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Arab Journal of Urology (2013) 11,68–73 Arab Journal of Urology (Ofﬁcial Journal of the Arab Association of Urology) www.sciencedirect.com STONES/ENDOUROLOGY POINT OF TECHNIQUE Percutaneous endoscopic nephropexy with a percutaneous suture passed through the kidney a, b a b a M. Lezrek , Y. El Harrech , K.H. Bazine , J. Sossa , M. Assebane , a a a b M. Alami , E.H. Kasmaoui , A. Beddouch , A. Ameur Department of Urology, Military Hospital Moulay Ismail, Meknes, Morocco Department of Urology, Military Hospital Mohamed V, Rabat, Morocco Received 24 October 2012, Received in revised form 1 January 2013, Accepted 1 January 2013 Available online 4 February 2013 KEYWORDS Abstract Objectives: To report a technique of percutaneous endoscopic nephro- pexy, using a polyglactin suture passed through the kidney, in patients with nephrop- Kidney; tosis. Nephroptosis; Patients and methods: Four women presenting with symptomatic right nephroptosis Percutaneous surgery; underwent a percutaneous endoscopic nephropexy. An upper-pole calyx was accessed per- Lateral modiﬁed posi- cutaneously and a 24-F working sheath was placed. Another needle access was made tion; through a lower-pole calyx and a #2 polyglactin suture was passed into the renal pelvis. It Nephropexy was then pulled out through the upper-pole tract using the nephroscope. A retroperitoneos- copy was performed and the tip of the nephroscope was used to cause nephrolysis. After inserting the nephrostomy tube the polyglactin suture was passed into the subcutaneous tissue and then tied without too much tension, to avoid cutting the parenchyma. Results: The operative duration was 33 min and the hospital stay after surgery was 3.5 days. The nephrostomy catheter was removed 5 days after surgery. There were no complications, especially no haemorrhagic, infectious, lithiasic or thoracic complica- Corresponding author. Address: Department of urology, Military Hospital Moulay Ismail, 50020 Me´ knes, Morocco. Tel.: +212 E-mail addresses: email@example.com, lezrekmohamed@ gmail.com (M. Lezrek). Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier 2090-598X ª 2013 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.aju.2013.01.002 Percutaneous endoscopic nephropexy with a percutaneous 69 tions. The four patients were relieved of their initial symptoms, with a mean follow-up of 28 months. Ultrasonography and/or intravenous urography showed the kidney at a higher location with the patient standing. Conclusions: This technique combines the nephrostomy tract used in percutaneous techniques with the suture and nephrolysis used in laparoscopic techniques. Moreover, this procedure seems to be safe, with satisfactory anatomical and clinical results and a lower morbidity. However, a larger series will be necessary to establish its long-term morbidity and success rate. ª 2013 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Introduction Operative technique Nephroptosis is deﬁned as a renal descent of more than Under general anaesthesia, the patients were placed in a two vertebral bodies when the patient moves from su- steep head-down split-leg modiﬁed lateral position , to pine to erect (standing). However, the kidney can move facilitate the cephalad displacement of the kidney. A 7-F back into a normal location when supine, which differ- ureteric catheter was inserted to administer contrast entiates it from an ectopic kidney . More than 170 dif- medium and to acutely dilate the collecting system. Un- ferent operative techniques and modiﬁcations for der ﬂuoroscopic guidance, an upper-pole calyx was ac- nephropexy have been described, but because of their cessed via an intercostal route. After inserting a safety use for the wrong indications, these techniques have guidewire, the tract was dilated, and a 24-F Amplatz been largely discredited . However, in the last decades sheath was placed. A 20.8-F nephroscope was then posi- tioned in the renal pelvis (Fig. 1). The collecting system there has been a renewed interest in symptomatic neph- was ﬁlled once again with contrast material, and another roptosis, with new criteria for diagnosis and new meth- needle access was made through a lower-pole calyx. A 6- ods of treatment, e.g. laparoscopic and percutaneous F PTFE dilator was placed in the renal pelvis over a nephropexy [1–6]. Here we report a new technique for percutaneous endoscopic nephropexy that combines guidewire. Subsequently, a #2 polyglactin suture was the nephrostomy tract used in percutaneous techniques, passed into the renal pelvis through the PTFE dilator, and the suture and nephrolysis used in laparoscopic like a guidewire. It was pulled out through the upper- techniques. pole tract using the nephroscope (Fig. 2). The Amplatz sheath and nephroscope were retrieved from the percuta- neous tract, to outside the kidney and the retro-renal fas- Patients and methods cia. Then a retroperitoneoscopy was performed, and the tip of the nephroscope