Nephroptosis

NEPHROPTOSIS* JARRATT P. ROBERTSON, M.D. AND PAUL L. SINGER, M.D. BIRMINGHAM,

T

HE range of mobiIity of a norma kidney varies from I to 5 cm. In addition to the vertica1 movement there is aIso a rotary movement on the transverse and IongitudinaI axis. The movabIe kidney must be distinguished from the ectopic kidney, as the Iatter has abnorma1 vascuIar and fascia1 attachments and is fixed in an abnormal pIace. The movabIe kidney has norma vascuIar and fascia1 attachments that are of unusual Iength and permit it to descend far beiow its norma position. The kidneys are Iocated on the posterior abdomina1 waI1 on either side of the dorsoIumbar vertebrae. The upper poIe Iies opposite the eIeventh or tweIfth dorsa1 vertebrae. The Ieft kidney is from I to 2 cm. higher than the right. The supports of the kidney are the renaI fascia, the perinephric fat, the renaI pedicIe, various Iigaments, and the intra-abdomina1 pressure. The renaI fascia, by its attachments to the diaphragm, spine, Iarge vesseIs, abdominal viscera, and the fibrous septa which traverse the perinephric fat, serves an important function in fixation of the kidney. The perinephric fat pIays a Iess important rBIe; it may be present in an increased amount in cases of marked ptosis. In chiIdren it does not exist before the tenth or tweIfth year, yet nephroptosis is seIdom encountered at that earIy age. The eIongated renaI pedicIe seen in movabIe kidney is probabIy the effect rather than the cause of the disorder, for otherwise it wouId be encountered in cases without ptosis and as frequentIy in the maIe as in the femaIe. However, KeIIy and Burnam, in a coIIection of 7,853 autopsies, found movabIe kidneys in 2.1 per cent of the maIes and 22.8 per cent of the femaIes.

ALABAMA

The various Iigaments and the intraabdomina1 pressure pIay a reIativeIy smaI1 part in fixation of the kidney. The shape of the renaI fossa, the renaI fascia, perinephric fat, and the pedicIe are the chief factors in maintaining the kidney in a norma position. Why does nephroptosis occur ten times as frequentIy in the femaIe as in the maIe, ten times as frequentIy on the right as on the Ieft side, and usuaIIy in the third, fourth, and fifth decades of Iife? In the male, the renaI fossae are deep, broad above and narrow beiow, forming a good bed for the kidney. In the femaIe, the reverse is true; the fossae are shaIIow, as broad or broader beIow as above, and do not form a bed for the kidney. The Iiver forces the right kidney down; the hepatic Aexure of the coIon is Iess secureIy anchored than the spIenic ffexure; a11 this makes for a Iess secure kidney on the right side. Pregnancy, with changes in the intraabdomina1 pressure and marked diIatation of the kidney peIvis and ureter, Ioosens the unsecure renaI attachments and encourages nephroptosis. The asthenic type of individua1 is especiaIIy prone to deveIop movabIe kidney as part of a genera1 visceroptosis, because of defective deveIopment of the muscuIar and fibrous tissue in a11 parts of the body. This type of individua1 is encountered with greater frequency in the femaIe than in the maIe. Trauma pIays a very minor part in nephroptosis. It shouId not be considered as a cause unIess there is a definite history of iniury resuItinp; in pain and tenderness in the iidney reGon, and unIess bIood is found in a catheterized specimen of urine at the time of the injury.

* From Department of Urology, HiIIman HospitaI, Birmingham, Alabama. 379

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Our observations have been that nephroptosis is frequently part of a genera1 visceroptosis, especiaIIy if the nephroptosis

HIDNEY

The movabIe kidney is of clinica and pathoIogic importance onIy insofar as it gives rise to infection, urinary obstruction,

AND INCISEO.

EXPOSED

FIG.

is biIatera1. Visceroptosis is graphicaIIy demonstrated in x-ray pictures taken in the upright position foIIowing a barium enema and mea1. As the kidney migrates down the posterior abdomina1 waI1 it rotates with the pedicIe as its axis. The abnorma1 movement of the kidney, with rotation and kinking of the ureter and peIvis, resuIts in obstruction and retention of urine in the pelvis. If the obstruction is sudden and compIete, a renaI colic known as DietI’s crisis foIIows; if incompIete and intermittent there is a retention of urine in the kidney peIvis, a duI1 aching pain, and eventuaIIy a hydroor pyohydronephrosis.

