Nephroptosis (omission of the kidney)

Nephroptosis (omission of the kidney) is a condition of the pathological mobility of the kidney, in which it is displaced from its bed and its mobility when taking the vertical position of the body exceeds the physiological boundaries. The range of normal mobility of the kidney in the standing person's position varies from 1 to 2 cm, and at a height of a deep inspiration - from 3 to 5 cm. The excess of these parameters determined another name of the disease - renal mobility. In nephroptosis patients, the kidney easily occupies both normal and unusual position.

Over four hundred years ago Mesus (1561) and Fr. De Pedemontium (1589) was the beginning of the doctrine of nephroptosis, but interest in it remains to this day.

[1], [2]

Epidemiology

The frequency of development of nephroptosis is largely related to the constitutional features of the organism, the conditions of life, the nature of the work performed, etc. The prevalence of this urological disease among women (1.54%) is ten or more times higher than among men (0.12%). This can be explained by the peculiarities of the structure and functioning of the female body: a wider pelvis, a weakening of the tone of the abdominal wall after pregnancy and childbirth. On average, nephroptosis is found in 1.5% of women and 0.1% of men aged 25-40 years, and of children aged 8-15 years. The pathological mobility of the right kidney is observed much more often, which is due to its lower location and weak ligamentous apparatus as compared to the left kidney. In the middle of the century it was suggested that the pathological displacement of the kidney may be a consequence of improper development of the circulation of the organ, as a result of which the vascular pedicle is formed longer. In addition, peripheral tissue in these patients is more developed. Which promotes an additional displacement of the kidney.

[3], [4], [5], [6], [7],

Causes of the nephroptosis

A number of pathogenetic factors contribute to the change in the ligamentous apparatus of the kidney and predisposes to the development of nephroptosis. The main causes of nephroptosis (omission of the kidney) are infectious diseases that decrease the activity of the mesenchyme, as well as a sharp weight loss and a decrease in the muscle tone of the abdominal wall. In the latter case, nephroptosis may be part of the splanchnoptosis.

When the kidney is held in a normal position, the abdominal ligaments play a role, the kidney bed formed by the fascia, the diaphragm and the muscles of the abdominal wall, and the actual fascial and fatty apparatus. Fixation of the right kidney is performed by folds of the peritoneum, covering it from the front and forming a series of ligaments - lig. Hepatorenal and lig. Duodenorenale. The left kidney is fixed with lig. Pancreaticorenale and lig lienorenale. In the fixation of the organ, a fibrous capsule tightly welded to the renal pelvis and, when going to the renal pedicle, merging with its membrane, is of great importance. Part of the fibrous fibers of the kidney's own capsule is part of the fascia that covers the feet of the diaphragm. This segment of the capsule is lig. Suspensorium rents - plays the main fixing role. 

Essential in the preservation of the correct position of the body belongs to the fatty capsule of the kidney - capsula adiposa renis. Reducing its volume contributes to the emergence of nephroptosis and the rotation of the kidney around the vessels of the kidney. In addition, the correct position of the organ is supported by the renal fascia and fibrous cords in the region of the upper pole of the kidney, as well as the dense fatty tissue between it and the adrenal gland. In recent years, a number of authors have expressed the view that the cause of nephroptosis is a generalized lesion of connective tissue in combination with hemostasis disorders.

Despite the centuries-old study of nephroptosis, there is still no consensus on the importance of individual anatomical formations for fixing the kidney in the bed while maintaining its physiological mobility necessary for normal functioning.

A special place in the emergence and development of nephroptosis is trauma, in which, due to ligament rupture or hematoma in the region of the upper segment of the kidney, the latter is displaced from its bed.