was used to achieve a blunt dissec- Four women (mean age 30.5 years, range 24–40) were tion between the retro-renal fascia and the abdominal diagnosed with symptomatic right nephroptosis. They wall (Fig. 3A). The retro-renal fascia was traversed fol- had recurrent right ﬂank or abdominal pain after long lowing the guidewire. The dissection was then continued periods of standing or increased activity. The patients between the kidney and the retro-renal fascia, liberating were typically thin, with a mean (range) body mass in- the posterolateral aspect of the kidney (Fig. 3B–C). The dex of 19.2 (18.9–20.4) kg/m . No patient had a high- nephroscope and Amplatz sheath were once again intro- blood pressure, especially when standing. They had duced into the calyceal cavity following the security undergone many consultations and several periods of guidewire. A 20-F Foley catheter was positioned in the analgesic drug therapy over the previous years, with a renal pelvis through the upper tract (Fig. 4). Its balloon mean (range) time to diagnosis of 4 (6–3) years. Ultraso- was inﬂated with 3 mL of sterile water and contrast med- nography showed a descent of the right kidney in the ium. A mild traction was placed on the kidney to bring it lower abdomen when the patients passed from supine to its highest retroperitoneal position, which was con- to standing. IVU conﬁrmed the right renal descent, with ﬁrmed by a nephrostogram. The 18-G diamond-tip nee- tilting of the kidney when the patients moved from su- dle was passed under the skin, from the upper to the pine to erect. In two cases, a radionuclide renal scan lower puncture site (Fig. 5A). The suture was introduced conﬁrmed the decrease in renal perfusion when the into the needle and pulled out in the upper skin incision patient moved from supine to standing. The study was (Fig. 5B). Thus, the polyglactin suture was passed, into approved by the hospital ethics committee. After in- the subcutaneous tissue, from the lower to the upper formed consent, patients underwent a percutaneous puncture site, and then tied without too much tension, endoscopic nephropexy. to avoid cutting the parenchyma (Fig. 4). 70 Lezrek et al. Results Percutaneous nephropexy was technically possible in all four patients, and the mean (range) operative duration was 33 (28–37) min. Analgesic intravenous paracetamol was used on the ﬁrst day after surgery, and no further analgesic therapy was needed. To allow initial scarring and ﬁxation of the kidney, the patients were advised to stay in bed in the dorsal position for 2 days. Mechanical methods of thromboprophylaxis (anti-embolism stockings, leg movements), and low-molecular-weight heparin, were used to prevent thromboembolic compli- cations. One patient had a mild fever (38.7 C) on the ﬁrst day, but that resolved spontaneously. Although there was a retroperitoneal dissection there was no large extravasation, nor any other complication, especially haemorrhagic, infectious or thoracic. The patients had an uneventful discharge and the mean (range) hospital stay after surgery was 3.5 (2–5) days. The nephrostomy catheter was removed 5 days after taking the nephrosto- gram. There were no late complications secondary to the suture into the calyceal system, and no haemorrhage, infection or stone formation. The patients reported a subjective resolution of their initial symptoms. Ultraso- nography and/or IVU showed the kidney at a higher Figure 1 An upper-pole calyx is accessed via an intercostal position, with the patient erect, than before surgery route; the nephroscope is positioned in the renal pelvis. Another (Fig. 6), with a mean (range) follow-up of 28 (7–60) needle access was made through a lower-pole calyx, then a months. hydrophilic guidewire, and a 5- or 6-F PTFE dilator were inserted. Alternatively, the lower-pole calyx puncture could be made at the Discussion start, before upper-pole access. Currently, advanced radiological imaging has allowed the accurate diagnosis of well-documented symptomatic nephroptosis. Moreover, the advent of minimally inva- sive surgical techniques, which have lower morbidity, has restored interest in nephroptosis, and generated reports of new operative techniques in its management . In the present study we showed the feasibility and describe in detail a new technique of percutaneous neph- ropexy. Our technique combines some features of percu- taneous and laparoscopic nephropexy. Thus, it used a nephrostomy tract, a percutaneous suture, and nephrol- ysis through the unique percutaneous tract. In these few patients the procedure was possible in a quick operation, and with little or no morbidity. In addition, it was effec- tive, as the patients reported a subjective resolution of the symptoms during the follow-up. Laparoscopic nephropexy is considered the standard therapy for symptomatic nephroptosis , as it provides a successful outcome in 85–100% of patients . More- Figure 2 A nephroscopic view; a two-prong forceps grasps the