Nephroptosis (kidney prolapse).

Nephroptosis (prolapse of the kidney) is a condition of pathological mobility of the kidney, in which it shifts from its bed and its mobility when taking a vertical body position exceeds physiological limits. The range of normal mobility of the kidney in a standing position fluctuates from 1 to 2 cm, and at the height of a deep breath - from 3 to 5 cm. Exceeding these parameters has determined another name for the disease - pathological mobility of the kidney (ren mobile). In patients with nephroptosis, the kidney easily takes both a normal and an unusual position.

More than four hundred years ago, Mesus (1561) and Fr. de Pedemontium (1589) laid the foundation for the study of nephroptosis, but interest in it continues to this day.

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Epidemiology

The incidence of nephroptosis is largely related to the constitutional features of the body, living conditions, 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, weakening of the abdominal wall tone after pregnancy and childbirth. On average, nephroptosis is detected in 1.5% of women and 0.1% of men aged 25-40 years, and in children - aged 8-15 years. Pathological mobility of the right kidney is observed much more often, which is associated with its lower location and weak ligamentous apparatus compared to the left kidney. In the middle of the century, it was suggested that pathological displacement of the kidney may be a consequence of improper development of the organ's blood circulation, as a result of which the vascular pedicle is formed longer. In addition, the perirenal tissue in such patients is less developed. which contributes to additional displacement of the kidney.

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Causes nephroptosis

A number of pathogenetic factors contribute to changes in the renal ligament apparatus and predispose to the development of nephroptosis. The main causes of nephroptosis (kidney prolapse) are infectious diseases that reduce the activity of the mesenchyme, as well as sudden weight loss and decreased muscle tone of the abdominal wall. In the latter case, nephroptosis may be part of splanchnoptosis.

The abdominal ligaments, the renal bed formed by the fascia, diaphragm and muscles of the abdominal wall, and the fascial and fatty apparatus proper play a role in maintaining the kidney in its normal position. The right kidney is fixed by the peritoneal folds covering it from the front and forming a series of ligaments - lig. hepatorenal and lig. duodenorenale. The left kidney is fixed by lig. pancreaticorenale and lig lienorenale. The fibrous capsule, tightly fused with the renal pelvis and merging with its membrane when passing to the renal pedicle, plays a great role in fixing the organ. Some of the fibrous fibers of the renal capsule proper are part of the fascia covering the diaphragmatic crura. This section of the capsule - lig. suspensorium rents - plays the main fixing role.

The fatty capsule of the kidney - capsula adiposa renis - plays a significant role in maintaining the correct position of the organ. A decrease in its volume contributes to the development of nephroptosis and rotation of the kidney around the vessels of the renal pedicle. In addition, the correct position of the organ is maintained by the renal fascia and fibrous bands in the area of the upper pole of the kidney, as well as dense fatty tissue between it and the adrenal gland. In recent years, a number of authors have expressed the opinion that the cause of nephroptosis is a generalized lesion of connective tissue in combination with hemostasis disorders.

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

A special place in the occurrence and development of nephroptosis is occupied by trauma, in which, due to a rupture of the ligaments or a hematoma in the area of the upper segment of the kidney, the latter is displaced from its bed.

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Symptoms nephroptosis

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

This is why a large discrepancy has been found between the number of people with nephroptosis and the number of people suffering from this disease.

This fact indicates the large compensatory capabilities of the kidneys, allowing us to talk about the asymptomatic course of nephroptosis. Often, the doctor discovers increased mobility of the kidney by chance when examining a patient for another disease. Sometimes this accidental finding becomes the chronological beginning of the disease of nephroptosis, since patients, and often doctors, begin to explain all the symptoms of nephroptosis that the patient presents or develops only by the discovered nephroptosis and, in this delusion, decide on an unjustified operation.

Symptoms of a mobile kidney in the absence of changes in its hemo- and urodynamics are scanty and barely noticeable. Usually, symptoms of nephroptosis are limited to moderate dull pain in the lumbar region, which intensifies with physical exertion and disappears at rest or when the body is in a horizontal position. The pain is reflex in nature and is caused by tension in the nerve branches of the renal hilum and its bed. At the same time, general weakness, loss of appetite, intestinal disorders, weight loss, depression, and neurasthenia occur.

Progression of nephroptosis further leads to the appearance of new or significant increase in previously existing symptoms of nephroptosis. The pain may acquire the character of renal colic. By this time, complications of nephroptosis usually develop: pyelonephritis, renal venous hypertension, arterial hypertension, hydronephrotic transformation. In a number of observations, an attack of pyelonephritis, total macrohematuria and arterial hypertension are the first symptoms of nephroptosis.

