RU2847411C1 - Method for surgical treatment of patients with nephroptosis and upper pole renal cyst - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: the invention relates to medicine, namely to surgical urology. Paraumbilical laparoscopic access is performed. The parietal peritoneum and pre-renal fascia are dissected obliquely in the area of the upper pole of the kidney. The cyst wall is separated from the upper pole to the border with the renal parenchyma. The cyst is opened using an electrosurgical instrument. The contents of the cyst are aspirated. Form a trapezoidal flap from the surface of the cyst adjacent to the lumbar muscle, with a width of at least 3.5 cm at the base, at least 2.5 cm at the apex, and a length of at least 6 cm, with the wide base facing the upper pole of the kidney. The flap is fixed with three sutures to the tendinous centre of the diaphragm using non-absorbable suture material.

EFFECT: elimination of the possibility of pathological rotation of the kidney, preservation of the physiological mobility of the kidney.

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Description

The invention relates to medicine, namely to surgical urology, and can be used in the treatment of patients with a pathologically mobile kidney, in combination with a cyst of the upper pole of the kidney, to maintain physiological mobility, on the one hand, which is necessary for the normal function of the kidney, and on the other hand, fixation of the upper pole, preventing rotation of the kidney.

In the last 10-15 years, the following surgical methods have been most frequently used for the treatment of nephroptosis, depending on the chosen surgical approach: lumbotomy approach, often with fixation of the pathologically mobile kidney using a muscle flap in various modifications; percutaneous, laparoscopic, retroperitoneoscopic, and minimally invasive mini-approaches of nephropexy.

Until recently, a method of kidney fixation using a muscle flap cut from the lumbar muscle was widely used in clinical practice [Urology, Moscow, 1997, edited by N.A. Lopatkin, p. 143]. With the patient lying on the healthy side and the subcostal ridge extended, a Fedorov lumbotomy is performed, exposing the retroperitoneal space layer by layer. The kidney is bluntly and sharply freed from planar adhesions and adherences. The kidney is exposed and carefully mobilized. After this, it is retracted and tilted medially, exposing its posterior surface. At the level of the mid-portion of the kidney, the renal capsule is incised transversely for 2-2.5 cm, and a tunnel is formed with a straight instrument to the lower pole. A 2-2.5 cm long capsule incision is made in the lower pole at the end of the tunnel formed along the posterior surface. This incision creates a tunnel similar to the first, but along the anterior surface, ending slightly below the mid-section of the kidney. This creates a hook-shaped tunnel in the subcapsular space of the kidney. A pedicled flap, 1-1.5 cm wide and 8-10 cm long, is dissected from the medial psoas muscle. The muscle flap is transected at the junction of the muscle and tendon. The free distal end of the muscle flap is ligated with catgut suture and inserted into the tunnel under the fibrous capsule along the posterior surface of the kidney, encircling the lower pole and exiting through an opening in the fibrous capsule along the anterior surface. The muscle flap is secured to the renal capsule with absorbable sutures on both sides of all capsule incisions.

The disadvantages of the above method include a high probability of recurrence of nephroptosis, as well as the possibility of rotation of the kidney in the frontal plane, which causes "twisting" of the vascular pedicle with subsequent ischemia and atrophy of the organ, which, according to E.S. Shpilenya, occurs in 5-8% of cases [Shpilenya E.S. Surgical treatment of nephroptosis: ... author's abstract. diss. candidate of medical sciences, Leningrad, 1988]. It is also possible that disturbances in the urodynamics of the upper urinary tract (UUT) may persist, which is the cause of recurrent pyelonephritis, leads to the development of urolithiasis, and persistent pain.

