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Experiences With the Deming Nephropexy1
EXPERIENCES WITH THE DEMING NEPHROPEXY1 A. I. DODSON
N ephroptosis has occupied a prominent place in urological literature since 1841 when Rayer described the movable kidney as a definite clinical entity with characteristic signs and symptoms. In 1881, Hahn performed the first nephropexy, resecting a portion of the fatty capsule and suturing the perirenal fat to the lumbar incision. Because of recurrences resulting from the rather loose attachment made by suturing the fatty capsule to the lumbar wound, Bassini modified Hahn's operation by taking sutures through the fibrous capsule of the kidney. Since Hahn's original operation was described, numerous methods of suturing the kidney in place have been devised; in fact papers on this subject usually present a new operation or some modification of an old operation. At the present time most surgeons who perform nephropexies fix the kidney by sutures through the intact or reflected capsule, by strips of fascia reflected from the renal capsule or nearby structures, or by suturing the perirenal fat and fascia to the lumbar muscles below the kidney. Any of these operations may be successful if the kidney is properly prepared and care is taken to suture it in its normal anatomical position. Operations upon the kidney are always followed by rather extensive adhesions. Actual recurrence of renal ptosis is rarely encountered. The poor results that follow nephropexy are usually from the improper selection of cases, from faulty technique in which some accessory pathologic condition is not corrected, or the kidney and ureter are not completely liberated. An important part of the operation is complete liberation of the upper ureter and pelvis and careful dissection of all perirenal fat and fascia from the kidney. The ptosed kidney is often complicated by adhesions to the ureter, by aberrant vessels or by ureteropelvic pathologic lesion. When there are no such complications, pronounced degrees of renal mobility are often found in which the kidney empties normally with no discomfort to the patient. Regardless of the method of suspension to be used, the preparation of the kidney and its bed is the same. Adequate exposure is necessary so that the kidney, the upper portion of the ureter, and the renal fossa can be easily seen. An ample curved lumbar incision is usually more satisfactory, though it is rarely necessary to divide the posterior fibers of the oblique muscles of the abdomen. After making the incision and ligating all bleeding vessels, the operation is continued by first separating the posterior portion of the perirenal fascia from the lumbar muscles as far posteriorly as practical. A longitudinal incision is then made in the fascia about opposite the medial border of the kidney and is extended both upward and downward. A clean incision in the fascia permits it to be reflected forward and preserved for use in protecting and supporting the kidney when it has been placed in its bed. 1 Read at annual meeting, American Association of Genito-Urinary Surgeons, Stockbridge, Mass., June 12, 1943.
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A. I. DODSON
The fascia after having been divided is carefully dissected from the kidney and, together with the perirenal fat, is reflected medially, carrying before it the parietal peritoneum. These structures are retracted anteriorly, giving adequate exposure to the kidney and renal fossa. When adhesions from the perirenal fascia to the kidney are not readily separated by blunt dissection, they should be divided with scissors to prevent tearing the renal capsule. The kidney thus exposed is held by an assistant while the surgeon separates all adhesions from the lower pole of the kidney, beginning at the convex border and continuing around the lower pole until the ureteropelvic area is reached. Small blood vessels entering the lower pole are ligated and divided, but if a vessel is large enough to supply an extensive area of the kidney, it should be preserved. When the ureteropelvic area is reached, the ureter is identified and carefully liberated as far downward as can be done with safety. All adhesions are divided and any kinks or other obstructive lesions are corrected. Adhesions are then separated from the renal pelvis and the ureteropelvic area is examined. If there is stenosis of the pelvic orifice or high implantation of the ureter, an appropriate plastic operation should be done. After the lower pole, pelvis and ureter have been freed of adhesions, the assistant retracts the kidney downward, slightly elevating the upper pole while all fat and adhesions are separated from this area and from the vascular pedicle. The kidney is now ready to be fixed in place. The renal fossa is prepared by removing all fat and fascia from the lumbar muscles well above the costal margin. Occasionally, the liver encroaches upon this area and light adhesions must be broken up to permit the kidney to be placed in a sufficiently elevated position. Until recently I have combined the principles of the operations devised by Howard A. Kelly and Clyde L. Deming. Two suspending sutures are used. The first suture is placed at about the junction of the middle and lower thirds of the kidney and the second suture near the lower pole. These sutures are carried through the margin of the quadratus muscle, the first suture as high up as it can be conveniently placed and the second an appropriate distance below the first. After the kidney has been elevated in position and the sutures are pulled taut, the kidney elevator of the table is lowered and the kidney and ureter are again examined before the sutures are tied. To insure good drainage of the lower calyces the upper pole of the kidney should point a little medially and the lower pole outward. The ureter should be straight but not taut and there should be no tension on the vessels of the renal pedicle. If all is in good order, the suspending sutures are tied. The perirenal fascia and fat are then brought across the anterior surface of the kidney and sutured to the lumbar muscles immediately below the kidney. Two sutures are used, one about a centimeter external to the ureter and piercing the fascia near the edge of the peritoneum, and the other piercing the muscle and fascia about five centimeters lateral to the first suture. These sutures are placed beneath the lower pole of the kidney and when they are tied the space beneath the kidney is partly obliterated and the fascia forms a sling beneath the lower pole which gives additional support. A rubber tissue drain is then inserted behind the kidney and the wound is closed.