[8], [9], [10], [11], [12], [13], [14]

Symptoms of the nephroptosis

For normal functioning of the kidney, stability of the pressure in the retroperitoneal space and mobility of the organ within the I lumbar vertebrae are necessary. When these conditions are met, the blood circulation in the kidney is maintained and a complete outflow of urine is carried out. A slight increase in the range of movements of the kidney, both orthostatic and respiratory, to some extent changes the hemodynamics of the organ and creates conditions for the outflow of urine from the pelvis at elevated pressure. These changes are usually weakly expressed and often do not cause symptoms of nephroptosis.

That is why a large discrepancy was found between the number of people with nephroptosis and the number of people suffering from this disease.

This fact testifies to the large compensatory possibilities of the kidneys allowing to speak about the asymptomatic course of nephroptosis. Often, the physician discovers an increase in the mobility of the kidney by chance when examining the patient for another disease. Sometimes this random finding becomes the chronological onset of nephroptosis, as patients, and often doctors, begin to explain all the symptoms of nephroptosis presented or emerging in the patient only with the detected nephroptosis and are mistaken for an unreasonable operation in this error.

Symptoms of a moving kidney in the absence of changes in its hemo- and urodynamics are scanty and subtle. Usually, the symptoms of nephroptosis are limited to moderate dull pain in the lumbar region, which increases with physical activity and disappears at rest or when the body is horizontal. Pain has a reflex character and is caused by the tension of the nerve branches of the kidney and its lodge. At the same time there are general weakness, decreased appetite, intestinal disorders, weight loss, depression and neurasthenia.

Progression of nephroptosis in the future leads to the appearance of new or to a significant enhancement of previously existing symptoms of nephroptosis. Pain can acquire the nature of renal colic. By this time, complications of nephroptosis usually develop: pyelonephritis, renal venous hypertension, arterial hypertension, hydronephrosis transformation. In a number of cases, the attack of pyelonephritis, total macrohematuria and arterial hypertension are the first symptoms of nephroptosis.

Stages

• I stage: on inhalation, it is possible to clearly feel the lower segment of the kidney through the anterior abdominal wall, which again leaves in the hypochondrium during exhalation;
• II stage: the whole kidney in the vertical position of the person leaves the hypochondrium, but in the horizontal position again returns to its usual place or the palpating hand easily and painlessly enters it there;
• III stage: the kidney not only completely leaves the hypochondrium, but also easily shifts into a large or small pelvis.

In connection with the characteristics of the retroperitoneal space, the different strength and length of the ligamentous apparatus, the kidneys are not descending in a strictly vertical direction. In the process of gliding in the retroperitoneal space, the organ rotates around the transverse axis (vessel-gate-body of the kidney), as a result of which its lower pole approaches the middle axis of the body, and the upper pole moves laterally. The kidney is thrown back. If in the first stage of nephroptosis these changes are not very pronounced, then in the II stage the rotation of the kidney around the axis reaches a considerable degree. In this case, the kidney vessels sharply stretch, and their diameter decreases. Tipping and rotation of the kidney lead to the twisting of the vessels, while the diameter of the renal artery decreases by a factor of 1.5-2 (corresponding to an increase in its length). Even more is the venous outflow from the lowered kidney, which is associated with the twisting of the main vein around the artery. As the pathological body is enlarged, the degree of inflection of the ureter usually normal in its length increases, so that in the III stage of nephroptosis this inflection may become fixed and lead to the formation of a persistent expansion of the pelvis and calyces of the kidney as a result of a chronic disturbance of the outflow of urine from the pelvis, i.e. To the formation of pyeloectasia.

Nephroptosis II-III stage can cause a significant violation of renal hemo-, urodynamics and lymph drainage. Narrowing of the renal artery as a result of its tension and rotation causes kidney ischemia, and a violation of outflow in the renal vein for the same reasons leads to venous hypertension. Which in combination with a violation of lymph drainage contributes to the development of the inflammatory process - pyelonephritis, in many respects causing its chronic course. Pyelonephritis can lead to the development of adhesions around the kidney (paranephritis), fixing the organ in a pathological position (fixed nephroptosis)! Constant changes in the pathological range of kidney movements affect the nerve plexus (paraaortal) organ gates and its innervation. 

