NEPHROPEXY:
FACT OR FICTION?
MICHAEL
J. O’DEA,
M.D.
WILLIAM
L. FURLOW,
M.D.
From the Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT -At the Mayo Clinic, from 1940 through 1974,21 patients have undergone nephropexyfor nephroptosis. Fourteen of the 16 patients with long-term follow-up were cured; 2 of the 16 patients were partially relieved. An additional 2 patients who had one-year follow-up examinations were asymptomatic. Three patients were lost to follow-up. In this series results with the various methods offixation did not differ, and results in patients who retained their normal position postoperatively as compared with those whose kidneys reverted to their preoperative level also did not differ. Patients who had psychologic disorders fared as well as those who did not. Greater use of renography probably could be made in the assessment of symptoms. Although this review does not suggest that nephropery for primary nephroptosis be restored to its former appeal of the 193Os, we suggest that its use be considered again in urologic surgery.
Movable kidney was first described by Franciscus de Pedemontanus in the fourteenth century.* In 1841 Rayer informed the medical profession that movable kidney was a definite clinical entity with characteristic symptoms.’ In 1878 Martin popularized nephrectomy as treatment, but although relief was obtained in that case, pathologic examination of the kidney revealed no abnormality. 1,2 Subsequently, various operations, many of them mutilating, were performed, including removal of the renal capsule, piercing of the renal parenchyma with absorbable and nonabsorbable sutures, and even impalement of the kidney on the exposed end of the twelfth rib. Incomplete diagnostic evaluation and inappropriate application of this operation led to a wave of disapproval, and the procedure was lost to the profession until the early part of the twentieth century. At that time the popularization and advances in urographic technique permitted a more thorough understanding of the problem and a clearer concept of how to treat nephroptosis. Deming in 19302 and Burford in 1946l reported very satisfactory results with nephropexy for symptomatic nephroptosis. At the present time, however, the operation is seldom performed, except as an adjunct to primary reconstructive procedures on the kidney and upper ureter.
UROLOGY
/ JULY 1976
/ VOLUME
VIII,
NUMBER
1
For some time we have questioned the therapeutic value of nephropexy in the treatment of symptomatic nephroptosis. Urologic texts support the popular impression that renal ptosis should be considered a normal condition and that surgical correction of the ptotic kidney is seldom if ever warranted.3*4 Although we agree in general with these authors, we believe the subject should be reassessed. We herein report our experiences with primary nephropexy performed in 21 patients who had symptomatic nephroptosis. Material
and Methods
Primary nephropexy alone was performed at the Mayo Clinic on 21 patients between 1940 and 1974. There were 16females and 5 males (a female to male ratio of 3: 1) whose ages ranged from seven to sixty-one years and averaged thirtyfour years. Most of the patients were in the third and fourth decades (Table I). Findings Presenting signs and symptoms. All but 1 patient had pain (Table II). The most common region of pain was the ipsilateral lower quadrant (11 of 21 patients). Pain was usually described as
9
Age distribution
TABLE I. Age (Years) 1 11 21 31 41 51 61
to to to to to to to
TABLE III.
No. of Patients Investigation*
10 20 30 40 50 60 70
Excretory urography (21)
Urinalysis (21) Urine culture (21)
TOTAL
21
dull. Three patients had histories of recurrent urinary tract infection. Seven patients had a palpable mobile kidney; in 5 of these the kidney was tender to palpation. The interval from onset of symptoms to presentation varied greatly, ranging from one week to five years, with an average of two years. investigative studies. As part of the urologic workup all 21 patients had routine urinalysis, urine culture, chemical measurement of renal function, and excretory urography (Table III). Nineteen (90 per cent) of the patients had a very mobile kidney, as evidenced by a change in kidney position greater than the distance of one vertebra in both the supine and upright positions. This finding is in accordance with the definition of nephroptosis, as stated by Emmett and Witten. Fourteen (67 per cent) of the patients had evidence of obstruction to the collecting system which resulted in pyelocaliectasis. Eight of the 14 patients had possible obstruction of the ureteropelvic junction; this was further suggested in 2 of the 8 patients who had retrograde pyelography performed. Only 3 patients had urinary tract infection. Renal function, as judged by serum creatinine or
TABLE II.