Stages

• Stage I: when inhaling, the lower segment of the kidney can be clearly felt through the anterior abdominal wall, which, when exhaling, again goes into the hypochondrium;
• Stage II: the entire kidney emerges from the hypochondrium when a person is in a vertical position, but in a horizontal position it returns to its usual place or the palpating hand easily and painlessly inserts it there;
• Stage III: the kidney not only completely exits the hypochondrium, but also easily shifts into the large or small pelvis.

Due to the peculiarities of the retroperitoneal space, different strength and length of the ligamentous apparatus, the kidney does not descend in a strictly vertical direction. The organ, in the process of sliding downwards in the retroperitoneal space, rotates around the transverse axis (vessels-gate-body of the kidney), as a result of which its lower pole approaches the middle axis of the body, and the upper one moves to the lateral side, i.e. the kidney is thrown back. If in stage I of nephroptosis these changes are expressed insignificantly, then in stage II the rotation of the kidney around the axis reaches a significant degree. In this case, the renal vessels are sharply stretched, and their diameter decreases. Throwing back and rotation of the kidney lead to twisting of the vessels, while the diameter of the renal artery decreases by 1.5-2 times (corresponding to the increase in its length). The venous outflow from the lowered kidney is even more imputed, which is associated with the twisting of the main vein around the artery. As the pathological displacement of the organ increases, the degree of bending of the ureter, which is normally long, increases, so that in stage III of nephroptosis this bending can become fixed and lead to the formation of a persistent expansion of the renal pelvis and calyces due to chronic obstruction of urine outflow from the pelvis, i.e. to the formation of pyelectasis.

Nephroptosis of stage II-III can cause significant disturbance of renal hemo-, urodynamics and lymph outflow. Narrowing of the renal artery as a result of its tension and rotation causes kidney ischemia, and disturbance of outflow through the renal vein for the same reasons leads to venous hypertension. Which, in combination with disturbance of lymph outflow, contributes to the development of the inflammatory process - pyelonephritis, largely 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 plexuses (paraaortic) of the organ gate and its innervation.

Changes in hemodynamics and urodynamics are the main factors that create prerequisites for the development of pyelonephritis or vasorenal hypertension, which in turn forms the entire clinical picture of the disease. Moreover, hemodynamic disturbances in nephroptosis are more typical than disturbances in the urodynamics of the upper urinary tract. It should be noted that venous hypertension and ischemia that occur in nephroptosis can lead to true nephrogenic hypertension. The latter is often transient and depends on the position of the body. It is often not diagnosed or misdiagnosed (vegetative-vascular hypertension, etc.). At the same time, arterial hypertension in such patients is resistant to drug treatment.

Previously, it was believed that morphological and functional changes in the kidney with nephroptosis are weakly expressed. However, when examining the biopsy material of a pathologically mobile kidney, this was not confirmed. The most common morphological changes in nephroptosis are considered to be thyroidization of the tubules and atrophy of their epithelium, infiltration with lymphoid-histiocytic cells and neutrophils. Less common are interstitial, periglomerular and perivasal sclerosis, glomerulosclerosis. With a combination of nephroptosis and chronic pyelonephritis, stromal-cellular and tubulo-stromal changes are more often observed, less common are stromal-vascular changes. They are detected even in stage I of the disease and a short period of clinical manifestations and are considered an indication for surgical treatment of nephroptosis.

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

• anatomical and topographic variability of the origin of the vascular pedicle and its direction (ascending, horizontal, descending);
• limited structural and physiological distensibility of blood vessels (a. v. renalis).

This is why the kidney rarely shifts into the pelvis, but when it does, it rotates around the vascular pedicle, which is the determining factor in the occurrence of hemodynamic disorders. The latter depend on the rotation angle in all planes, reaching 70° or more. Hemodynamic disorders that occur when the kidney rotates are more pronounced than when it descends.

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

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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. Obstructed venous outflow and impaired passage of urine through the upper urinary tract create favorable conditions for the development of infection in the interstitial tissue of the kidney. Pyelonephritis sharply worsens the course of the disease. Headache, increased fatigue, abdominal pain, fever, transient hypertension occur.

Hydronephrotic transformation does not always accompany nephroptosis, since the obstruction of urine outflow in this disease is temporary. This complication is more typical of fixed nephroptosis with a fixed kink of the ureter. The development of hydronephrosis is possible in the presence of an additional vessel, ureteral stricture, but hydronephrotic transformation or megaureter occur infrequently.