Changes in hemodynamics and urodynamics are the main factors creating prerequisites for the development of pyelonephritis or vasorenal hypertension, which in turn forms the entire clinical picture of the disease. Moreover, hemodynamic disorders in nephroptosis are more characteristic than violations of urodynamics of the upper urinary tract. It should be noted that venous hypertension and ischemia arising from nephroptosis can lead to true nephrogenic hypertension. The latter often has a transitory character and depends on the position of the body. Often, it is not diagnosed or an erroneous diagnosis is made (vegetovascular hypertension, etc.). In this case, arterial hypertension in such patients is resistant to drug treatment.

Previously, it was believed that the morphological and functional changes in the kidney during nephroptosis are poorly expressed. However, it was not confirmed when studying the biopsy material of the pathologically moving kidney. The most frequent morphological changes in nephroptosis are the tubular thyroidization and atrophy of their epithelium, infiltration with lymphoid-histiocytic cells and neutrophils. Less common are interstitial, periglomerular and perivasal sclerosis, glomerulosclerosis. When combined nephroptosis and chronic pyelonephritis, stromal-cell and tubulo-stromal, more rarely stromal-vascular changes are more often observed. They are found even in the first stage of the disease and a short period of clinical manifestations and are considered an indication for the surgical treatment of nephroptosis.

Factors determining the maximum mobility of the kidney and changes in its intraorganic hemodynamics:

• anatomical and topographic variability of the site of the vascular pedicle and its direction (ascending, horizontal, descending);
• limited structural and physiological vascular dilatability (a.V. Renalis).

That is why the kidney is rarely shifted to the pelvis, but it does rotate around the vascular pedicle - the determining factor in the occurrence of hemodynamic disorders. The latter depend on the rotation angle in all planes reaching 70 ° and more. Hemodynamic disorders that occur with the rotation of the kidney are more pronounced than when it is omitted.

I and II stages of nephroptosis are more often diagnosed in children aged 8-10 years, III - at an older age.

[15], [16], [17]

Complications and consequences

Pyelonephritis is the most common complication of nephroptosis.

Chronic pyelonephritis complicates the course of the latter in 45% of cases, acute purulent pyelonephritis - in 3%, and acute non-obstructive pyelonephritis - in 8.7% of cases. Difficult venous outflow and violation of the passage of urine along the upper urinary tract create favorable conditions for the development of infection in the interstitial tissue of the kidney. Pyelonephritis dramatically worsens the course of the disease. There is a headache, fatigue, abdominal pain, fever, transient hypertension.

Hydronephrosis transformation does not always accompany nephroptosis, since the outflow of urine in this disease is temporary. This complication is more typical of fixed nephroptosis with a fixed ureteral bend. It is possible to develop hydronephrosis in the presence of an additional vessel, stricture of the ureter, but hydronephrosis transformation or megaureter appear infrequently.

Macro- and microhematuria in nephroptosis usually result from renal venous hypertension. They are provoked by physical stress, occurs more often by the end of the working day, and can completely disappear after the patient has remained at rest or in a horizontal position. Renal venous hypertension, characteristic of nephroptosis, creates the necessary conditions for the expansion of the veins of the fornicinal zones and the formation of the venous fornic canal.

Arterial hypertension as a symptom of nephroptosis has a vasorenal character, i.e. Is caused by a narrowing of the renal artery in response to its tension and torsion. First, orthostatic arterial hypertension occurs. With the long-term existence of nephroptosis, fibromuscular stenosis of the renal artery develops as a result of microtraumas of its wall with regular tension and torsion.