Modifications of the Rivoir-Pytel-Lopatkin nephropexy method are known. One of the modifications is a method of nephropexy of a pathologically mobile kidney in tuberculosis of the urinary tract, which uses a polypropylene mesh [RU patent #2411916, published April 20, 2004, authors Meshkov S.V., Galilei M.V., Zhurkina O.V.]. The authors propose suturing one end of a synthetic implant to the lumbar muscle, then wrapping the lower pole of the kidney and fixing the free end of the tape to the anterior surface of the kidney. Fixation of a prolapsed kidney with a polypropylene mesh, compared to the method of fixation of the kidney with an automuscle, is a shorter operation, technically simpler, and associated with fewer intra- and postoperative complications. However, the use of a muscle flap and prolonged patient stay on strict bed rest for up to 21 days leads to a decrease in quality of life. Fixing the kidney with a polypropylene mesh allows for early mobilization of the patient—they can walk the next day. However, a dense infiltrate forms in the mesh fixation area, eventually resulting in a coarse, deforming scar. Contact between the lumbar muscles and the polypropylene mesh causes tight adhesion of the muscle fibers to the synthetic material, impairing their function. Furthermore, the mesh implant, with its varying thickness due to the intersecting individual threads, has a traumatic effect, comparable to a "grater," damaging the renal capsule in the fixation area, leading to compression, disrupting circulation, and the development of chronic inflammation and the risk of malignancy.

Another well-known modification is a method for treating nephroptosis by suturing the prerenal fascia to the quadratus lumborum muscle to form a suspensory [Deming operation, Urologic surgery. Editor J.F. Glenn. Third edition, 1983. Pp. 253-254]. The essence of this method is to make a lumbar incision, expose the kidney, and reposition it in an orthotopic position. The prerenal fascia is fixed to the quadratus lumborum muscle with 5-8 sutures.

However, this method has a significant drawback: it does not ensure sufficient effectiveness of nephropexy in the orthotopic position. Inertial loads on the adjoining edges of the muscle and fascia during caudal or rotational displacement of the kidney can exceed acceptable limits and cause recurrent nephroptosis or obstructive uropathy, leading to the development of hydronephrosis. The above-described nephropexy method can cause abnormal kidney rotation, as it lacks a suture fixation mechanism that evenly distributes the load across the anterior surface of the kidney.

The disadvantage of the lumbotomy approach is its traumatic nature—it involves extensive muscle transection, disrupting the innervation, blood flow, and lymphatic circulation of the lateral abdominal muscles. Therefore, with open lumbotomy, the patient's recovery period is prolonged, and postoperative complications such as hernias, abdominal wall atony, and others are possible.

Minimally invasive surgeries for nephroptosis have obvious advantages over open surgeries: less trauma, good cosmetic results, an easier postoperative period, and a shorter hospital stay.

A known method of laparoscopic nephropexy [RU Patent No. 2342095, dated December 27, 2008] involves mobilizing the kidney, fixing it in a physiological position, and inserting a polypropylene mesh tape under its lower pole. This technique utilizes a polypropylene mesh 15 cm long and 3 cm wide, with one end longitudinally split in the middle to a depth of 8 cm, forming a split Y-shaped end. After the kidney is moved to a physiological position, the unsplit end of the polypropylene mesh is secured to the periosteum of the twelfth rib or to the anterior surface of the psoas muscle with Z-shaped sutures made of non-absorbable suture material. After passing the polypropylene mesh under the lower pole of the kidney, the split Y-shaped end is fixed to the lower pole of the kidney with simultaneous correction of the pathological rotation with a continuous suture in a checkerboard pattern with a prolene thread on an atraumatic needle or with four staples using a herniostapler.

Similar to the above-described method is the method of laparoscopic nephropexy [patent RU No. 2367368 from 20.09.2009], which consists of moving the colon downward and medially; dissecting the peritoneum and its prerenal fascia at the lower end of the kidney and fixing the upper edge of the peritoneal flap together with the renal fascia to the lumbar muscles with 4-5 ligatures along the edge of the lower pole of the kidney, and the free lower edge of the peritoneal flap to the upper one, like a duplication, using a needle inserted through the endoport.

The disadvantages of these methods include the inability to recreate the topographic and anatomical features of the kidney's position, fixation, and physiological mobility by using and incorporating nearby fixed structures—muscles—into the suture. The use of synthetic materials in some cases inevitably leads to inflammation and scarring involving the kidney itself, resulting in limited mobility and impaired function. The use of a herniostapler does not always ensure reliable fixation of the graft to the lumbar muscles and kidney, leading to recurrence of the disease.