Initial manifestations
Manifestation Pain Lower quadrant Upper quadrant Flank Generalized in lower abdomen Low back Pyrexia Recurrent urinary tract infection Nocturia Relief with recumbency Palpable mobile kidney Tenderness on examination
10
Investigations and results
No. of Patients 11 2 6 2 3 1 3 3 4 7 5
No. of Patients
Results Nephroptosis Pyelocaliectasis Ureteropelvic junction obstruction (?) Pus cells Gram-negative bacilli (Escherichia coli)
19 8 6 3 3
Renal function studies Urea (18) Normal Serum Normal creatinine (7) Renography (3) Reduced function Retrograde Suggestive of ureteropelvic junction pyelography (2) obstruction *Figures
in parentheses
TABLE IV.
indicate
number
18 7 3 2
of patients.
Method of renal fixation No. of Patients
Procedure
Capsule fixation to iliopsoas fascia Fixation of capsule through eleventh interspace Nephrostomy and iliopsoas anchor Fixation through eleventh interspace; iodoform gauze between lower pole and peritoneum; pedicle denervation Fixation to iliopsoas fascia with pedicle denervation Fixation to iliopsoas fascia; iodoform gauze around lower pole to peritoneum
8 7 3 1
1 1
plasma urea levels, was normal in all 21 patients. Renograms obtained in 3 patients indicated reduction in blood flow to the affected side in all 3. In most of the patients (17 of 21), the right kidney was ptotic. No patient had bilateral renal ptosis. Most of the patients had Surgical techniques. capsule fixation either to the iliopsoas fascia or through the eleventh interspace (Table IV). In more recent years the technique has been mainly that of capsule fixation through the eleventh interspace. Results and follow-up. Nephropexy was successful and the patient cured if he or she remained asymptomatic for more than two years. Follow-up was by telephone or letter. Only 3 patients were lost to follow-up. The average follow-up period for
UROLOGY
/
JULY 1976
/
VOLUME
VIII,
NUMBER
1
this group, excluding the 2 patients who were less than one year postoperatively, was 11.4 years. If these two short-term follow-up cases are excluded, we find that 14 of 16 patients were completely relieved of their symptoms (Table V). The other 2 patients had partial relief of their symptoms. The two patients currently who were followed up for less than two years postoperatively are also symptom free. Comment The causes of nephroptosis vary. Nephroptosis with visceroptosis is not common; we saw none in our series. Deming, 2 however, noted 9 patients with visceroptosis in his series of 74 patients. A gastrointestinal series is not always needed to make such a diagnosis because the viscera are frequently outlined by gas shadows on the renal film. Bilateral nephroptosis is likely to be a part of the visceroptosis. Deformity of the spine may lead to nephroptosis. However, we saw no such deformities in our series. Nearly all of our patients ha J loss of perirenal fat or lack of perirenal fat. This feature probably is the greatest contributing cause of primary nephroptosis. This finding was not limited to the thin patients in our series. Nephroptosis was far more prevalent in women, was usually noted in patients in their third decade, and was more common on the right side. These findings are in agreement with previous reports in the literature. The ptotic kidney must not be confused with the ectopic kidney. The movable kidney takes its blood supply from an approximately normal position but leaves its previously normal lumbar bed. Symptomatic nephroptosis should be diagnosed with considerable reservation. Many of the patients have intraperitoneal organ disease as a cause of their symptoms. The finding of nephroptosis with an easily palpable kidney is in itself no indication for surgery. All patients should have a full urologic investigation, and a gastrointestinal series and cholecystography also might be advisable in selected patients. TABLE
Results
V.
oftreatment
by nephropexy in 16
patients*
Result
No. of Patients
“Cured” Improved Failure
14 2 0
Length of Follow-up (Years) Range Average 2 to 28 5 to 7 . . .
11 6 .
.
*Additional 2 patients have been followed up for 1 year only (both are asymptomatic), and 3 patients were lost to follow-up.