EXPERIENCES WITH DEMING NEPHROPEXY
517
For the past 3 years I have discontinued the use of the suspending sutures and depend entirely upon the perirenal fascia and fat to hold the kidney in position. No sutures are placed in the kidney or its capsule. The following paragraph is from Deming's description of the operation: "The perirenal fat is all stripped off the kidney which, with its vessels and ureter, is then delivered into the wound. It is important that all adhesions be removed from the upper as well as the lower pole. The ureter, which is either tortuous or badly kinked, should be made free. Special attention should be noted concerning the kidney fossa-whether shallow, absent or deep. The liver sometimes is adherent to the posterior abdominal wall so that it is impossible to place the kidney in its bed without freeing the right lobe. The hand should be inserted under the right lobe of the liver to the diaphragm. ·when this is done, the kidney can be replaced sufficiently high to remove all kinks and most of the tortuosities of the ureter. The kidney can be made to occupy practically an intrathoracic position with the lower pole lying opposite the last rib. The upper pole should be carried medially and the lower pole outward to give independent drainage to the lower calyx. With the kidney held in position a series of interrupted mattress sutures of No. 0 chromic catgut is placed through the perirenal fascia and peritoneum to the quadratus muscle. Perirenal fascia is always excessive so that it is easily approximated. Precautions must be taken not to include the bowel medially. The first stitch should be placed about 1 cm. from the ureter and as high as possible on the quadratus muscle posteriorly (fig. 1). Care should always be taken not to include any nerves in these sutures of chromic gut. A series of 5 to 8 sutures is necessary to close this aperture. These form a basket sling for the kidney so that it is impossible for the organ to descend (fig. 2). This row of sutures is now reinforced by bringing up all the extraperitoneal fat and suturing it with 2 or 3 mattress sutures to the quadratus muscle below the other line of sutures. This fat acts as a support and fills the space previously occupied by the kidney. The wound is then closed in layers with No. 2 plain catgut and the skin with interrupted silk without drainage." Deming's operation is certainly the most physiological of any so far devised. Neither the kidney nor its capsule is disturbed, and it is held in place at least in part by normal support. Adhesions certainly occur between the renal capsule and the kidney bed to help hold the kidney in place. In my experience removal of a portion of the capsule is not necessary for this purpose. From January 1940 until January 1941 eighteen patients were operated upon for the relief of renal ptosis. There were 3 males and 15 females. Their ages were from 13 to 52 years. The duration of symptoms varied from 1 to 10 years, the average was 4 years. Eight patients complained of repeated attacks of pyelitis, 2 were examined because of frequency of urination and a history of pyuria. The remaining 8 complained of pain in the loin and abdomen. Three of the 18 patients had had gastro-intestinal studies because of indigestion. The ptosis was complicated by stone in 2 patients and a plastic operation on the renal pelvis was necessary in 3. Sixteen patients have been entirely relieved of their symptoms. Two not entirely relieved, have general viceroptosis and have been treated for indigestion
518
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and abdominal pain for many years. They have both been relieved of the acute attacks of pain which before they -were operated upon occasionally required opiates. The following case reports arc characteristic of this group of patients.
