedure, well-known as the Washington University technique (transperitoneal laparoscopic retroperitoneal nephropexy), is described in information in Intraoperative Details.


Circle (U) nephrostomy pipe insertion


Note the picture below.


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circle (U) nephrostomy tube treatment. The nephrostomy tube enters over the 12th rib, passes through the kidney through an upper pole, and also exits v a middle calyx and also below the 12th rib, suspending the kidney. (Reprinted from Hoenig DM, Hemal AK, Shalhav AL, Clayman RV. Nephroptosis: a "disparaged" condition revisited. Urology. Oct 1999;54(4):590-6, through permission indigenous Elsevier.)
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In this procedure, very first described by Szekely and also colleagues in 1997, a 14F-16F nephrostomy tube is put through two points in the middle and upper calices, with the pipe entering over the 12th rib and exiting listed below the 12th rib, developing a sling supplied to suspend the kidney to the 12th rib. The tube is then sutured come the skin with moderate tension and also left in place for 2-3 mainly to permit sufficient scar formation for kidney fixation. <28>


In a long-term outcome research of 90 patients end 12 years, Szekely and also colleagues to be able to present a 79% irreversible success price with nephrostomy pipe insertion based upon pain intensity. They report a typical operative time the 18 minutes and also an mean hospital continue to be of 3 days because that the procedure. This method, although doing not have in extensive application, is considered a low-morbidity, easy-to-perform, cost- and also time-effective alternate to laparoscopic nephropexy by those adept in that use. <29> However, due to the fact that this method is not prevalent in application, corroborating data from various other institutions regarding its success are absent.



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Preoperative Details


Preoperative consultation consists of the following:


thorough medical history
Perioperative antibiotics
feasible preoperative mechanically bowel ready of low-sediment diet and glycerin enema for bowel decompression come facilitate laparoscopy

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Intraoperative Details


Transperitoneal laparoscopic retroperitoneal nephropexy


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Transperitoneal laparoscopic nephropexy. The lateral border of the renal capsule has been sutured come quadratus lumborum fascia. In addition, the remarkable flap that the hepatic triangular ligament has been sutured come the anterior renal capsule. (Reprinted indigenous Elashry OM, Nakada SY, McDougall EM, Clayman RV. Laparoscopic nephropexy: Washington university experience. J Urol. Nov 1995;154(5):1655-9, through permission indigenous Elsevier.)
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This procedure was very first successfully performed by Urban and colleagues in 1993 in ~ Washington university in St. Louis, Missouri. <30>


A transperitoneal approach is wanted over a retroperitoneal strategy because it enables for horizontal and also vertical permanent of the kidney if eliminating the need for conversion from retroperitoneal to transperitoneal approach in the rare situation when the kidney is both ptotic and also markedly displaced anteriorly. <16> However, much more recent researches have shown success and symptom resolution in retroperitoneal technique laparoscopic nephropexy using nonabsorbable sutures put horizontally fairly than in the standard vertical distribution. <31>


Retroperitoneal laparoscopic nephropexy may be particularly indicated in patient who have actually undergone prior abdominal muscle surgery. <6> Furthermore, tissue adhesives such as butyl cyanoacrylate have presented initial success in affixing the kidney to the retroperitoneum. <24, 23> In 2002, Gyftopoulos et al verified that, v a mean follow-up of 25 months, 9 patients who had actually undergone adhesive nephropexy had far-reaching improvement on pains scales, and proper kidney permanent on follow-up radiographic studies. <32> Nonetheless, additional long-term outcome studies are still needed.


The procedure described below has been offered in multiple long-term outcome series of laparoscopic nephropexy and also has proven to it is in a for sure treatment connected with low morbidity that resolves symptoms as result of nephroptosis. <8, 9, 21>


The patience is put in the lateral decubitus position. A Veress needle is passed right into the peritoneum, and also the abdomen is consequently insufflated come 25 mm Hg. A 12-mm umbilical port is placed, complied with by insertion of a 30° 10-mm laparoscope. Three additional ports are also placed, as follows:


A 12-mm port subcostally in ~ the midclavicular heat (Note that a 5-mm port have the right to be substituted, if preferred; in this case, every sutures are then happen via the 12-mm umbilical port.)
A 5-mm port in the anterior axillary line at the level that the umbilicus
A 5-mm harbor subcostally in the anterior axillary line

An scratch is made in ~ the heat of Toldt. The right colon is mobilized and the retroperitoneum exposed. The Gerota fascia is incised, and the kidney is dissected and also mobilized ~ above the anterior, posterior, superior, inferior and lateral elements using electrosurgical scissors and a hook electrode. The medial portion of the kidney deserve to be left undisturbed. The posterior wall surface of the retroperitoneum is bluntly dissected to expose fascia overlying the psoas major and quadratus lumborum muscles.


The patient is then repositioned in a steep head-down position, allowing for cephalad displacement that the kidney. The kidney is affixed using straightforward or horizontal mattress sutures of 1-0, nonabsorbable, intracorporeal sutures along the lateral border the the renal capsule from the top to lower pole of the kidney. The sutures space then placed through the fascia that the quadratus lumborum. Intracorporeal knot tie or Lapra-Ty clips have the right to be offered for suture fixation. In addition, newer technologies such as polyglactin mesh, fibrin glue, or nonabsorbable polymer clips can be used to secure the kidney in ar high in the retroperitoneum or to add to the defense of other varieties of repairs. <21, 33> A horizontal line of fixation can additionally be produced by anastomosing the superior aspect of the incised posterior coronary hepatic ligament to the anterior renal capsule with nonabsorbable sutures.


