Nephroptosis should be treated only in the rarely patients who current with a full range of symptoms and confirmation that the diagnosis with one of the imaging researches described above (see Imaging Studies).

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Owing to hypochondriac actions that regularly accompany symptomatic nephroptosis, nonsurgical treatments space recommended together a first-line intervention. Part such treatments include weight gain, treatment with cradle medications, abdominal muscle 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 corsets were in usual use throughout the 1900s. <3> comparable to a truss for treating a hernia, these ideologies are every temporizing maneuvers.



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Surgical Therapy


All operation therapies for nephroptosis are based on the principle that the ptotic kidney should be irreversibly fixed right into its normal position by securing the kidney or perinephric tissue (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 couple of of the influential surgical actions are discussed below.


Nephropexy

This procedure is provided to affix the kidney to the retroperitoneal organization via open up or laparoscopic surgery. The renal capsule is attached to the psoas or quadratus lumborum muscle v nonabsorbable sutures, fascial or muscle bands, and/or polyglactin mesh. <1> This procedure was pioneered through Bassini and is at this time the most generally used open up surgical nephropexy technique. Making use of the 12th rib as a sling or skewer has usually fallen out of favor.


Endourological procedures

In the last 20 years, the endourological steps laparoscopic nephropexy and also circle (U) nephrostomy tube insertion have got favor as surgical therapies for nephroptosis. <3>


Laparoscopic nephropexy


This is a laparoscopic procedure that closely duplicates the open nephropexy described above but that results in substantially lower morbidity. Laparoscopic nephropexy confers a far-ranging and durable development in top quality of life in around 70%-90% the patients who undergo the procedure. <20, 8, 21, 22> The technique is practiced at plenty of centers with considerable laparoscopic experience.


In 1997, Fornara and colleagues compared open v laparoscopic nephropexy. The typical operative time to be 49 minutes and 61 minutes, respectively. Postoperative analgesic manage was measure up to it is in an median of 15 mg morphine equivalents in the laparoscopic group and 38 mg in the open up group. In the laparoscopic group, the median hospital stay was 3.7 days, matches 16 days in the open up surgery group. In addition, split renal duty improved native 38% come 47% postoperatively in the laparoscopic group. <20>


Multiple laparoscopic procedural approaches exist, consisting of the use of absorbable mesh, fixation staples, and/or sutures placed through Gerota fascia and also sutures through the renal capsule. Many studies have presented that tissue adhesives (eg, butyl cyanoacrylate) and medical devices (eg, tension-free vaginal tape) can likewise be provided to secure the kidney high in the retroperitoneum. <23, 24, 25> effective kidney fixation has been reported through the sliding cup techniqueutilizing suture and also nonabsorbable polymer clips. <26>


Multiple permanent 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, proved that, postprocedure, 71% of patients reported an innovation in quality of life and also showed an 80%-91% reduction in pain.


The original laparoscopic procedure, well-known as the Washington University an approach (transperitoneal laparoscopic retroperitoneal nephropexy), is defined in information in Intraoperative Details.


Circle (U) nephrostomy tube insertion


Note the picture below.


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


In a long-term outcome research of 90 patients end 12 years, Szekely and also colleagues were able to show a 79% irreversible success rate with nephrostomy pipe insertion based on pain intensity. They report a median operative time of 18 minutes and also an mean hospital stay of 3 days for the procedure. This method, although doing not have in extensive application, is considered a low-morbidity, easy-to-perform, cost- and also time-effective alternative to laparoscopic nephropexy by those adept in that use. <29> However, due to the fact that this an approach is not extensive in application, corroborating data from other institutions as to its success space absent.



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Preoperative Details


Preoperative consultation has the following:


thorough medical background
Perioperative antibiotics
feasible preoperative mechanically bowel preparation of low-sediment diet and also glycerin enema because that 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 that the renal capsule has actually been sutured come quadratus lumborum fascia. In addition, the premium flap that the hepatic triangle ligament has actually been sutured come the anterior renal capsule. (Reprinted native Elashry OM, Nakada SY, McDougall EM, Clayman RV. Laparoscopic nephropexy: Washington university experience. J Urol. Nov 1995;154(5):1655-9, through permission from Elsevier.)
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This procedure was an initial successfully performed by Urban and colleagues in 1993 at Washington university in St. Louis, Missouri. <30>


A transperitoneal strategy is desired over a retroperitoneal approach because it permits for horizontal and vertical fixation of the kidney when eliminating the require for conversion native retroperitoneal to transperitoneal technique in the rare instance when the kidney is both ptotic and markedly displaced anteriorly. <16> However, much more recent research studies have presented success and also symptom resolution in retroperitoneal approach laparoscopic nephropexy using nonabsorbable sutures put horizontally rather than in the classic vertical distribution. <31>


