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Translumbar Nephrocolopexy
TuB JOURNAL OF UROLOGY
YoL 66, No. 2, August 1951 Printed in U.S.A.
TRANSL UMBAR NEPHROCOLOPEXY FRANCISCO BARQUIN Prom the Department of Urology, JIIilitary Hospital, Havana, Cuba
The fact that a few of the cases operated on by us for nephroptosis returned complaining that they were not free of their symptoms, prompted us to carry out a more complete study in all these cases. In all suspected case of nephroptosis, we take a minute history; and, besides the routine urological examination, we do a gastro-intestinal series and barium enemas. vVe have observed that tbese patients are nervous individuals and their usual complaints are: loss of weight, gastric distress, constipation, and loss of appetite, besides the cardinal symptom of nephralgia. In this study vve observed tbat nephroptosis is not uncommonly associated with enteroptosis (Glenard's disease) or a displacement downward of the colon, particularly in women, in whom these conditions are more prevalent. This observation prompted us to devise the operation, translumbar nephrocolopexy. The technique is the usual lumbar incision and the Lowsley ribbon gut technique is carried out for the nephropexy (figs. 1 to 5). Following tbis procedure, the peritoneum is opened, the appendix is removed, the anterior band of the ascending colon is identified and is followed upwards the distance of 6 to 8 inches to the point where it turns, which corresponds with the hepatic flexure of the colon (fig. 6). The anterior band at the level of the hepatic angle is sutured, using State suture material, to the superior angle of the peritoneal wound and to the ribbon gut at the inferior pole of the kidney. In the past 4 years, we have performed this operation on 67 cases, all of them women between the ages of 20 and 45 years, and weighing between 80 and 110 pounds. All were improved clinically, and the gain in weight ranged between 11 and 45 pounds. I ·wish to present for your consideration some illustrations of these cases, before and after the operation (figs. 7 to 12). SUMMARY
It has been shown by the postoperative study presented that the kidney and hepatic angle of the colon have been restored to their normal anatomical position by the technique of transl um bar nephrocolopexy. The observation has been tbat patients' general health improves as shown the gain in weight of 11 to 45 pounds, and the fact that these patients have been free of symptoms while we have had them under observation. Coincidentally, it has been shown that nephroptosis is frequently associated with a displaced colon; and that this condition is more prevalent in women. Read at annual meeting, Southeastern Section, American Urological Association, Gulfport, Miss., February 3, 1950. 173
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FRANCISCO BARQUIN
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Fm. 1. Nephropexy using chromicized ribbon gut. 1, Lumbar skin incision. 2, Kidney has been mobilized and delivered. Incising fibrous capsule of kidney. 3, Freeing capsule so as to expose about one sixth of renal surface. (From Lowsley and Kirwin: Clinical Urology. Baltimore: Williams & Wilkins, 1944.)
TRANSLUMBAR NEPHROCOLOPEXY
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Fm. 2. 1 to 4, Making incisions in fibrous capsule, at upper and lower poles, to hold ribbon gut in position. 5, Chromic ribbon gut with needle attached. 6, Ribbon gut in position about lower pole. Drawing gut through incisions in upper pole. (From Lowsley and Kirwin.)
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Fm. 3. Showing ribbon gut in position about two poles of kidney. One of strand about upper pole is tied to free end of strand about lower pole to hold two slings firmly in position when tension is made. (From Lowsley and Kirwin.)
Fm. 4. Needle studded end of upper sling of ribbon gut has been inserted through twelfth intercostal space, drawing kidney with its partly denuded cortex upward; it has then been firmly tied, so that the kidney is held in high position. Needle-studded end of lower sling is being drawn through quadratus lumborum muscle. (From Lowsley and Kirwin.)
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Fm. 5. Operation completed. Kidney drawn upward and outward, with urete · free and straight. (From Lowsley and Kirwin.)
Fm. 6. A, peritoneum is opened and appendix removed; B, anterior band of ascending colon is followed to hepatic flexure and sutured to superior angle of peritoneal wound and to ribbon gut at inferior pole of kidney; C, nephrocolopexy has been ended.