UROLOGY
/
JULY 1976
/
VOLUME
VIII, NUMBER
1
In our experience, the most common symptom was pain which was most often in the ipsilateral lower quadrant or ipsilateral flank. The underlying cause of the pain is not clear, but it probably resulted from retention of urine in the renal pelvis. Another possible explanation for pain associated with nephroptosis is the stretching of the peripelvic nerves or the elongation of the nerve plexus around the renal pedicle (or both). Findings on excretory urography were suggestive of obstruction of the ureteropelvic junction in 6 of the 21 patients and of pyelocaliectasis in 2 patients, and these findings prompted exploration. The 1 asymptomatic patient in our series had had a routine urogram for a known solitary kidney; obstruction of the ureteropelvic junction was diagnosed, and exploration was advised because of the solitary kidney. At exploration vessels were found crossing a redundant ureteropelvic junction, and nephropexy was performed. Twentytwo-year follow-up revealed an essentially normal excretory system. Nephropexy for primary nephroptosis in the absence of associated pyelocaliectasis was performed in the remaining 13 patients in our series. Of these 13 patients, 10 claimed to be free of symptoms after primary 1 patient was partially relieved of nephropexy, symptoms, and 2 were lost to follow-up. The average period of follow-up in these patients has been nine years. Analysis of the techniques employed indicates that no type of fixation is superior. The question arises whether or not the patients retained the normal position of the kidney on subsequent urographic study and whether this retention was related to cure. Fourteen of our patients had follow-up excretory urography from two months to twelve years after nephropexy (average two years). Eight of the 14 patients retained a normal postoperative kidney position; 7 were cured and 1 was partially improved. One ofthe patients had an excretory urogram that showed some improvement in renal position, and this patient was partially improved. Five of the 14 patients had no change in renal location after nephropexy; all 5, however, were asymptomatic on follow-up. No particular form of surgical treatment had any greater success in maintaining the normal position of the kidney. All forms of fixation stressed placing the kidney in a position that allowed free and dependent drainage of the pelvis into the ureter. Pedicle denervation was performed in 2 patients in the earlier part of our series. No comments can be made as to the advantages or disadvantages of this procedure.
11
Some authors have noted a variety of nervous symptoms. In our series an effort was made to search for such symptoms. Six patients had a Minnesota Multiphasic Personality Inventory test (MMPI): 3 h ad normal results and 3 had abnormal results. An additional 2 patients admitted to having mild depression. Six of these 8 patients were cured of their symptoms, and the other 2, both of whom admitted to feeling depressed, were partially relieved of their symptoms. A careful search for underlying emotional disorders is necessary in the preoperative evaluation of these patients; however, the presence of emotional problems, chronic anxiety, or “nervousness” should not automatically exclude nephroptosis as the cause of the patient’s pain syndrome. The use of the MMPI and a psychiatric interview as well as the treatment can be helpful in selecting patients who may benefit from primary nephropexy. We believe that nervousness and anxiety disorders can occur in any patient who has been subjected to a long period of pain and
12
discomfort. In the differential diagnosis the urologist should consider the syndrome of intermittent hydronephrosis as well as organic extrarenal disease, including both liver and gallbladder disease. Section of Publications Mayo Clinic Rochester, Minnesota 55901 (DR. O’DEA)
References
BURFORD, C. E.: Nephroptosis
with co-existing renal J. Ural. 55: 220 (1946). DEMING,~. L.: Nephroptosis: causes, relation to other viscera, and correction by a new operation, J.A. M.A. 95: 251 (1930). EMMETT, J. L., and WITTEN, D. M.: Clinical Urography: An Atlas and Textbook of Roentgenologic Diagnosis, 3rd ed., Philadelphia, W. B. Saunders Company, 1971, pp. 339-341, 346-349. GLENN, J. F.: Urologic Surgery by 33 Authors, Hagerstown, Maryland, Hoeber Medical Division, 1969, pp. 69, 134. lesions,
UROLOGY
/ JULY1976 / VOLUMEVIII, NUMBER1
FACT OR FICTION?