[18], [19], [20]

Diagnostics of the nephroptosis

Diagnosis of nephroptosis (omission of the kidney) is to question the patient. When he polls, you can establish that the appearance of blunt pain in the corresponding half of the abdomen or in the lumbar region has a clear connection with physical stress, increases in the vertical (usually in the afternoon) and subsides in a horizontal position and rest. When hematuria associated with nephroptosis, you can also establish a similar pattern. It is necessary to clarify which diseases were transferred to the patient, whether recently there was a place of trauma, weight loss.

On examination, attention is paid to the asthenic type of build, weak development of fatty tissue, reduced muscle tone of the anterior abdominal wall. In the process of examining the patient and talking with him, special attention is paid to his neuropsychic state, specifies the nature of the headache, the presence of changes in the functions of the intestine. Usually, the patient, especially in the vertical position, can palpate the lowered kidney! In each patient with a suspected nephroptosis, blood pressure is measured in two positions - sitting and lying. For example, in the morning (at rest), the blood pressure is measured in the horizontal position of the patient, then in the vertical position after a moderate load (walking, light jumps). The most accurate method for diagnosing arterial hypertension with nephroptosis is daily monitoring of arterial pressure.

Chromocystoscopy with nephroptosis comparatively rarely reveals a delay in the release of indigo carmine. In emergency cystoscopy, only patients with macrogmaturia who can accurately determine from which ureter blood is excreted into the bladder are needed.

Currently, the diagnosis of nephroptosis involves the use of mostly non-invasive and minimally invasive techniques: ultrasound, ultrasound of kidney vessels (for detecting hemodynamic disorders), CT, MRI, digital subtraction angiography. In most cases, these methods allow a precise diagnosis. Excretory urography performed in the horizontal and vertical position of the patient retains its importance. The displacement of the kidney is determined in relation to the vertebrae, comparing its location on the radiographs made in the indicated positions. The normal mobility of the kidneys is the height of the body of one-and-a-half vertebrae. A more pronounced mobility of the kidney suggests a nephroptosis, which can be confirmed with ultrasound.

Radioisotope diagnostics of nephroptosis is essential for determining the functions of the kidneys and their changes in the standing position, when it is possible to record and measure the degree of decrease in secretion and slowing of evacuation of urine. In this case, the detected violation of the secretory function of the kidneys, which increases with dynamic observation, is considered an additional indication for the operative treatment of nephroptosis.

Retrograde pyelography with nephroptosis is performed extremely rarely and with great caution.

Diagnosis of nephroptosis (ovulation of the kidney), especially complicated by arterial hypertension or forecanical bleeding, did not lose its importance arteriography and venography of the kidneys in the vertical position of the patient. These studies allow differential diagnosis with kidney dystopia (according to the level of renal artery detachment) and determine the presence of changes in the arterial and venous system of the organ.

To select a method of treatment, establish indications for surgery and diagnose splanchnoptosis perform an x-ray examination of the gastrointestinal tract (GIT).

In the detection of complications of nephroptosis, laboratory investigations of blood and urine that allow to diagnose the latent course of pyelonephritis (bacteriuria, leukocyturia) or renal venous hypertension are of great importance. In the latter case, orthostatic hematuria and / or proteinuria are observed.

[21]

Differential diagnosis

First of all, differential diagnosis of nephroptosis and kidney dystopia is carried out. For this purpose, use palpation, excretory urography, rarely - retrograde ureteropyelography, but absolutely accurately the diagnosis can be established only with the help of CT and angiography. Dystopia of the kidney is characterized by a lack of displacement of the organ in the hypochondrium after the patient's transition from the vertical to the horizontal position, but this can also be observed with fixed nephroptosis.

On excretory urograms, the dystopic kidney, which has not yet completed its physiological rotation along the vertical axis, has a shortened stretched ureter that extends from the renal pelvis located in the front or lateral. Only angiography allows to determine the presence of a dystopia and its appearance, as evidenced by arteries that depart from the aorta below the normal level. CT and angiography helps to detect the pathological mobility of a dystopic kidney (for example, with lumbar dystopia) and determine the required level of kidney fixation when performing nephropexy later.