Macro- and microhematuria in nephroptosis are usually a consequence of renal venous hypertension. They are provoked by physical exertion, occur more often by the end of the working day, and can completely disappear after the patient is 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 fornical zones and the formation of a venous fornical canal.

Arterial hypertension as a symptom of nephroptosis is of a vasorenal nature, i.e. caused by narrowing of the renal artery in response to its tension and torsion. Orthostatic arterial hypertension occurs first. With prolonged existence of nephroptosis, fibromuscular stenosis of the renal artery develops due to microtrauma of its wall with regular tension and torsion.

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Diagnostics nephroptosis

Diagnosis of nephroptosis (prolapse of the kidney) consists of questioning the patient. When questioning him, it can be established that the occurrence of dull pain in the corresponding half of the abdomen or in the lumbar region has a clear connection with physical exertion, intensifies in a vertical position (usually in the second half of the day) and subsides in a horizontal position and at rest. In case of hematuria associated with nephroptosis, a similar pattern can also be established. It is necessary to clarify what diseases the patient has suffered, whether there were recent injuries, weight loss.

During the examination, attention is paid to the asthenic body type, poor development of adipose tissue, and reduced muscle tone of the anterior abdominal wall. During the examination of the patient and conversation with him, special attention is paid to his neuropsychiatric state, the nature of the headache, and the presence of changes in bowel function are clarified. Usually, in the patient, especially in an upright position, it is possible to palpate a dropped kidney! In each patient with suspected nephroptosis, blood pressure is measured in two positions - sitting and lying. For example, in the morning (at rest), blood pressure is measured in the horizontal position of the patient, then in an upright position after moderate exercise (walking, light jumping). The most accurate method for diagnosing arterial hypertension in nephroptosis is considered to be daily monitoring of arterial pressure.

Chromocystoscopy in nephroptosis comparatively rarely allows detecting a delay in indigo carmine excretion. Only patients with macrohematuria, in whom it is possible to accurately determine from which ureter the blood is excreted into the bladder, require emergency cystoscopy.

Currently, nephroptosis diagnostics mainly involves the use of non-invasive and minimally invasive techniques: ultrasound, ultrasound Doppler imaging of renal vessels (to detect hemodynamic disturbances), CT, MRI, and digital subtraction angiography. In most cases, these methods allow for an accurate diagnosis. Excretory urography performed with the patient in a horizontal and vertical position remains important. The displacement of the kidney is determined in relation to the vertebrae by comparing its location on radiographs taken in the specified positions. Normal kidney mobility is the height of one to one and a half vertebrae. More pronounced kidney mobility suggests nephroptosis, which can be confirmed by ultrasound.

Radioisotope diagnostics of nephroptosis is essential for determining kidney function and its changes in a standing position, when it is possible to record and measure the degree of decreased secretion and slower evacuation of urine. In this case, the detected violation of the secretory function of the kidneys, increasing during dynamic observation, is considered an additional indication for surgical treatment of nephroptosis.

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

In the diagnosis of nephroptosis (kidney prolapse), especially complicated by arterial hypertension or fornical bleeding, arteriography and venography of the kidneys in the vertical position of the patient have not lost their importance. These studies allow differential diagnosis with renal dystopia (by the level of origin of the renal artery) and to determine the presence of changes in the arterial and venous system of the organ.

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

Laboratory blood and urine tests are of great importance in detecting complications of nephroptosis, allowing for the diagnosis of latent pyelonephritis (bacteriuria, leukocyturia) or renal venous hypertension. In the latter case, orthostatic hematuria and/or proteinuria are observed.

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Differential diagnosis

First of all, differential diagnostics of nephroptosis and renal dystopia are carried out. For this purpose, palpation, excretory urography, and rarely retrograde ureteropyelography are used, but an absolutely accurate diagnosis can only be established using CT and angiography. Renal dystopia is characterized by the absence of organ displacement in the hypochondrium after the patient moves from a vertical to a horizontal position, but this can also be observed with fixed nephroptosis.

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

When palpating the kidney, there is often a suspicion of a tumor of the abdominal organs, dropsy of the gallbladder, splenomegaly. cysts and tumors of the ovary, and if hematuria is present, the doctor must exclude a possible kidney tumor. The leading diagnostic methods used for the differential diagnosis of nephroptosis and the listed diseases are ultrasound, CT, and aortography.

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

Treatment nephroptosis

Conservative and surgical treatment of nephroptosis is used. Conservative treatment of nephroptosis (prolapse of the kidney) includes the use of an individually selected elastic bandage, which patients put on in the morning in a horizontal position of the body while exhaling before getting out of bed. Wearing a bandage is combined with a special set of therapeutic 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 exercise machine with a raised foot end. Exercises with loads in a standing position, certain sports related to running, jumping, lifting weights, falls are sharply limited or temporarily prohibited.