MICHAEL
J. O’DEA,
M.D.
WILLIAM
L. FURLOW,
M.D.
From the Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT -At the Mayo Clinic, from 1940 through 1974,21 patients have undergone nephropexyfor nephroptosis. Fourteen of the 16 patients with long-term follow-up were cured; 2 of the 16 patients were partially relieved. An additional 2 patients who had one-year follow-up examinations were asymptomatic. Three patients were lost to follow-up. In this series results with the various methods offixation did not differ, and results in patients who retained their normal position postoperatively as compared with those whose kidneys reverted to their preoperative level also did not differ. Patients who had psychologic disorders fared as well as those who did not. Greater use of renography probably could be made in the assessment of symptoms. Although this review does not suggest that nephropery for primary nephroptosis be restored to its former appeal of the 193Os, we suggest that its use be considered again in urologic surgery.
Movable kidney was first described by Franciscus de Pedemontanus in the fourteenth century.* In 1841 Rayer informed the medical profession that movable kidney was a definite clinical entity with characteristic symptoms.’ In 1878 Martin popularized nephrectomy as treatment, but although relief was obtained in that case, pathologic examination of the kidney revealed no abnormality. 1,2 Subsequently, various operations, many of them mutilating, were performed, including removal of the renal capsule, piercing of the renal parenchyma with absorbable and nonabsorbable sutures, and even impalement of the kidney on the exposed end of the twelfth rib. Incomplete diagnostic evaluation and inappropriate application of this operation led to a wave of disapproval, and the procedure was lost to the profession until the early part of the twentieth century. At that time the popularization and advances in urographic technique permitted a more thorough understanding of the problem and a clearer concept of how to treat nephroptosis. Deming in 19302 and Burford in 1946l reported very satisfactory results with nephropexy for symptomatic nephroptosis. At the present time, however, the operation is seldom performed, except as an adjunct to primary reconstructive procedures on the kidney and upper ureter.
UROLOGY
/ JULY 1976
/ VOLUME
VIII,
NUMBER
1
For some time we have questioned the therapeutic value of nephropexy in the treatment of symptomatic nephroptosis. Urologic texts support the popular impression that renal ptosis should be considered a normal condition and that surgical correction of the ptotic kidney is seldom if ever warranted.3*4 Although we agree in general with these authors, we believe the subject should be reassessed. We herein report our experiences with primary nephropexy performed in 21 patients who had symptomatic nephroptosis. Material
and Methods
Primary nephropexy alone was performed at the Mayo Clinic on 21 patients between 1940 and 1974. There were 16females and 5 males (a female to male ratio of 3: 1) whose ages ranged from seven to sixty-one years and averaged thirtyfour years. Most of the patients were in the third and fourth decades (Table I). Findings Presenting signs and symptoms. All but 1 patient had pain (Table II). The most common region of pain was the ipsilateral lower quadrant (11 of 21 patients). Pain was usually described as
9
Age distribution
TABLE I. Age (Years) 1 11 21 31 41 51 61
to to to to to to to
TABLE III.
No. of Patients Investigation*
10 20 30 40 50 60 70
Excretory urography (21)
Urinalysis (21) Urine culture (21)
TOTAL
21
dull. Three patients had histories of recurrent urinary tract infection. Seven patients had a palpable mobile kidney; in 5 of these the kidney was tender to palpation. The interval from onset of symptoms to presentation varied greatly, ranging from one week to five years, with an average of two years. investigative studies. As part of the urologic workup all 21 patients had routine urinalysis, urine culture, chemical measurement of renal function, and excretory urography (Table III). Nineteen (90 per cent) of the patients had a very mobile kidney, as evidenced by a change in kidney position greater than the distance of one vertebra in both the supine and upright positions. This finding is in accordance with the definition of nephroptosis, as stated by Emmett and Witten. Fourteen (67 per cent) of the patients had evidence of obstruction to the collecting system which resulted in pyelocaliectasis. Eight of the 14 patients had possible obstruction of the ureteropelvic junction; this was further suggested in 2 of the 8 patients who had retrograde pyelography performed. Only 3 patients had urinary tract infection. Renal function, as judged by serum creatinine or
TABLE II.