When palpation of the kidney is often a suspicion of a tumor of the abdominal cavity, edema of the gallbladder, splenomegaly. Cysts and ovarian tumors, and if hematuria is present, the doctor should exclude a possible kidney tumor. The leading diagnostic methods used for differential diagnosis of nephroptosis and listed diseases, ultrasound, CT, aortography.

In renal colic, differential diagnosis of nephroptosis with acute diseases of the abdominal cavity organs and female genital organs is carried out.

Treatment of the nephroptosis

Apply conservative and surgical treatment of nephroptosis. Conservative treatment of nephroptosis (omission of the kidney) involves the use of an elastic bandage, selected individually, which patients wear in the morning in the horizontal position of the body on exhalation before getting out of bed. Wearing a bandage is combined with the performance of a special complex of physiotherapy exercises to strengthen the muscles of the anterior abdominal wall and the lumbosacral muscles. Most of these exercises are performed in a lying position or on a special simulator with an elevated leg end. Exercises with loads in the standing position, the employment of certain sports related to jogging, jumping, lifting of gravity, falls, sharply restrict or temporarily prohibit. 

The exception is swimming, which has a positive effect in the complex treatment of nephroptosis. Some patients have to change the work associated with prolonged walking, wearing heavy weights, vibration. If the patient has significantly lost weight before the onset of clinical symptoms, nephroptosis (kidney dips) is combined with increased nutrition to increase the layer of adipose tissue around the kidney. Implementation of these recommendations, on the one hand, helps to reduce the degree of nephroptosis. On the other hand, it serves as a prophylaxis for complications caused by a pathological displacement of the kidney.

Nephroptosis, discovered accidentally or being a consequence or an integral part of the general splanchnoptosis, is not considered an indispensable indication for surgery.

Nephroptosis is treated mainly by conservative methods and only in rare cases (in 1-5% of patients) is performed operative treatment of nephroptosis. It consists in fixing the kidney to its normal bed. The necessary requirement for surgery is a combination of firm and reliable fixation with preservation of the physiological mobility of the kidney. Simultaneously with the elimination of the pathological displacement of the kidney, its rotation around the vertical axis is also eliminated. In addition, the operation should not change the position of the physiological axis of the kidney and lead to the development of an inflammatory process around it (especially in the area of its legs and LMS).

Indications for surgery with nephroptosis:

• pain, depriving the patient of work capacity:
• pyelonephritis, resistant to conservative treatment;
• vasorenal hypertension, usually orthostatic arterial hypertension;
• renal venous hypertension with forneck bleeding;
• hydronephrosis;
• nephrolithiasis.

Contraindications: general splinoptosis, elderly patients, severe intercurrent diseases, unnecessarily increase the risk of surgical intervention.

Preoperative preparation depends on the complications of nephroptosis, which necessitated the implementation of nephropexy. When pyelonephritis is prescribed antibacterial and anti-inflammatory treatment; with forecal hemorrhage hemostatic therapy; with arterial hypertension, antihypertensive drugs, etc. Three days before the operation, the foot end of the patient's bed is raised by 20-25 cm to adapt the patient to the position in which he will be postoperatively. Of particular importance is the study of coagulograms, since the patient after the operation for quite a long time will comply with bed rest. In addition, this position of the body ensures the movement of the kidney upward and helps reduce pain or its disappearance. At the same time, patients should learn to perform the act of urinating lying in bed.

Since the end of the last century, more than 150 methods of nephropexy have been described. A fascination with various ways of its implementation until the 30s of the XX century. Was replaced by disappointment in the operative treatment of nephroptosis, associated with a high incidence of unsuccessful results. New pathogenetic aspects of nephroptosis, clarified in the 50's, again aroused interest in the problem of surgical treatment of the disease. By this time many of the previously described methods of fixing the kidney have lost their value and they have ceased to be used. Some of them retained, if not practical, at least, historical value.