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


The procedure described listed below has been provided in multiple long-term outcome series of laparoscopic nephropexy and has proven to be a for sure treatment linked with low morbidity the resolves symptoms because of nephroptosis. <8, 9, 21>


The patient is inserted in the lateral decubitus position. A Veress needle is passed right into the peritoneum, and the abdomen is consequently insufflated to 25 mm Hg. A 12-mm umbilical port is placed, adhered to by insertion that a 30° 10-mm laparoscope. Three extr ports are also placed, together follows:


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

An incision is made in ~ the line of Toldt. The appropriate colon is mobilized and also the retroperitoneum exposed. The Gerota fascia is incised, and the kidney is dissected and also mobilized on the anterior, posterior, superior, inferior and also lateral aspects using electrosurgical scissors and also a hook electrode. The medial portion of the kidney have the right to be left undisturbed. The posterior wall surface of the retroperitoneum is bluntly dissected to expose fascia overlying the psoas significant and quadratus lumborum muscles.


The patient is then repositioned in a steep head-down position, allowing for cephalad displacement of the kidney. The kidney is affixed using an easy or horizontal mattress sutures the 1-0, nonabsorbable, intracorporeal sutures along the lateral border that the renal capsule from the top to reduced pole of the kidney. The sutures room then put through the fascia the the quadratus lumborum. Intracorporeal knot tie or Lapra-Ty clips can be offered for suture fixation. In addition, more recent technologies such together polyglactin mesh, fibrin glue, or nonabsorbable polymer clips have the right to be supplied to secure the kidney in ar high in the retroperitoneum or to include to the defense of other types of repairs. <21, 33> A horizontal heat of fixation can additionally be created by anastomosing the superior element of the incised posterior coronary hepatic ligament come the anterior renal capsule v nonabsorbable sutures.


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



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Postoperative Details


Patients usually resume oral intake the night that surgery and begin ambulating on the an initial or second postoperative day, with discharge on the 2nd or third day. Usually, patient receive dental analgesics because that pain control and also return because that follow-up imaging research studies 2-6 months complying with the procedure. <16>



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Complications


Potential symptom of nephroptosis encompass the following <1> :


Pyelonephritis
Renal calculi
Hematuria
Hypertension
Kidney ischemia
Flank ache

Potential symptom of nephropexy encompass the complying with <20> :


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


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


A study by Hubner and colleagues (1994) verified that laparoscopic nephropexy had actually a mean operative time that 2.7 hours, with 10 mg that morphine forced for enough pain control following the procedure. Follow-up confirmed anecdotal resolution of symptoms and no significant kidney lower upon repeat intravenous pyelography. <35> However, the follow-up period in this examine was only 10.5 months.


In 2000, McDougall and also colleagues confirmed that, with an mean follow-up the 3.3 years, analogue ache scales improved by 80%, through 21% of patients taken into consideration cured and also 71% of patient improved. The procedure failure in only 7% (one patient). Radiographic studies confirmed that ptosis solved in every patients, and also renal role was the same as evaluate by serum creatinine levels. <8>


In 2001, Plas and colleagues released a study validating laparoscopic nephropexy with data garnered from patients through an median of 5.9 years of follow-up. <9> patience follow-up contained standing and also supine intravenous pyelography come confirm irreversible fixation of the kidney. Ptosis recurred in 20% that patients, while all patients report anecdotal improvement in symptoms.

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Most recently, Gozen and colleagues have shown laparoscopic nephropexy to it is in a suitable, established, and safe treatment for nephroptosis, through an advancement of symptoms, enhanced patient satisfaction, and also 71% of patients reporting an innovation in high quality of life over an typical follow-up that 8.2 years. Pain relief to be on one anecdotal basis only; 85% of patients to be pain-free postprocedure. <21>


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Future and also Controversies


The visibility of pathological nephroptosis and the necessity of its surgical treatment have actually been disputed by urologists for more than a century. However, current knowledge argues that, in the rare symptomatic patient, laparoscopic nephropexy deserve to prove to be a safe and effective therapy for symptomatic nephroptosis as recorded by ideal radiographic studies.


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


using tissue adhesives (these require more 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. Dice 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 that urological imaging. Clinical Urography. Philadelphia: Saunders; 2000. 2(1): 200; Ch 6.

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

Leonard RJ. Human gross Anatomy. New York: Oxford university Press; 1995. Vol 1: 119-22.

Nakada SY, McDougall EM, Clayman RV. Laparoscopic Nephropexy. Smith"s Textbook that Endourology. St. Louis: top 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 Wilkins; 2002. 4(1): 707-9; Ch 18.

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