Frn. 1. With the kidney held in position the first interrupted mattress suture is placed through the perirenal fascia and peritoneum to the quadratus muscle about one centimeter from the ureter. CASE REPORTS
Case 1. Mrs. A. H. H., 21 years of age, was admitted to St. Elizabeth's Hospital, January 11, 1940. She had suffered with frequency of urination for 5 years. At times she had had cloudy urine and burning on urination. About a month before her admission to the hospital, she had an acute atack of pyelitis while
EXPERIENCJ
519
visiting in Atlanta, and was examined by Dr. vV. E. Upchurch, who found that she had bilateral renal ptosis (fig. 3) and advised nephropexy because of the long history of urinary infection. January 12, the right kidney was operated upon. The operation combined the principles of the Kelly and Deming operation described in this paper. Ten days later the left kidney was suspended by the Deming method. The bilateral pyelogram taken in the upright position 3 weeks following the second operation
Fm. 2. The sutures have been placed and tied forming a sling of the fat and fascia which holds the kidney in a normal position. The wound is usually closed without drainage.
(fig. 4) shows both kidneys in good position and definite improvement in the appearance of the calyces. Following this experience the fixation sutures as employed by Kelly were abandoned as time-consuming and unnecessary. This patient has been entirely relieved of her discomfort and pyuria and has gained 20 pounds. Case 2. JVI. 0., female, aged 42 years, was admitted to the Hospital Division of the Medical College of Virginia August 1941, because of pain in the right
520
A. I. DODSON
lumbar area and right side of the abdomen. She had been pr,eyiously tadn;ritted twice because of the same complaint. A diagnmiis of right ,renal ptosis had been made and palliative treatment including a ptosis.belt had.been prescribed with very little benefit. She has been in almost constant pain for 2 years. The physical examination was negative except that she was under weight and the right kidney was palpaple and. tender. There was moderate, p}Tlµ'ia. Retrograde pyelogram with the. pa.tient. in.a,n upright position showed decided right renal ptosis (fig. 5). A nephropexy was done. She recovered rapidly and within 10 days was comfortable; The pyelogram made 1 month following operation (fig.
Frn. 3. Case I. Bilateral nephroptosis before operation
6) showed the kidney in good position. This patient, a frequent visitor to the out-patient clinic before operation, has remained free of pain for the past 2 years. Case 3. I. R., a 17 year old boy, was admitted to the Hospital Divison of the Medical College of Virginia in July 1942, because of pain in the right lumbar area and right upper quadrant of his abdomen. He had complained of indigestion and abdmninal pain for more than a year. An x-ray examination of his intestinal tract a yea;r before his admission to the hospital was negative. He stated that for several months when riding a horse he fastened a wide belt around his waist quite snugly to prevent pain in the right loin. An intravenous pyelogram was done because of pain in the right loin and pyuria. The left kidney appeared normal and the function of the right kidney was too poor to give a clear
EXPERIENCES vVITH DEMING NEPHROPEXY
Fm. 4 Fm. 5 Fm. 4. Case 1. Intravenous pyelogram one month following bilateral nephropexy FIG. 5. Case 2. Right renal ptosis before operation
FIG. 6. Case 2. Postoperative retrograde pyelogram
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outline of the renal pelvis. A retrograde pyelogram (fig. 7) done the day following his admission to the hospital showed slight ptosis and evidence of ureteropelvic obstruction. Following this pyelogram he became quite ill with high fever, rapid pulse, and muscle spasm over the right lumbar area. An effort to pass a catheter into the renal pelvis was unsuccessful. Immediate renal drainage was considered necessary. At operation the kidney was found greatly congested with a large pelvis distended with purulent urine. There was a definite kink at the ureteropelvic junction. After freeing the kidney of adhesions, the urine was aspirated from the renal pelvis through a large needle. A short
FIG. 7 FIG. 8 FIG. 7. Case 3. Preoperative pyelogram. There is moderate ptosis and' evidence of ureteropelvic obstruction. FIG. 8. Case 3. Intravenous urogram 3 months following ncphropexy and plastic operation on right ureteropelvic junction.