Finally, inspect for hemostasis in ~ the 5-mm port.



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Postoperative Details


Patients normally resume dental intake the night the surgery and also begin ambulating top top the first or 2nd postoperative day, v discharge on the 2nd or 3rd day. Usually, patients receive oral analgesics because that pain control and also return because that follow-up imaging studies 2-6 months adhering to the procedure. <16>



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Complications


Potential symptom of nephroptosis encompass the complying with <1> :


Pyelonephritis
Renal calculi
Hematuria
Hypertension
Kidney ischemia
Flank ache

Potential symptom of nephropexy incorporate the adhering to <20> :


Urinary tract epidemic
Uncorrected ptotic kidney
Retroperitoneal hematoma
Bowel injury or puncture during trocar location
counter to open up nephropexy
Muscle paresthesia
Genitofemoral nerve injury or entrapment
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Outcome and also Prognosis


Laparoscopic nephropexy and also circle U nephrostomy tube therapy for nephroptosis yield wonderful results, with efficient pain manage in correctly selected patients. <19, 34> Multiple irreversible outcome studies have shown that patient undergoing laparoscopic nephropexy have substantially reduced morbidity, reduced postoperative discomfort, and also a much faster recovery time 보다 patients undergoing open nephropexy.


A research by Hubner and also colleagues (1994) proved that laparoscopic nephropexy had actually a mean operative time of 2.7 hours, through 10 mg the morphine compelled for adequate pain manage following the procedure. Follow-up confirmed anecdotal resolution of symptoms and also no significant kidney descent upon repeat intravenous pyelography. <35> However, the follow-up duration in this examine was just 10.5 months.


In 2000, McDougall and colleagues confirmed that, with an average follow-up the 3.3 years, analogue pain scales enhanced by 80%, v 21% the patients considered cured and 71% of patients improved. The procedure fail in just 7% (one patient). Radiographic studies verified that ptosis addressed in every patients, and also renal function was the same as evaluate by serum creatinine levels. <8>


In 2001, Plas and colleagues released a research validating laparoscopic nephropexy through data garnered native patients with an average of 5.9 years of follow-up. <9> patient follow-up had standing and also supine intravenous pyelography come confirm permanent fixation that the kidney. Ptosis recurred in 20% of patients, while all patients report anecdotal innovation in symptoms.

See more: How Long Is The Surge How Long To Beat The Surge 2? The Surge 2: How Long To Beat


Most recently, Gozen and colleagues have shown laparoscopic nephropexy to it is in a suitable, established, and safe treatment for nephroptosis, with an improvement of symptoms, enhanced patient satisfaction, and 71% of patient reporting an advancement in top quality of life over an mean follow-up the 8.2 years. Ache relief was on one anecdotal basis only; 85% that patients were pain-free postprocedure. <21>


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Future and also Controversies


The presence of pathological nephroptosis and also the necessity of its operation treatment have actually been disputed by urologists for more than a century. However, present knowledge suggests that, in the rare symptomatic patient, laparoscopic nephropexy can prove to be a safe and also effective treatment for symptomatic nephroptosis as recorded by proper radiographic studies.


Many other possible therapies can improve top top transperitoneal or retroperitoneal laparoscopic nephropexy, such as the following:


using tissue adhesives (these require additional study)
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references

Winfield H. Nephroptosis. The 5-Minute Urology Consult. Philadelphia: Lippincott Williams and also Wilkins; 2000. Vol 1: 368-9.

Dietl J. Wanderende Nieren und deren Einklemmung. Wien Med. Wschr. 1864;14:563 (part I); 1864;14:579 (part II); 1864;14:593 (part III).

Hahn E. Die operative Behandlung der beweglichen Niere durch Fixation. Zentralbl Chirurgie. 1881. 29:449-556.

Bishoff JT, Kavoussi LR. Nephropexy. Campbell-Walsh Urology. Philadelphia: Saunders Elsevier; 2007. 9(2): 1776-8; Ch 51.

Friedenberg RM, Harris RD. Techniques and applications the urological imaging. Clinical Urography. Philadelphia: Saunders; 2000. 2(1): 200; Ch 6.

Barth R, Nino-Murcia M, DeVries PA, Friedland GW. Congenital anomalies the the urinary tract. Clinical Urography. Philadelphia: Saunders; 2000. 2(1): 725; Ch 11.

Leonard RJ. Human gun Anatomy. Brand-new York: Oxford college Press; 1995. Vol 1: 119-22.

Nakada SY, McDougall EM, Clayman RV. Laparoscopic Nephropexy. Smith"s Textbook the Endourology. St. Louis: quality Medical; 1996. 1(2): 945-7; Ch 58.

Landman J, McDougall EM, Gill IS, Clayman RV. Retroperitoneum: Nephropexy. Adult and Pediatric Urology. Philadelphia: Lippincott Williams and also Wilkins; 2002. 4(1): 707-9; Ch 18.

Szekely J, Bagheri F, Villa nyi K, Pusztai C, et al. Percutaneous nephropexy through U-tube nephrostomy: long-term follow-up of one alternative an approach for treatment of symptomatic nephroptosis. Urology. 2006. 68 (Supplement 5A):227.