Initial manifestations
Manifestation Pain Lower quadrant Upper quadrant Flank Generalized in lower abdomen Low back Pyrexia Recurrent urinary tract infection Nocturia Relief with recumbency Palpable mobile kidney Tenderness on examination
10
Investigations and results
No. of Patients 11 2 6 2 3 1 3 3 4 7 5
No. of Patients
Results Nephroptosis Pyelocaliectasis Ureteropelvic junction obstruction (?) Pus cells Gram-negative bacilli (Escherichia coli)
19 8 6 3 3
Renal function studies Urea (18) Normal Serum Normal creatinine (7) Renography (3) Reduced function Retrograde Suggestive of ureteropelvic junction pyelography (2) obstruction *Figures
in parentheses
TABLE IV.
indicate
number
18 7 3 2
of patients.
Method of renal fixation No. of Patients
Procedure
Capsule fixation to iliopsoas fascia Fixation of capsule through eleventh interspace Nephrostomy and iliopsoas anchor Fixation through eleventh interspace; iodoform gauze between lower pole and peritoneum; pedicle denervation Fixation to iliopsoas fascia with pedicle denervation Fixation to iliopsoas fascia; iodoform gauze around lower pole to peritoneum
8 7 3 1
1 1
plasma urea levels, was normal in all 21 patients. Renograms obtained in 3 patients indicated reduction in blood flow to the affected side in all 3. In most of the patients (17 of 21), the right kidney was ptotic. No patient had bilateral renal ptosis. Most of the patients had Surgical techniques. capsule fixation either to the iliopsoas fascia or through the eleventh interspace (Table IV). In more recent years the technique has been mainly that of capsule fixation through the eleventh interspace. Results and follow-up. Nephropexy was successful and the patient cured if he or she remained asymptomatic for more than two years. Follow-up was by telephone or letter. Only 3 patients were lost to follow-up. The average follow-up period for
UROLOGY
/
JULY 1976
/
VOLUME
VIII,
NUMBER
1
this group, excluding the 2 patients who were less than one year postoperatively, was 11.4 years. If these two short-term follow-up cases are excluded, we find that 14 of 16 patients were completely relieved of their symptoms (Table V). The other 2 patients had partial relief of their symptoms. The two patients currently who were followed up for less than two years postoperatively are also symptom free. Comment The causes of nephroptosis vary. Nephroptosis with visceroptosis is not common; we saw none in our series. Deming, 2 however, noted 9 patients with visceroptosis in his series of 74 patients. A gastrointestinal series is not always needed to make such a diagnosis because the viscera are frequently outlined by gas shadows on the renal film. Bilateral nephroptosis is likely to be a part of the visceroptosis. Deformity of the spine may lead to nephroptosis. However, we saw no such deformities in our series. Nearly all of our patients ha J loss of perirenal fat or lack of perirenal fat. This feature probably is the greatest contributing cause of primary nephroptosis. This finding was not limited to the thin patients in our series. Nephroptosis was far more prevalent in women, was usually noted in patients in their third decade, and was more common on the right side. These findings are in agreement with previous reports in the literature. The ptotic kidney must not be confused with the ectopic kidney. The movable kidney takes its blood supply from an approximately normal position but leaves its previously normal lumbar bed. Symptomatic nephroptosis should be diagnosed with considerable reservation. Many of the patients have intraperitoneal organ disease as a cause of their symptoms. The finding of nephroptosis with an easily palpable kidney is in itself no indication for surgery. All patients should have a full urologic investigation, and a gastrointestinal series and cholecystography also might be advisable in selected patients. TABLE
Results
V.
oftreatment
by nephropexy in 16
patients*
Result
No. of Patients
“Cured” Improved Failure
14 2 0
Length of Follow-up (Years) Range Average 2 to 28 5 to 7 . . .
11 6 .
.
*Additional 2 patients have been followed up for 1 year only (both are asymptomatic), and 3 patients were lost to follow-up.