A good therapeutic effect can be achieved using the method of intraperitoneal fixation of the kidney using the I.P. Pogorelko approach [patent RU No. 2430689 dated 10.10.2011; Method of intraperitoneal fixation of the kidney / Russkikh A.N., Andreychikov A.V., Samotesov P.A., Gorbunov N.S., Firsov M.A. // Siberian Medical Review. - 2010. No. 3. - P. 47-49], where the colon is retracted medially, the lower pole of the pathologically mobile kidney is identified and placed in a physiological position. An oblique transverse incision is then made through the parietal peritoneum and prerenal fascia at the level of the lower pole. The entire peritoneal-fascial layer is dissected down to the fibrous capsule of the kidney, equal to the diameter of its lower pole. The kidney is inserted into it and the fibrous capsule of the kidney is fixed to the peritoneum with individual interrupted sutures using catgut thread. This allows the kidney to be fixed in a physiological position, preventing its pathological rotation. Horizontal pathological mobility of the kidney often accompanies vertical pathological mobility. The wound is sutured tightly in layers without the installation of drains.

The technical result is an increase in the reliability of nephropexy, the elimination of the likelihood of pathological rotation of the kidney while maintaining the physiological mobility of the kidney and the elimination of the disadvantages and complications that occur when using a mesh polypropylene implant.

The technical result is achieved by performing laparoscopic nephropexy with autologous tissues according to modifications developed by us.

In clinical practice, a combination of abnormal kidney mobility and a cyst (4) at the upper pole of the kidney (2) is often encountered. We have developed an addition to the standard technique, which utilizes the wall of an emptied cyst (4). This involves fixing the upper pole (2) of the kidney using a flap cut from the cyst wall (4). The flap is taken from the previously incised and emptied wall of the cyst (4) at the upper pole (2) of the kidney, securing it to the tendinous component of the diaphragm (3). This step of fixing the upper pole (2) of the kidney, which we developed, is performed as follows.

A paraumbilical laparoscopic approach is performed to visualize the surgical procedure. Two 5 mm trocars are placed 12-15 cm apart in the hypochondrium and lateral abdomen for the "working" instruments: endodissector, endoscissors, electrosurgical instrument, and needle holder. Another 5 mm endoport can be placed in the epigastrium for liver retraction. After placement of the endoports, pneumoperitoneum is created. The colon is mobilized and retracted. Using an electrosurgical instrument, an oblique transverse incision of 3-4 cm is made through the parietal peritoneum (5) and the prerenal fascia in the area of the upper pole of the kidney (2). The cyst (4) of the upper pole of the kidney (2) is isolated up to the junction with the renal parenchyma. The wall of the cyst (4) adjacent to the incision of the parietal peritoneum (5) is opened, its contents are aspirated, and an urgent cytological examination is performed. Then the wall of the cyst (4) is excised, forming a trapezoid flap (7) from the surface adjacent to the psoas muscle, the wide base of which is directed towards the upper pole of the kidney (2). The width of the flap (7) at its base is not less than 3.5 cm, at the apex not less than 2.5 cm, and the length is not less than 6 cm (Figure 3). Next, above the upper pole of the kidney (2), parallel to the incision (5), a second incision of the parietal peritoneum is made, and the tendinous component of the diaphragm (3) is isolated. The kidney is displaced toward the diaphragm until pathological mobility is eliminated. The isolated trapezoid flap (7) is fixed to the tendinous component of the diaphragm (3) by suturing its apex with three sutures (8).

The cyst wall is also subjected to rapid histological examination. The anatomical integrity of the peritoneum is restored.

Thus, the kidney is suspended by the cyst wall (4) and maintains the physiological mobility necessary for normal renal function. At the same time, fixation of the upper pole (2) prevents rotation of the kidney.

Six patients underwent surgery using this technique. No technical difficulties were encountered during the procedure, including cyst isolation, flap dissection and fixation, or bleeding from the cyst wall and/or renal parenchyma. The postoperative period was uneventful for all patients.