longitudinal incisi0n was made through the ureteropelvic area and a No. 10 urethral catheter was inserted down the ureter about 4 inches. The proximal end of the catheter was passed out through a stab wound in the posterior wall of the pelvis. A small window was cut in the portion of the catheter lying in the pelvis. The tip of a larger catheter was drawn into the pelvis through the renal parenchyma near the lower pole for additional drainage. The incision at the ureteropelvic junction was then closed transversely increasing the width of the pelvic orifice. A rubber tissue drain was placed behind the renal pelvis and a nephropexy was done. The patient's temperature which was 105 F. plus at the time of operation did not go above 102 F. the following day and was normal
EXPERIENCES Wrl'H DEMING NEPHROPEXY
523
within a week. An intravenous pyelogram done 3 months after the operation (fig. 8) showed the kidney in good position with good function and the urine was entirely normal. He returned to a military school in September 1942, and has taken part in the regular activities without discomfort of any kind. Case 4- L. W., a 13 year old girl, -was admitted to the Medical Service of the Hospital Division of the Medical College of Virginia, September 18, 1942, because of fever and pain in the right lower quadrant of the abdomen. The urine contained numerous pus cells. The patient gave a history of 4 similar attacks during
FIG. 9 FIG.10 FIG. 9. Case 4. Renal ptosis "·ith kinking of ureter and dilated renal pelvis FIG. 10. Case 4. Postoperative intravenous urogram. Note improvement in contour of the renal pelvis.
5 years previous to her admission to the hospital. The acute symptoms responded to rest in bed and the administration of sulfathiazole. An intravenous pyelogram showed definite dilatation of the right renal pelvis and a tortuous ureter. On October 12, she was transferred to the urological service, and aretrograde pyelogram was made of the right kidney with the patient in the upright position. There was definite ptosis of the kidney, dilatation of the renal pelvis with a tortuous irregularly dilated ureter (fig. 9). Two days later a nephropexy was done. The convalescence was uneventful and the pyelogram
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A. I. DODSON
made 3 weeks later showed the kidney in good position with definite reduction in the size of the renal pelvis (fig. 10). She was discharged entirely free of symptoms and has remained in excellent health.
Medical Arts Bldg., Richmond. Va. REFERENCES MATHE, CHARLES PIERRE: History of Urology (American Urological Assoc.). Baltimore: Williams & Wilkins Co., 1933, pp. 309-329. KELLY AND BURNAM: Diseases of the Kidneys, Ureters and Bladder, New York and London: D. Appleton and Co., vol. 1, pp. 504-518. DEMING, CLYDE LEROY: Nephroptosis and its correction. Trans. Am. A. Genito-Urin. Surg., 22: 131-147, 1929.
N ephroptosis has occupied a prominent place in urological literature since 1841 when Rayer described the movable kidney as a definite clinical entity with characteristic signs and symptoms. In 1881, Hahn performed the first nephropexy, resecting a portion of the fatty capsule and suturing the perirenal fat to the lumbar incision. Because of recurrences resulting from the rather loose attachment made by suturing the fatty capsule to the lumbar wound, Bassini modified Hahn's operation by taking sutures through the fibrous capsule of the kidney. Since Hahn's original operation was described, numerous methods of suturing the kidney in place have been devised; in fact papers on this subject usually present a new operation or some modification of an old operation. At the present time most surgeons who perform nephropexies fix the kidney by sutures through the intact or reflected capsule, by strips of fascia reflected from the renal capsule or nearby structures, or by suturing the perirenal fat and fascia to the lumbar muscles below the kidney. Any of these operations may be successful if the kidney is properly prepared and care is taken to suture it in its normal anatomical position. Operations upon the kidney are always followed by rather extensive adhesions. Actual recurrence of renal ptosis is rarely encountered. The poor results that follow nephropexy are usually from the improper selection of cases, from faulty technique in which some accessory pathologic condition is not corrected, or the kidney and ureter are not completely liberated. An important part of the operation is complete liberation of the upper ureter and pelvis and careful dissection of all perirenal fat and fascia from the kidney. The ptosed kidney is often complicated by adhesions to the ureter, by aberrant vessels or by ureteropelvic pathologic lesion. When there are no such complications, pronounced degrees of renal mobility are often found in which the kidney empties normally with no discomfort to the patient. Regardless of the method of suspension to be used, the preparation of the kidney and its bed is the same. Adequate exposure is necessary so that the kidney, the upper portion of the ureter, and the renal fossa can be easily seen. An ample curved lumbar incision is usually more satisfactory, though it is rarely necessary to divide the posterior fibers of the oblique muscles of the abdomen. After making the incision and ligating all bleeding vessels, the operation is continued by first separating the posterior portion of the perirenal fascia from the lumbar muscles as far posteriorly as practical. A longitudinal incision is then made in the fascia about opposite the medial border of the kidney and is extended both upward and downward. A clean incision in the fascia permits it to be reflected forward and preserved for use in protecting and supporting the kidney when it has been placed in its bed. 1 Read at annual meeting, American Association of Genito-Urinary Surgeons, Stockbridge, Mass., June 12, 1943.