UROLOGY
/
JULY 1976
/
VOLUME
VIII, NUMBER
1
In our experience, the most common symptom was pain which was most often in the ipsilateral lower quadrant or ipsilateral flank. The underlying cause of the pain is not clear, but it probably resulted from retention of urine in the renal pelvis. Another possible explanation for pain associated with nephroptosis is the stretching of the peripelvic nerves or the elongation of the nerve plexus around the renal pedicle (or both). Findings on excretory urography were suggestive of obstruction of the ureteropelvic junction in 6 of the 21 patients and of pyelocaliectasis in 2 patients, and these findings prompted exploration. The 1 asymptomatic patient in our series had had a routine urogram for a known solitary kidney; obstruction of the ureteropelvic junction was diagnosed, and exploration was advised because of the solitary kidney. At exploration vessels were found crossing a redundant ureteropelvic junction, and nephropexy was performed. Twentytwo-year follow-up revealed an essentially normal excretory system. Nephropexy for primary nephroptosis in the absence of associated pyelocaliectasis was performed in the remaining 13 patients in our series. Of these 13 patients, 10 claimed to be free of symptoms after primary 1 patient was partially relieved of nephropexy, symptoms, and 2 were lost to follow-up. The average period of follow-up in these patients has been nine years. Analysis of the techniques employed indicates that no type of fixation is superior. The question arises whether or not the patients retained the normal position of the kidney on subsequent urographic study and whether this retention was related to cure. Fourteen of our patients had follow-up excretory urography from two months to twelve years after nephropexy (average two years). Eight of the 14 patients retained a normal postoperative kidney position; 7 were cured and 1 was partially improved. One ofthe patients had an excretory urogram that showed some improvement in renal position, and this patient was partially improved. Five of the 14 patients had no change in renal location after nephropexy; all 5, however, were asymptomatic on follow-up. No particular form of surgical treatment had any greater success in maintaining the normal position of the kidney. All forms of fixation stressed placing the kidney in a position that allowed free and dependent drainage of the pelvis into the ureter. Pedicle denervation was performed in 2 patients in the earlier part of our series. No comments can be made as to the advantages or disadvantages of this procedure.
11
Some authors have noted a variety of nervous symptoms. In our series an effort was made to search for such symptoms. Six patients had a Minnesota Multiphasic Personality Inventory test (MMPI): 3 h ad normal results and 3 had abnormal results. An additional 2 patients admitted to having mild depression. Six of these 8 patients were cured of their symptoms, and the other 2, both of whom admitted to feeling depressed, were partially relieved of their symptoms. A careful search for underlying emotional disorders is necessary in the preoperative evaluation of these patients; however, the presence of emotional problems, chronic anxiety, or “nervousness” should not automatically exclude nephroptosis as the cause of the patient’s pain syndrome. The use of the MMPI and a psychiatric interview as well as the treatment can be helpful in selecting patients who may benefit from primary nephropexy. We believe that nervousness and anxiety disorders can occur in any patient who has been subjected to a long period of pain and
12
discomfort. In the differential diagnosis the urologist should consider the syndrome of intermittent hydronephrosis as well as organic extrarenal disease, including both liver and gallbladder disease. Section of Publications Mayo Clinic Rochester, Minnesota 55901 (DR. O’DEA)
References
BURFORD, C. E.: Nephroptosis
with co-existing renal J. Ural. 55: 220 (1946). DEMING,~. L.: Nephroptosis: causes, relation to other viscera, and correction by a new operation, J.A. M.A. 95: 251 (1930). EMMETT, J. L., and WITTEN, D. M.: Clinical Urography: An Atlas and Textbook of Roentgenologic Diagnosis, 3rd ed., Philadelphia, W. B. Saunders Company, 1971, pp. 339-341, 346-349. GLENN, J. F.: Urologic Surgery by 33 Authors, Hagerstown, Maryland, Hoeber Medical Division, 1969, pp. 69, 134. lesions,
UROLOGY
/ JULY1976 / VOLUMEVIII, NUMBER1