An exception is swimming, which has a positive effect in the complex treatment of nephroptosis. Some patients have to change jobs associated with long walks, carrying heavy objects, vibration. If the patient has lost a lot of weight before the clinical symptoms of nephroptosis appear, the treatment of nephroptosis (prolapse of the kidney) is combined with enhanced nutrition to increase the layer of fatty tissue around the kidney. Following these recommendations, on the one hand, helps to reduce the degree of nephroptosis. On the other hand, it serves as a prevention of complications caused by pathological displacement of the kidney.

Nephroptosis, discovered by chance or being a consequence or component of general splanchnoptosis, is not considered a mandatory indication for surgery.

Nephroptosis is treated mainly by conservative methods and only in rare cases (in 1-5% of patients) is surgical treatment of nephroptosis performed. It consists of fixing the kidney to its normal bed. A necessary requirement for the operation is a combination of strong 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 pedicle and LMS).

Indications for surgery for nephroptosis:

• pain that disables the patient:
• pyelonephritis resistant to conservative treatment;
• vasorenal hypertension, usually orthostatic arterial hypertension;
• renal venous hypertension with forepcal bleeding;
• hydronephrosis;
• nephrolithiasis.

Contraindications: general splenomegaly, elderly patients, severe intercurrent diseases that unreasonably increase the risk of surgical intervention.

Preoperative preparation depends on the complications of nephroptosis that necessitate nephropexy. In case of pyelonephritis, antibacterial and anti-inflammatory treatment is prescribed; in case of fornical bleeding, hemostatic therapy; in case of 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 after the operation. The study of the coagulogram is of particular importance, since the patient will be on bed rest for quite a long time after the operation. In addition, this body position ensures the upward movement of the kidney and helps to reduce pain or eliminate it. At the same time, patients should learn to urinate while lying in bed.

Since the end of the last century, over 150 methods of nephropexy have been described. The enthusiasm for various methods of performing it before the 1930s was replaced by disappointment in the surgical treatment of nephroptosis, associated with a high frequency of unsuccessful results. New pathogenetic aspects of nephroptosis, clarified in the 1950s, reawakened interest in the problem of surgical treatment of the disease. By this time, many of the previously described methods of fixing the kidney had lost their significance and were no longer used. Some of them retained, if not practical, then at least historical value.

All existing surgical treatments for nephroptosis can be divided into the following groups:

• fixation of the kidney with sutures inserted into the fibrous capsule or parenchyma of the organ;
• fixation to the fibrous capsule of the kidney without suturing it or using its flaps with partial decapsulation of the organ;
• fixation with extrarenal tissues (perinephric tissue, muscles) without suturing or with suturing of the fibrous capsule.

The most common interventions of the first group include:

• operation according to S.P. Fedorov: fixation of the kidney with catgut No. 5 for the fibrous capsule to the 12th rib;
• a similar technique according to Kelly Dodson (1950) with fixation not only to the 12th rib, but also to the lumbar muscles;
• a modification of the Domingue method (1980), in which the suspension fixation is supplemented by suturing the paranephric fat to the lumbar muscles, supporting the kidney under the lower pole.

The second group of operations includes the methods of Alberran-Marion, Vogel, and Narath, the general principle of which is fixation of the kidney to the 12th rib using cut flaps or in a tunnel of the fibrous capsule.

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

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

The most physiological operations at present are considered to be the fourth group, which allow achieving nephropexy using muscle flaps.

The most successful is considered to be the Rivoir method (1954), in which the kidney is fixed with a muscle flap to the 12th rib, which practically deprives the organ of mobility. In 1966, a modification of this intervention was proposed - the Pytel-Lopatkin operation, which has found the widest distribution. It is usually performed under endotracheal anesthesia with controlled breathing.

Several modifications of this intervention have been proposed. In the presence of an additional vessel in the lower segment of the kidney, E. B. Mazo (1966) proposed splitting the muscle flap to prevent its compression. Yu. A. Pytel (1978) recommended always performing nephropexy with a split muscle flap not only for more secure fixation of the organ, but also to prevent oscillatory movements of the kidney to the lateral and medial sides. M. D. Javad-Zade (1976) proposed conducting the muscle flap in a transverse subcapsular tunnel under the lower pole of the kidney. Yu. S. Tashiev (1976) used a fascial-muscular flap from the transverse abdominal muscle to fix the kidney.