515
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A. I. DODSON
The fascia after having been divided is carefully dissected from the kidney and, together with the perirenal fat, is reflected medially, carrying before it the parietal peritoneum. These structures are retracted anteriorly, giving adequate exposure to the kidney and renal fossa. When adhesions from the perirenal fascia to the kidney are not readily separated by blunt dissection, they should be divided with scissors to prevent tearing the renal capsule. The kidney thus exposed is held by an assistant while the surgeon separates all adhesions from the lower pole of the kidney, beginning at the convex border and continuing around the lower pole until the ureteropelvic area is reached. Small blood vessels entering the lower pole are ligated and divided, but if a vessel is large enough to supply an extensive area of the kidney, it should be preserved. When the ureteropelvic area is reached, the ureter is identified and carefully liberated as far downward as can be done with safety. All adhesions are divided and any kinks or other obstructive lesions are corrected. Adhesions are then separated from the renal pelvis and the ureteropelvic area is examined. If there is stenosis of the pelvic orifice or high implantation of the ureter, an appropriate plastic operation should be done. After the lower pole, pelvis and ureter have been freed of adhesions, the assistant retracts the kidney downward, slightly elevating the upper pole while all fat and adhesions are separated from this area and from the vascular pedicle. The kidney is now ready to be fixed in place. The renal fossa is prepared by removing all fat and fascia from the lumbar muscles well above the costal margin. Occasionally, the liver encroaches upon this area and light adhesions must be broken up to permit the kidney to be placed in a sufficiently elevated position. Until recently I have combined the principles of the operations devised by Howard A. Kelly and Clyde L. Deming. Two suspending sutures are used. The first suture is placed at about the junction of the middle and lower thirds of the kidney and the second suture near the lower pole. These sutures are carried through the margin of the quadratus muscle, the first suture as high up as it can be conveniently placed and the second an appropriate distance below the first. After the kidney has been elevated in position and the sutures are pulled taut, the kidney elevator of the table is lowered and the kidney and ureter are again examined before the sutures are tied. To insure good drainage of the lower calyces the upper pole of the kidney should point a little medially and the lower pole outward. The ureter should be straight but not taut and there should be no tension on the vessels of the renal pedicle. If all is in good order, the suspending sutures are tied. The perirenal fascia and fat are then brought across the anterior surface of the kidney and sutured to the lumbar muscles immediately below the kidney. Two sutures are used, one about a centimeter external to the ureter and piercing the fascia near the edge of the peritoneum, and the other piercing the muscle and fascia about five centimeters lateral to the first suture. These sutures are placed beneath the lower pole of the kidney and when they are tied the space beneath the kidney is partly obliterated and the fascia forms a sling beneath the lower pole which gives additional support. A rubber tissue drain is then inserted behind the kidney and the wound is closed.