over, it causes less postoperative pain, a briefer hospital- #2 polyglactin suture, which is passed into the renal pelvis via a 6- isation, lower morbidity, and briefer convalescence than F PTFE dilator. The suture is pulled out through the upper-pole tract using the nephroscope. after open surgery . Percutaneous endoscopic nephropexy with a percutaneous 71 Figure 3 (A) A retroperitoneoscopic view, after the Amplatz sheath and nephroscope were withdrawn in the percutaneous tract outside the retro-renal fascia. A space is developed outside the retro-renal fascia. The black hydrophilic guidewire and the purple suture are traversing the percutaneous tract gap. (B) The retro-renal fascia was traversed following the guidewire. A nephrolysis is developed, liberating the posterolateral aspect of the kidney, until reaching the lower pole access with the purple suture penetrating the renal capsule and parenchyma. (C) Sometimes a blunt dissection is performed with the help of the ‘opening and closing’ of a two-prong forceps. tion in centres with little or no access to laparoscopic expertise or equipment . Thus, a ‘one-point nephro- pexy’ was reported using a simple nephrostomy tube placement , or a nephropelvi-ureteric catheter inserted percutaneously . For more anchoring, a two-point technique was used with a circle (U) nephrostomy tube  or with two Council-tip catheter nephrostomy tubes . The rationale for these percutaneous nephropexy methods is the observation that after placing a percuta- neous nephrostomy tube, the scar is sufﬁcient to hold the kidney in place [1,2,4]. However, compared to lapa- roscopy, the main limitation of percutaneous neph- ropexies is the inability to perform an adequate nephrolysis, to induce adhesions and form a ‘surgical scar’ to secure the kidney ﬁrmly in a higher position . Consequently, a perirenal dissection, as in our tech- nique, is used to induce these additional adhesions, which might be more resistant to gravity than the nephrostomy tract alone. In addition, the polyglactin suture holds the kidney in place, giving time for perire- nal ﬁbrosis to organise and mature. Therefore there is no need for prolonged indwelling of a nephrostomy tube. Moreover, our procedure has the advantages of percutaneous nephropexy, i.e. it has low morbidity, is easy to perform, is low-cost, takes less time and is as effective as laparoscopy. Also, it has the advantages of laparo-endoscopic single-site surgery, e.g. reduced mor- bidity and improved cosmetic results . Figure 4 The balloon of the nephrostomy Foley catheter was inﬂated with 3 mL of sterile water and contrast medium. A mild However, this technique has the disadvantages of per- traction was placed on the kidney to bring it against the cutaneous renal surgery, i.e. a risk of haemorrhage and abdominal wall. The #2 polyglactin suture is passed into the renal risks of intercostal tract complications. Also, with the collecting system between the lower and the upper calyx, in the polyglactin suture through the collecting system, there subcutaneous tissue between the upper and lower skin punctures, was concern about percutaneous ﬁstulation, tearing and then tied in the upper skin incision. through the renal parenchyma, and the risk of stone for- mation, none of which occurred in any patient. This technique cannot detect nor correct an incomplete colon Several methods of percutaneous nephropexy have rotation, which is a possible underlying pathogenic been reported, with an 88% success rate as assessed mechanism of nephroptosis . Also, the study has some symptomatically [1,2,4]. Moreover, they are a good op- 72 Lezrek et al. Figure 5 (A) The 18-G diamond-tip needle is passed under the skin, from the upper to the lower puncture site, and passed through the lower skin puncture, alongside the suture. (B) The suture is introduced into the needle and pulled out in the upper skin incision. Figure 6 (A) IVU before surgery, with the patient upright, shows descent and tilting of the right kidney, with a kink in the proximal ureter. (B) IVU at 40 months after surgery, with the patient upright, shows the right kidney in a higher position. limitations, as there were too few patients to draw ﬁrm gery, are needed to verify the safety and effectiveness conclusions other than the feasibility of the procedure. of this technique. There was no objective evaluation of the patients (qual- ity-of-life questionnaires, pain analogue scales). Conﬂict of interest For future improvement and less invasiveness it would be possible to perform a renal dilatation of 10 None. F, and use a rigid ureteroscope to extract the suture, without a working sheath, similar to the technique we Funding use to make a second simultaneous percutaneous tract in complex stone extraction . The nephrolysis might The study and the report were not funded. be performed with the same rigid ureteroscope or with the nephroscope after dilating the percutaneous entry References alone. In conclusion, this technique of