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I.

pain and peIvic diIatation. Pain and urinary obstruction are usuaIIy associated, so that it is rare to find one without the other. OnIy about one case of nephroptosis in ten gives rise to serious symptoms, since this severity depends upon the degree of obstruction rather than on mobiIity. A freeIy movabIe kidney is usuaIIy accompanied by a freeIy movabIe ureter, which often does not cause obstruction. A kidney sIightIy movabIe with a ureter heId stationary by adhesions or aberrant vessels is more IikeIy to produce serious obstruction because of the acute anguIation of the ureter at the stationary point. The puI1 of the kidney on the pedicIe seIdom produces sufficient pain to warrant opera-

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tion, since the discomfort is part of that produced by the genera1 visceroptosis and the associated gastrointestina1 symp-

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productive of symptoms and pathoIogy. The foIIowing routine is folIowed in making the pyeIograms. With the catheters in

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toms. Suspension of one or both kidneys wiI1 not reIieve such pain. MobiIity of the kidney is better demonstrated by UreteropyeIography than by paIpation. In paIpating to determine the position of a kidney with the subject in the recIining position, one may fai1 to fee1 an exaggerated movabIe kidney which has sIipped into norma pIace. Thick abdominal waIIs or forced rigidity may aIso prevent paIpation of a kidney that decends to the peIvic brim. It is easier to make the diagnosis of nephroptosis than to ascertain if the symptoms are due to it or to other causes. OnIy by cystoscopy and urography can the symptomIess and non-pathoIogic nephroptosis be differentiated from that

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pIace the first x-ray is made to ruIe out caIcuIi. For the second pIate the head of the tabIe is Iowered, and the kidney peIves are fiIIed with the pyeIographic soIution to show the height to which the kidneys ascend and the shape of the renaI peIves. The third pIate is made with the patient in the upright position, the ureters being fiIIed with the pyeIographic soIution and the catheters removed; this shows the maximum descent of the kidney, the tortuosity of the ureter, and the obstruction if present. The patient remains in the upright position for seven minutes before the fourth and Iast x-ray is made, to determine if the emptying time is normaI. A kidney peIvis and ureter free of obstruction shouId empty in seven minutes.

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Nephroptoses are divided into three main groups: (I) the asymptomatic; (2) those with renaI symptoms; and (3) those,

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marked the hydronephrosis and obstruction, the greater wiII be the delay in the emptying time.

FIG. 3.

with symptoms not renal in character. Each of these groups is subdivided into those with and without pyeIographic evidence of peIvic diIatation, those with and without infection, those with and without obstruction, and those with a normal or a deIayed emptying time. or absence of pelvic The presence dilatation is determined from the pyeloExamination of the specimens grams. of urine collected from the renal pelves separates the infected from the noninfected. The pyeIograms demonstrate those with a norma emptying time and without diIatation or obstruction and differentiate them from those with a deIayed emptying time, obstruction, and diIatation of the renaI peIvis. The more

The mere diagnosis of nephroptosis is not sufficient for scientific treatment. A kidney may be ptosed and yet be symptomIess, free of infection, without diIatation or obstruction, and have a normal emptying time. In such a case treatment wouId not be indicated. On the other hand, nephroptosis may be part of a general visceroptosis with infection, diIatation and obstruction. In this type a nephropexy shotrId be done to prevent additiona kidney damage and aid in cIearing up the infection by giving better drainage, even if it does not relieve the patient of pains caused by the general visceroptosis, The suspension of one pathoIogic kidney will not relieve the patient of a muhitude

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of pains caused by a genera1 visceroptosis and the pathoIogy associated with it. X-rays in the upright position foIIowing

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primariIy to reIieve pain; and (3) those requiring treatment to prevent additiona kidney damage. -

PTOSPO

FIG.

the taking of a barium enema and mea1 graphicaIIy demonstrate the genera1 visceroptosis. At the time of cystoscopy overdistention of the kidney peIvis may produce the same or a different type of pain than that of which the patient compIains. If the pain is of the same type as that noted by the patient, then a nephropexy wiI1 probabIy give reIief. The pain from nephroptosis is usuaIIy due to infection and increase in the renaI pressure from ureteropeIvic obstruction. The typica pain is duII and aching in character and is noted in the Iumbar region, sometimes radiating down the ureter. For treatment nephroptosis are divided into three groups: (I) those requiring no treatment; (2) those requiring treatment

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Ptosis unassociated with pain, infection, obstruction, or diIatation, and accompanied by a norma emptying time usuaIIy requires no treatment. The ptosis is usuaIIy part of a symptomIess visceroptosis. Those cases requiring treatment for reIief of pain present part or a11 of the foIIowing findings : uretera or UreteropeIvic obstruction, diIatation of the kidney peIvis, infection, pain, and deIay in the emptying time. Treatment is indicated in the Iast group even if it is feIt in advance that it wiI1 not reIieve the patient of a11symptoms. The treatment of nephroptosis is divided into: (I) nonsurgica1; (2) surgica1. By nonsurgica1 treatment is meant the empIoyment of abdominal supports, exercise to deveIop the abdomina1 muscIes,