All existing surgical treatment of nephroptosis can be divided into the following groups:

• fixation of the kidney by sutures carried out in the fibrous capsule or parenchyma of the organ;
• fixation for the fibrous capsule of the kidney without its flashing or with the help of its flaps with partial decapsulation of the organ;
• fixation by extrarenal tissues (paranephric fiber, muscles) without flashing or with the piercing of the fibrous capsule.

The most common interventions of the first group include:

• operation on S.P. Fedorov: fixation of the kidney with catgut No. 5 for the fibrous capsule to the XII rib;
• a similar technique for Kelly Dodson (1950) with fixation not only to the XII rib, but also to the lumbar muscles;
• modification of Doming's method (1980), in which the suspension fixation is complemented by sewing to the lumbar muscles of paranephalus, supporting the kidney under the lower pole.

The second group of operations include the methods of Alberra-Marion, Vogel, Narata, the general principle of which is the fixation of the kidney to the XII rib with the help of cut flaps or in the tunnel of the fibrous capsule.

In the operations of the third group, various alloplastic materials are used to fix the kidney to the XII or XI rib: kapron, nylon, perlon, teflon without perforation and with perforation in the form of strips, nets, hammocks, etc.

The above operations have not found wide application, since they provide reliable and strong fixation of the kidney, often lead to the development of relapses, deprive the kidney of physiological mobility, thus violating its hemo- and urodynamics. Often after their implementation, there is a need for a second operation. In addition, synthetic materials cause the development around the kidney of a significant inflammatory process with the formation of scars, which also deprive the body of mobility and change the position of its longitudinal axis.

The most physiological at the present time consider the operations of the fourth group, allowing to achieve nephropexy with the help of muscle grafts.

The most successful method is Rivoir (1954), in which the kidney is fixed with a muscle flap to the XII rib, which practically deprives the organ of mobility. In 1966, a modification of this intervention was proposed by the Pytel-Lopatkin operation, which was most widely used. It is performed, as a rule, under endotracheal anesthesia with controlled breathing.

Several modifications of this intervention are proposed. In the presence of an additional vessel in the lower segment of the kidney, E.B. Mazo (1966) proposed for the prevention of his compression to split the muscle graft. Yu.A. Pytel (1978) recommended always performing nephropexy with a split muscle graft, not only for stronger fixation of the organ, but also for preventing the vibrational movements of the kidney to the lateral and medial sides. M.D. Javad-Zade (1976) proposed to carry out a muscle flap in a transverse subcapsular tunnel under the lower pole of the kidney. Yu.S. Tashchiev (1976) used for fixing the kidney a fascia-muscle flap from the transverse abdominal muscle.

After surgery, the patient usually keeps bed rest until the 14th day. In the first seven days, the foot end of the bed is raised by 10-15 cm. Anti-inflammatory therapy continues for 10-14 days. To prevent straining during defecation, patients are prescribed a laxative and microclysters. After cessation of discharge from the wound, drainage is removed.

At present, several new methods of operative treatment of nephroptosis are presented. Employees of the Omsk State Medical Academy proposed a method of mini-available nephropexy, consisting in using a ring retractor with a lighter to form an operating field of the "barrel" type in order to reduce traumatism in nephropexia and maintain a sufficient functional effect.

Authors from Yekaterinburg use in their work a method of minimally invasive nephropexy, a feature of which is the use of a retroperitoneoscope and binocular optics with a 4-6-fold increase, which helps to reduce the number of complications in the intra- and postoperative period, reduce the time of surgery and the earlier activation of patients in postoperative period.