EXPERIENCES WITH DEMING NEPHROPEXY
517
For the past 3 years I have discontinued the use of the suspending sutures and depend entirely upon the perirenal fascia and fat to hold the kidney in position. No sutures are placed in the kidney or its capsule. The following paragraph is from Deming's description of the operation: "The perirenal fat is all stripped off the kidney which, with its vessels and ureter, is then delivered into the wound. It is important that all adhesions be removed from the upper as well as the lower pole. The ureter, which is either tortuous or badly kinked, should be made free. Special attention should be noted concerning the kidney fossa-whether shallow, absent or deep. The liver sometimes is adherent to the posterior abdominal wall so that it is impossible to place the kidney in its bed without freeing the right lobe. The hand should be inserted under the right lobe of the liver to the diaphragm. ·when this is done, the kidney can be replaced sufficiently high to remove all kinks and most of the tortuosities of the ureter. The kidney can be made to occupy practically an intrathoracic position with the lower pole lying opposite the last rib. The upper pole should be carried medially and the lower pole outward to give independent drainage to the lower calyx. With the kidney held in position a series of interrupted mattress sutures of No. 0 chromic catgut is placed through the perirenal fascia and peritoneum to the quadratus muscle. Perirenal fascia is always excessive so that it is easily approximated. Precautions must be taken not to include the bowel medially. The first stitch should be placed about 1 cm. from the ureter and as high as possible on the quadratus muscle posteriorly (fig. 1). Care should always be taken not to include any nerves in these sutures of chromic gut. A series of 5 to 8 sutures is necessary to close this aperture. These form a basket sling for the kidney so that it is impossible for the organ to descend (fig. 2). This row of sutures is now reinforced by bringing up all the extraperitoneal fat and suturing it with 2 or 3 mattress sutures to the quadratus muscle below the other line of sutures. This fat acts as a support and fills the space previously occupied by the kidney. The wound is then closed in layers with No. 2 plain catgut and the skin with interrupted silk without drainage." Deming's operation is certainly the most physiological of any so far devised. Neither the kidney nor its capsule is disturbed, and it is held in place at least in part by normal support. Adhesions certainly occur between the renal capsule and the kidney bed to help hold the kidney in place. In my experience removal of a portion of the capsule is not necessary for this purpose. From January 1940 until January 1941 eighteen patients were operated upon for the relief of renal ptosis. There were 3 males and 15 females. Their ages were from 13 to 52 years. The duration of symptoms varied from 1 to 10 years, the average was 4 years. Eight patients complained of repeated attacks of pyelitis, 2 were examined because of frequency of urination and a history of pyuria. The remaining 8 complained of pain in the loin and abdomen. Three of the 18 patients had had gastro-intestinal studies because of indigestion. The ptosis was complicated by stone in 2 patients and a plastic operation on the renal pelvis was necessary in 3. Sixteen patients have been entirely relieved of their symptoms. Two not entirely relieved, have general viceroptosis and have been treated for indigestion
518
A. I. DODSOK
and abdominal pain for many years. They have both been relieved of the acute attacks of pain which before they -were operated upon occasionally required opiates. The following case reports arc characteristic of this group of patients.
Frn. 1. With the kidney held in position the first interrupted mattress suture is placed through the perirenal fascia and peritoneum to the quadratus muscle about one centimeter from the ureter. CASE REPORTS
Case 1. Mrs. A. H. H., 21 years of age, was admitted to St. Elizabeth's Hospital, January 11, 1940. She had suffered with frequency of urination for 5 years. At times she had had cloudy urine and burning on urination. About a month before her admission to the hospital, she had an acute atack of pyelitis while
EXPERIENCJ
519
visiting in Atlanta, and was examined by Dr. vV. E. Upchurch, who found that she had bilateral renal ptosis (fig. 3) and advised nephropexy because of the long history of urinary infection. January 12, the right kidney was operated upon. The operation combined the principles of the Kelly and Deming operation described in this paper. Ten days later the left kidney was suspended by the Deming method. The bilateral pyelogram taken in the upright position 3 weeks following the second operation
Fm. 2. The sutures have been placed and tied forming a sling of the fat and fascia which holds the kidney in a normal position. The wound is usually closed without drainage.
(fig. 4) shows both kidneys in good position and definite improvement in the appearance of the calyces. Following this experience the fixation sutures as employed by Kelly were abandoned as time-consuming and unnecessary. This patient has been entirely relieved of her discomfort and pyuria and has gained 20 pounds. Case 2. JVI. 0., female, aged 42 years, was admitted to the Hospital Division of the Medical College of Virginia August 1941, because of pain in the right
520
A. I. DODSON
lumbar area and right side of the abdomen. She had been pr,eyiously tadn;ritted twice because of the same complaint. A diagnmiis of right ,renal ptosis had been made and palliative treatment including a ptosis.belt had.been prescribed with very little benefit. She has been in almost constant pain for 2 years. The physical examination was negative except that she was under weight and the right kidney was palpaple and. tender. There was moderate, p}Tlµ'ia. Retrograde pyelogram with the. pa.tient. in.a,n upright position showed decided right renal ptosis (fig. 5). A nephropexy was done. She recovered rapidly and within 10 days was comfortable; The pyelogram made 1 month following operation (fig.