Thus, we have developed a method incorporating new technical steps: fixation of the upper pole of the kidney using a trapezoidal flap with a wide base facing the kidney. The flap is at least 3.5 cm wide at the base, at least 2.5 cm wide at the apex, and at least 6 cm long. The flap is formed from the posterior surface of the upper pole cyst. The kidney is then positioned in a physiologically favorable position and fixed by suturing this flap to the tendinous component of the diaphragm with three sutures using non-absorbable suture material. This type of kidney fixation increases cushioning against caudal and rotational displacement of the organ in a vertical body position, eliminates pathological mobility of the kidney, ensuring reliable fixation of the organ in a physiological position, and avoids trauma to surrounding tissues and the kidney itself. Optimal flap placement from the cyst wall in the upper pole area eliminates rotation of the kidney and lateral displacement, thereby improving urodynamics by protecting the ureteropelvic junction from kinking, which may occur in a vertical body position.

This nephropexy technique allows for simple and reliable kidney fixation in cases of nephroptosis combined with an upper pole cyst, using local tissues without the use of synthetic implants. This simultaneously preserves the kidney's physiological mobility, improves treatment outcomes, and allows for faster rehabilitation of patients with this condition. Furthermore, patients undergoing surgery using our technique have shown no recurrences for over a year since the surgery, and no exacerbations of pyelonephritis have been reported.

Case Study 1. Patient V., 45, was admitted to the Urology Department with a diagnosis of grade 2 right nephroptosis. Symptomatic arterial hypertension. Chronic pyelonephritis, latent phase. Upon admission, she complained of pain in the projection of the right kidney, which intensified after physical exertion and in the evening. Blood pressure fluctuated, with increases up to 150/90 mmHg. The diagnosis was confirmed by ultrasound (right hydronephrosis up to 7-9 mm) and excretory urography performed in the wedge and otrostasis. Surgical treatment was indicated for the patient - right nephropexy.

A Fedorov lumbotomy was performed on the right side in the uninvolved lateral decubitus position with the subcostal ridge advanced. The kidney was mobilized. A pedicled muscle flap was dissected from the psoas muscle and divided at the level of the muscle-tendon transition. It was 1.5 cm wide and 8 cm long. The flap end was secured with a catgut retainer. Subcapsular tunnels, 2.0 cm wide, were created on the posterior and anterior surfaces of the kidney. The muscle flap was inserted into these tunnels, first on the posterior surface and then on the anterior surface of the kidney. The flap end was fixed to the renal capsule with the ends of the catgut retainer. Additionally, the flap was secured to the renal capsule with #3 PGA sutures on both sides of all capsule incisions. Hemostasis was achieved. The perimysium of the psoas muscle was sutured. A drain was placed in the retroperitoneal space through the counter-incision. The surgical wound was sutured layer by layer. The postoperative period was uneventful. The intradermal suture was removed on the eighth day, the wound healed by primary intention, and the patient was discharged from the department on the ninth day.

At a 6-month follow-up examination, the patient complained of intermittent nagging pain over her right kidney and a blood pressure of 135-140/85-90 mmHg, requiring antihypertensive medications on demand. Blood and urine tests were normal. A U3 study performed in the supine and sitting positions revealed normal kidney position and size, no left-sided dilation of the renal pelvis, and persistent hydronephrosis of 6-8 mm on the right. Respiratory mobility of the kidneys was preserved. Doppler ultrasound of the kidneys revealed a decrease in diameter and elongation of the renal artery and vein, increased maximum pulse velocity in the distal portion and intraorgan branches of the renal artery, increased maximum blood flow velocity in the renal vein, and a relatively low resistance index.