Proponents of nephropexy performed by percutaneous nephrostomy suggest that it is effective in the operative treatment of nephroptosis and can be comparable in results with laparoscopic nephropexy (88.2% satisfactory results). The essence of the method consists in performing percutaneous nephrostomy in nephroptosis. Nephrostomy drainage is removed a few days after the operation. However, it should be borne in mind that in this operation, the kidney parenchyma is injured, which increases the likelihood of complications such as renal bleeding, subcapsular hematoma of the kidney, long-lasting non-healing fistula, urinary stench, pyoinflammatory processes in the retroperitoneal space, etc., with widespread introduction into the urological the practice of minimally invasive surgical methods is currently widely used in the method of laparoscopic nephropexy.

The technique of its implementation is different from the traditional operation of NA. Lopatkin.

In the last decade, nephropexy is increasingly performed by laparoscopic method, but at the same time, since the kidney is not widely isolated, its suspension by the upper segment can not eliminate the organ rotation. In this connection, a number of authors propose a modified kidney fixation with artificial materials, in particular a split flap of a prolene mesh, which makes it possible to level out the above-mentioned lack of laparoscopic nephropexy. In this case, the latter allows us to obtain good and satisfactory long-term results in 98.3% of cases.

Technique of laparoscopic nephropexy

Operative intervention is performed from four laparoports in the position of the patient on a healthy side with the lowered head end of the operating table.

In contrast to the traditional operation of NA. Lopatkin, a cut fibrous bridge on the anterior surface of the kidney is crossed in the middle. Muscle flap of m. The iliopsoas, the distal end of which is bandaged with a polysorb thread, is placed on the anterior surface of the kidney between the flaps of the exfoliated fibrous capsule and fixed high by the thread to the fatty capsule. The detached leaves of the fibrous capsule are placed on a muscle bundle and fixed with 4-6 titanium clips.

After the fixation of the kidney, the back of the parietal peritoneum is closed with several titanium clips or is sewn with an atraumatic thread using the Endostic device or an intra-abdominal manual suture. The retroperitoneal space is drained with a thin tube for 12-24 h.

Patients in the postoperative period for six days observe strict bed rest (the head end of the bed is lowered). The disadvantage of this variant of laparoscopic nephropexy (as well as open nephropexy) is the long stay of the patient in bed.

Fixation of the kidney with a polypropylene mesh allows early activation of the patient: the next day he can walk.

The technique of kidney fixation in nephroptosis with a polypropylene mesh is as follows. Perform access from three laparoports located on the side of the lesion. Trocars with a diameter of 10 and 11 mm are located on the anterior abdominal wall: a trocar with a diameter of 10 mm - along the middle clavicular line at the level of the navel, 11 mm - along the front axillary line (under the edge arch), and one trocar with a diameter of 5 mm - along the anterior axillary line above the wing of the ilium.

It is advisable to introduce a trocar for a laparoscope with oblique optics along the anterior axillary line at the navel level.

A strip of polypropylene mesh 2 cm wide and 7-8 cm long is fixed to the muscles of the lumbar region by a furrier needle with two U-shaped ligatures through a cut of skin 1 cm long under the XII rib along the anterior scapular line. The nodes of the U-shaped sutures are dipped deep into the subcutaneous tissue, and one nodal suture is applied to the cutaneous wound. The other end of the polypropylene mesh is cut lengthwise by 3-4 cm and fixed with a herniostepler in the form of the letter "V" on the front surface of the kidney, displaced by the retractor upwards.

When performing laparoscopic nephropexy in the early postoperative period, the physiological parameters of the kidney mobility are much earlier restored (in comparison with the open method). This fact can be explained by a more gentle laparoscopic technique. There is an early activation of the patient after surgery, which greatly improves the psychoemotional state of the patient and predetermines calmly the further course of the postoperative period.

Forecast

The prognosis of nephroptosis is favorable. Relapses of the disease are rare. The choice of the operative tics of the technique of the operation being performed and the prognosis of the disease as a whole depend on the concomitant diseases of the kidney (hydronephrosis, urolithiasis, pyelonephritis), the surgical intervention in which is accompanied by the treatment of the detected nephroptosis.