After the operation, the patient usually remains in bed until the 14th day. During the first seven days, the foot of the bed is raised by 10-15 cm. Anti-inflammatory therapy is continued for 10-14 days. To prevent straining during defecation, patients are prescribed a laxative and microclysters. After the discharge from the wound stops, the drainage is removed.

Currently, several new methods of surgical treatment of nephroptosis are presented. The staff of the Omsk State Medical Academy proposed a method of mini-accessible nephropexy, which consists of using a ring retractor with an illuminator to form a "barrel" type surgical field in order to reduce trauma during nephropexy and maintain a sufficient functional effect.

The authors from Yekaterinburg use in their work a method of minimally invasive nephropexy, the peculiarity of which is the use of a retroperitoneoscope and binocular optics with 4-6-fold magnification, which helps to reduce the number of complications in the intra- and postoperative period, reduce the time of surgical intervention and earlier activation of patients in the postoperative period.

Proponents of performing nephropexy by percutaneous nephrostomy claim that it is effective in surgical treatment of nephroptosis and can be comparable in results with laparoscopic nephropexy (88.2% satisfactory results). The essence of the method is to perform percutaneous nephrostomy for nephroptosis. Nephrostomy drainage is removed a few days after surgery. However, it should be taken into account that this operation causes injury to the renal parenchyma, which increases the likelihood of complications such as renal bleeding, subcapsular hematoma of the kidney, long-term non-healing fistulas, urinary leakage, purulent-inflammatory processes in the retroperitoneal space, etc. In connection with the widespread introduction of minimally invasive surgical treatment methods into urological practice, the laparoscopic nephropexy method is currently widely used.

The technique of its implementation differs from the traditional operation according to N.A. Lopatkin.

In the last decade, nephropexy has been increasingly performed laparoscopically, but since the kidney is not widely isolated, it is impossible to eliminate organ rotation by suspending it by the upper segment. In this regard, a number of authors propose modified fixation of the kidney with artificial materials, in particular a split flap made of prolene mesh, which allows leveling the above-mentioned disadvantage of laparoscopic nephropexy. At the same time, the latter allows obtaining good and satisfactory remote results in 98.3% of cases.

Laparoscopic nephropexy technique

The surgical intervention is performed from four laparoports with the patient lying on the healthy side with the head end of the operating table lowered.

Unlike the traditional operation according to N.A. Lopatkin, the cut fibrous bridge along the anterior surface of the kidney is crossed in the middle. The muscle flap from m. iliopsoas, the distal end of which is tied with a polysorb thread, is placed on the anterior surface of the kidney between the flaps of the exfoliated fibrous capsule and is highly fixed with a thread to the fat capsule. The exfoliated sheets of the fibrous capsule are placed on the muscle bundle and fixed with 4-6 titanium clips.

Once the kidney is fixed, the posterior leaflet of the parietal peritoneum is closed with several titanium clips or sutured with an atraumatic thread using the Endostich device or an intra-abdominal manual suture. The retroperitoneal space is drained with a thin tube for 12-24 hours.

Patients in the postoperative period observe strict bed rest for six days (the head of the bed is lowered). The disadvantage of this version of laparoscopic nephropexy (as well as open nephropexy) is considered to be the patient's long stay in bed.

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

The technique of kidney fixation in nephroptosis with a polypropylene mesh is as follows. Access is performed from three laparoports located on the affected side. Trocars with a diameter of 10 and 11 mm are placed on the anterior abdominal wall: a trocar with a diameter of 10 mm - along the midclavicular line at the level of the navel, 11 mm - along the anterior axillary line (under the costal 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 insert a trocar for a laparoscope with oblique optics along the anterior axillary line at the level of the umbilicus.

A strip of polypropylene mesh 2 cm wide and 7-8 cm long is fixed to the muscles of the lumbar region with a furrier's needle using two U-shaped ligatures through a 1 cm long skin incision under the 12th rib along the anterior scapular line. The knots of the U-shaped sutures are immersed deep into the subcutaneous tissue, and one interrupted suture is applied to the skin wound. The other end of the polypropylene mesh is cut longitudinally by 3-4 cm and fixed with a hernia stapler in the shape of the letter "V" on the anterior surface of the kidney, displaced upward by the retractor.

When performing laparoscopic nephropexy in the early postoperative period, physiological parameters of kidney mobility are restored much earlier (compared to the open method). This fact can be explained by the more gentle laparoscopic technique. The patient is activated early after surgery, which significantly improves the patient's psychoemotional state and predetermines a calm further course of the postoperative period.

Forecast

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