Frn. 3. Case I. Bilateral nephroptosis before operation
6) showed the kidney in good position. This patient, a frequent visitor to the out-patient clinic before operation, has remained free of pain for the past 2 years. Case 3. I. R., a 17 year old boy, was admitted to the Hospital Divison of the Medical College of Virginia in July 1942, because of pain in the right lumbar area and right upper quadrant of his abdomen. He had complained of indigestion and abdmninal pain for more than a year. An x-ray examination of his intestinal tract a yea;r before his admission to the hospital was negative. He stated that for several months when riding a horse he fastened a wide belt around his waist quite snugly to prevent pain in the right loin. An intravenous pyelogram was done because of pain in the right loin and pyuria. The left kidney appeared normal and the function of the right kidney was too poor to give a clear
EXPERIENCES vVITH DEMING NEPHROPEXY
Fm. 4 Fm. 5 Fm. 4. Case 1. Intravenous pyelogram one month following bilateral nephropexy FIG. 5. Case 2. Right renal ptosis before operation
FIG. 6. Case 2. Postoperative retrograde pyelogram
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A. I. DODSON
outline of the renal pelvis. A retrograde pyelogram (fig. 7) done the day following his admission to the hospital showed slight ptosis and evidence of ureteropelvic obstruction. Following this pyelogram he became quite ill with high fever, rapid pulse, and muscle spasm over the right lumbar area. An effort to pass a catheter into the renal pelvis was unsuccessful. Immediate renal drainage was considered necessary. At operation the kidney was found greatly congested with a large pelvis distended with purulent urine. There was a definite kink at the ureteropelvic junction. After freeing the kidney of adhesions, the urine was aspirated from the renal pelvis through a large needle. A short
FIG. 7 FIG. 8 FIG. 7. Case 3. Preoperative pyelogram. There is moderate ptosis and' evidence of ureteropelvic obstruction. FIG. 8. Case 3. Intravenous urogram 3 months following ncphropexy and plastic operation on right ureteropelvic junction.
longitudinal incisi0n was made through the ureteropelvic area and a No. 10 urethral catheter was inserted down the ureter about 4 inches. The proximal end of the catheter was passed out through a stab wound in the posterior wall of the pelvis. A small window was cut in the portion of the catheter lying in the pelvis. The tip of a larger catheter was drawn into the pelvis through the renal parenchyma near the lower pole for additional drainage. The incision at the ureteropelvic junction was then closed transversely increasing the width of the pelvic orifice. A rubber tissue drain was placed behind the renal pelvis and a nephropexy was done. The patient's temperature which was 105 F. plus at the time of operation did not go above 102 F. the following day and was normal
EXPERIENCES Wrl'H DEMING NEPHROPEXY
523
within a week. An intravenous pyelogram done 3 months after the operation (fig. 8) showed the kidney in good position with good function and the urine was entirely normal. He returned to a military school in September 1942, and has taken part in the regular activities without discomfort of any kind. Case 4- L. W., a 13 year old girl, -was admitted to the Medical Service of the Hospital Division of the Medical College of Virginia, September 18, 1942, because of fever and pain in the right lower quadrant of the abdomen. The urine contained numerous pus cells. The patient gave a history of 4 similar attacks during
FIG. 9 FIG.10 FIG. 9. Case 4. Renal ptosis "·ith kinking of ureter and dilated renal pelvis FIG. 10. Case 4. Postoperative intravenous urogram. Note improvement in contour of the renal pelvis.
5 years previous to her admission to the hospital. The acute symptoms responded to rest in bed and the administration of sulfathiazole. An intravenous pyelogram showed definite dilatation of the right renal pelvis and a tortuous ureter. On October 12, she was transferred to the urological service, and aretrograde pyelogram was made of the right kidney with the patient in the upright position. There was definite ptosis of the kidney, dilatation of the renal pelvis with a tortuous irregularly dilated ureter (fig. 9). Two days later a nephropexy was done. The convalescence was uneventful and the pyelogram
524
A. I. DODSON
made 3 weeks later showed the kidney in good position with definite reduction in the size of the renal pelvis (fig. 10). She was discharged entirely free of symptoms and has remained in excellent health.
Medical Arts Bldg., Richmond. Va. REFERENCES MATHE, CHARLES PIERRE: History of Urology (American Urological Assoc.). Baltimore: Williams & Wilkins Co., 1933, pp. 309-329. KELLY AND BURNAM: Diseases of the Kidneys, Ureters and Bladder, New York and London: D. Appleton and Co., vol. 1, pp. 504-518. DEMING, CLYDE LEROY: Nephroptosis and its correction. Trans. Am. A. Genito-Urin. Surg., 22: 131-147, 1929.