Clinical example 2. Patient N., 37, was admitted to the Urology Department #1 with a diagnosis of grade 2 right nephroptosis and a cyst in the upper pole of the right kidney. Stage 1 arterial hypertension. Chronic pyelonephritis, latent phase. The patient considered herself ill for 3 years, when the above-described complaints began to bother her. Upon admission, the patient complained of pain in the projection of the right kidney, which deprived the patient of the ability to work. Over the past year, she had two attacks of pyelonephritis, periodically, after physical exertion, increases in blood pressure to 140/85 mm Hg. The diagnosis was confirmed by ultrasound data and excretory urography performed in ortho- and clinostasis. The presence of pain syndrome, recurrent course of the disease, symptomatic arterial hypertension were indications for surgery. Surgical treatment was prescribed for the patient - laparoscopic nephropexy on the right.

Under multimodal combined anesthesia, with the patient in the supine position and a cushion placed under the lower right rib cage. After three antiseptic treatments of the surgical field, carboxyperitoneum was created via a Veress needle through a right paraumbilical approach, a 10 mm trocar was inserted, and a laparoscope was inserted. During abdominal examination, the liver, gallbladder, and stomach were normal in size, color, and consistency. Additional trocars for the "working" instrument were: 5 mm in the right hypochondrium, 5 mm in the right iliac region, and 5 mm in the epigastrium, for liver retraction. Pathological mobility of the right kidney was detected. The ascending colon and the hepatic angle of the transverse colon were displaced medially and inferiorly. A cyst was outlined in the area of the upper pole of the right kidney. The parietal peritoneum and the prerenal fascia above it were dissected obliquely using a Ligashur apparatus, and the cyst wall was isolated up to the junction with the renal parenchyma. The cyst wall was opened along the anterior surface, its contents—clear, transparent fluid—were aspirated, and an urgent cytological examination was performed. The cyst wall was then excised in such a way that a trapezoidal flap was formed from the posterior surface, with a wide base facing the kidney. The flap was 4 cm wide at the base, 3 cm at the apex, and 6 cm long. The tendinous component of the diaphragm was isolated. Subsequently, after identifying and eliminating pathological mobility, the kidney was given a physiologically advantageous position and fixed by suturing the apex of the flap to the tendinous component of the diaphragm with three sutures, using non-absorbable suture material—Prolene 3.0. The cyst wall was also sent for express histological examination. Coagulation hemostasis was established. The integrity of the retroperitoneal space was restored by fusion of the peritoneum using a Ligashur electrosurgical instrument. Skin sutures and an aseptic dressing were applied.

The postoperative period was uneventful. The patient was active on the second postoperative day. She was discharged home on the fifth postoperative day, under outpatient urological observation, with recommendations to wear a support brace for one month during physical activity.

At a follow-up examination four months after surgery, pain was absent, blood pressure was 130/80 mmHg, and blood and urine test results were within normal limits. Ultrasound examination in a standing position revealed the right kidney to be in a typical position, with respiratory excursion maintained. Excretory urography revealed the typical position of the right kidney, shifted by half the lumbar vertebral body, and normal urodynamics. Doppler ultrasound revealed vascular resistance indices in the right kidney to be within normal limits.

Description of the figures.

Fig. 1. Dissection of the prerenal fascia

1 - lower pole of the kidney;

2 - upper pole of the kidney

3 - tendon component of the diaphragm;

4 - cyst

5 - incision of the parietal peritoneum

6 - spine

Figure 2. A trapezoidal flap is cut out of the cyst and sutured.

1 - lower pole of the kidney;

2 - upper pole of the kidney

3 - tendon component of the diaphragm;

4 - cyst

6 - spine

7 - trapezoid flap cut from the cyst wall

8 - sutures for fixing the trapezoid flap.

Claims (1)

A method of laparoscopic nephropexy in case of combination of nephroptosis with cyst of upper pole of kidney, including paraumbilical laparoscopic approach, oblique transverse dissection of parietal peritoneum and prerenal fascia in the area of upper pole of kidney, characterized in that cyst wall is isolated from upper pole to border with renal parenchyma, cyst is opened with electrosurgical instrument and its contents are aspirated; trapezoidal flap is formed from cyst surface, adjacent to lumbar muscle, the width of which at the base is not less than 3.5 cm, at the apex not less than 2.5 cm, length not less than 6 cm, wide base facing upper pole of kidney, flap is fixed with three sutures to tendinous center of diaphragm with non-absorbable suture material.