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rest in bed with the foot eIevated, and to increase the peridietary measures nephric fat. The measures are empIoyed

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shows that the pain is due to the ptosis, and (2) to prevent additiona kidney damage and aid in cIearing up the infection,

AEPLACEQ~

FIG.

with the hope that the kidney may be heId in pIace unti1 the increase in the perinephric fat, the improvement in the muscuIar tone, and the adhesions wiI1 retain it in its proper position. The abdomina1 support at times works very satisfactoriIy, more by giving reIief from the genera1 visceroptosis than by actuaIIy supporting the kidney. FoIIowing six weeks’ rest in bed and a satisfactory weight gain, our pyeIograms in the upright position have in every instance shown the ptosis to be the same as before the rest. The patients fee1 better for a few weeks because of the gain in weight and improvement in the genera1 physica condition despite the fact that the ptosis persists. SurgicaI suspension is indicated (I) to reIieve pain if the examination concIusiveIy

5.

regardIess of the fact that it does not reIieve the patient of a muItitude of pains and compIaints due to a genera1 visceroptosis and its associated gastrointestina1 symptoms. The foIIowing technique is empIoyed in doing a nephropexy and has given satisfactory surgica1 resuIts. The incision in the renaI fascia is made as far posterior as possible in order that it may Iater be empIoyed as a support for the kidney. The kidney is freed of a11 adhesions and fat; the ureter is expIored and if any adhesions are present they are dissected out. The capsuIe of the kidney is incised aIong its outer border from the midIine to the upper poIe and turned back. This giyes a raw area at the upper poIe. Three No. oo chromic catgut sutures are Inserted

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until the axis of the pelvis is in a direct line with the ureter. (Fig. 6.) The renaI fascia is now cIosed, puIIed over and

in the roIIed back capsuIe on the posterior side. The ends of the sutures are Ieft Iong. Incisions I inch Iong and 34 inch apart

I(IDNEY

American

F&ED

AT ANGLE

FIG. 6.

are made in the capsuIe of the kidney on the anterior and posterior sides at the Iower poIe, (Fig. I.) A strand of ribbon catgut is passed through these incisions and tied on the outer border of the kidney. The superior renaI fossa is cIeansed of aI1 fat, and the kidney anchored as high as possibIe to the posterior abdomina1 waI1 with the three previousIy mentioned chromic catgut sutures. (Fig. 2.) This brings the raw kidney surface in contact with the posterior abdomina1 muscIes. The ribbon catgut is passed through the muscles above or below the tweIfth rib at the posterior angIe of the incision. (Fig. 3.) This forces the kidney high in the renaI fossa, straightens the ureter of a11 kinks (Figs. 4 and 5), and raises the lower paIe of the kidney

anchored to the posterior abdomina1 waI1. The fascia and the perinephric fat is pushed down unti1 it is beIow the lower poIe of the kidney. This is one of the most important steps of the suspension as it forms a support or hammock upon which the Iower poIe of the kidney and pedicIe rests. A smaI1 rubber tissue drain is pIaced to the Iower poIe of the kidney and removed in forty-eight hours. The incision is cfosed in Iayers. A heavy pack is incorporated running paraIIe1 with in the dressing, Poupart’s Iigament and acting in the same way as a kidney pad in an abdominal support. The patient remains in bed with the foot of the bed eIevated 18 inches for three weeks, with instructions to remain Aat on his back during that time if possibIe,

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to permit

the formation of adhesions that wiIl hoId the kidney in pIace. In the fina anaIysis the kidney remains in position because of adhesions and the support constructed from the renaI fascia and not because of the type of sutures empIoyed. CONCLUSIONS I. Nephroptosis occurs ten times as frequentIy in the femaIe as in the male,

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and ten times as frequentIy on the right as the Ieft side. 2. It is usuaIIy part of a genera1 visceroptosis. 3. Treatment is indicated to reIieve pain and prevent additiona kidney damage. 4. Surgery is indicated in onIy about IO per cent of the cases. 3. A surgica1 technique is presented that has given satisfactory resuIts in our hands

AT present, wide surgica1 excision in the form of either Iobectomy or pneumonectomy has more successes to its credit than any other method and offers the best Iikelihood of permanent cure [in primary carcinoma of the Iung]. From-“Primary Carcinoma of the Lung” by Edwin J. Simons (Yearbook PubIishers).