percutaneous neph-  Srirangam SJ, Pollard AJ, Adeyoju AA, O’Reilly PH. Nephrop- tosis: seriously misunderstood? BJU Int 2009;103:296. ropexy appears to be a feasible treatment option for pa-  Khan AM, Holman E, Toth C. Percutaneous nephropexy. Scand tients with symptomatic documented nephroptosis. J Urol Nephrol 2000;34:157–61. However, a longer follow-up and more extensive experi-  Castillo Rodrı´guez M, Larrea Masvidal E, Herna´ ndez Silverio D, ence, with an objective evaluation before and after sur- Carauna Valdes-Go´ mez A, Labrada Rodrı´guez MV, Cuesta Percutaneous endoscopic nephropexy with a percutaneous 73 Megias A. Percutaneous nephropexy in the treatment of renal Some studies showed that there is an associated colo- ptosis. Arch Esp Urol 1999;52:250–6. nic malrotation and/or a long mesocolon which allow  Sze´ kely JG. Re. Laparoscopic nephropexy: Washington Univer- the kidney to move freely in medial or caudal direction. sity experience (letter to the editor). J Urol 1997;157:266. This would therefore require ﬁxation together with the  Hoenig DM, Hemal AK, Shalhav AL, Clayman RV. Percutane- ous nephrostolithotomy, endopyelotomy and nephropexy in a kidney. single session. J Urol 1998;160:826–7. Most of the previous open surgical techniques and  Bishoff JT, Kavoussi LR. Laparoscopic surgery of the kidney. In: most of the minimally invasive techniques have been Walsh PC, Retik AB, Vaughan ED, Wein AJ, editors. Campbell’s performed by a retroperitoneal approach which may ex- urology. 9th ed. Philadelphia: Saunders; 2007. p. 1759–809 plain the poor results (poor symptomatic improvement) [Chapter 51].  Lezrek M, Ammani A, Bazine K, Assebane M, Kasmaoui el H, in the past as this pathognomonic mechanism was not Qarro A, et al. The split leg modiﬁed lateral position for revealed. Also, none of the authors who have used trans- percutaneous renal surgery and optimal retrograde access to the peritoneal techniques have mentioned the ﬁnding of an upper urinary tract. Urology 2011;78:217–20. incomplete rotation of the colon.  Liatsikos E, Kyriazis I, Kallidonis P, Do M, Dietel A, Stolzen- In this article, the authors present a technique where burg JU. Pure single-port laparoscopic surgery or mix of techniques? World J Urol 2012;30:581–7. the kidney is ﬁxed with an absorbable suture (2-polygl-  Wadstrom J, Haggman M. Laparoscopic nephropexy exposes a actin – Vicryl). The suture passes through the collecting possible underlying pathogenic mechanism and allows successful system and parenchyma instead of renal capsule and is treatment with tissue gluing of the kidney and ﬁxation of the tied without tension in the subcutaneous tissue. Theoret- colon to the lateral abdominal wall. Int Braz J Urol 2010;36:10–7. ically there is a slight concern that this suture may cut  Lezrek M, Bazine KH, Amani A, Assebane M, Ghoundale O, through the kidney tissue. However, from our own expe- Qarro A, et al. V30 ‘tips and tricks’ of percutaneous surgery in the split leg modiﬁed lateral position: optimal simultaneous rience of inferior mobilisation of the kidney with a thor- anterograde and retrograde access. Eur Urol Suppl 2011;10:351. ough-and-thorough guidewire through the lower calyx for upper pole puncture during PCNL we may say that even with a much more solid guidewire no slicing of the kidney occurs. It remains to be seen however whether the intra-calyceal part of the suture can lead to stone Editorial comment formation. The mean operative time was only 33 min which is I believe the article ‘‘Percutaneous endoscopic nephro- shorter than any of the other methods. I believe that this pexy with a percutaneous suture passed through the kid- procedure could be performed as a day case or short- ney’’ is a new and stunningly simple point of technique. stay procedure. There have been reported different surgical tech- There is no doubt that this alternative technique is niques to ﬁx mobile kidneys (ren mobilis) since Hans easy, probably safe, less time consuming and therefore ﬁrst reported such a procedure in 1881. cost-effective. Clinical application will establish its Whereas for a century open nephropexy was per- long-term efﬁcacy. formed suturing the kidney to the posterior ipsilateral abdominal wall, over the last decades laparoscopical Noor Buchholz and percutaneous techniques have been applied in a Director of Endourology & Stone Services, Dept. of Urology, minimally invasive fashion. Laparoscopy sutured the The Royal London Hospital, Bartshealth NHS Trust, London, kidney in the same place as in open surgery whereas per- UK cutaneous nephropexy used the formation of scar tissue E-mail address: firstname.lastname@example.org around a nephrostomy to anchor the kidney. Laparo- scopic nephropexy showed more promising results with a low morbidity.
Arab Journal of Urology – Taylor & Francis
Published: Mar 1, 2013
Keywords: Kidney; Nephroptosis; Percutaneous surgery; Lateral modified position; Nephropexy
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