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FRANCISCO BARQUIN
Frn. 7. Case 1. A, preoperative vertical film. Marked ptosis of right kidney. B, hepatic angle of colon in iliac fossa. C, postoperative film, vertical position. Right kidney of hepatic angle of colon in normal position. Case 2. A, preoperative vertical film. Right renal pelvis at level of body of fourth lumbar vertebra. Hepatic angle of colon, full of gas, over iliac crest. B and C, postoperative films, vertical position. Right kidney in normal position. Hepatic angle of colon, full of gas, over lower third of anterior aspect of kidney.
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Fm. 8. Case 3. A, preoperative vertical film. Mild ptosis of right kidney. B, hepatic angle of colon under right iliac crest. C, postoperative film, vertical position. Right renal pelvis in normal position, but not so hepatic angle of colon, which was fixed a little low during colopexy. Case 4. A, preoperative vertical film. Lower pole of kidney just above iliac crest. B, hepatic angle of colon just above iliac crest. C, postoperative film, vertical position. Right kidney and hepatic angle of colon both in normal position.
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FRANCISCO BARQUfN
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Fm. 9. Case 5. A, preopenit1ve vertical film. Marked ptosis of right kidney. Hepatic angle of colon above iliac crest. B, postoperative film, vertical position. Right kidney and hepatic angle of colon in normal position. Case 6. A, preoperative vertical film. Inferior pole of right renal silhouette touching iliac crest. Transverse colon and its hepatic angle, both full of barium, very ptotic at bottom of pelvic vone. B, postoperative vertical film. Transverse colon and its hepatic angle quite elevated, especially at angle, which is ampl:i, in contact with rear aspect of kidney. C, no change in film taken 6 months later.
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Fm. 10. Case 7. A, preoperative vertical film. Marked ptosis of right kidney and hepatic angle of colon. B, postoperative film, vertical position. Right kidney and its hepatic angl0 in normal position. Case 8. A, preoperative vertical film. Mild ptosis of right kidney. B, postoperative film, vertical position. Right kidney and hepatic angle considerably raised. C, film taken 23 days after discharge of patient. Colon and right kidney still in normal position.
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FRANCISCO BARQUIN
Fm. 11. Case 9. A, preoperative vertical film. Right renal pelvis at level of body of fourth lumbar vertebra. B, lower pole of right kidney at iliac crest; hepatic angle of colon in right iliac fossa. C, postoperative film, vertical position. Right kidney in normal position. Hepatic angle of colon above anterior aspect of kidney. Case 10. A, preoperative vertical film. Right renal pelvis, slightly ptotic, at level of body of third lumbar vertebra. On left side, marked ptosis of kidney. Transverse colon (indicated by arrows) on floor of pelvis. B, film taken 10 hours after ingestion of barium show ing same result. C, postoperative film, vertical position. Right kidney only slightly raised. Hepatic angle of colon correctly sutured to middle section of anterior aspect of kidney. 0
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Fm. 12. Case 11. A, preoperative vertical film. Bilateral renal ptosis and kink of left ureter. B, transverse colon, hammock fashion, on floor of pelvis. Hepatic angle at level of iliac crest together with kidney. C, postoperative vertical film. Good result, right kidney being fixed high at level of third lumbar vertebra. D, hepatic angle of colon, high above iliac crest, fixed at middle section of anterior aspect of right kidney.
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FRANCISCO BARQUIN
REFERENCES BANET, V.: Clinica y Terapeutica Quirugicas. Havana, 1938, pp. 123-131. DoDSON, A. I.: Urological Surgery. St. Louis: C. V. Mosby Co., 1944, pp. 239-'240. GAzzoLo, J. J.: Trat. de las Enf. Genitourinarias, 1944, pp. 948-960. HERMAN, L.: The Practice of Urology. Philadelphia: W. B. Saunders Co., 1945, pp. 179-18R. LowsLEY, 0. S. AND Krnwrn, T. J.: Clinical Urology. Baltimore: Williams & Wilkins, 1944, . vol. 1, pp. 141-149; vol. 2, pp. 339-472, 682. MARION, G.: Tecnica Quirurgica. 1932, vol. 2, pp. 188-193. PELOUZE, P. S.: Office Urology. Philadelphia: W. B. Saunders Co., 1941, pp. 518-520.
YoL 66, No. 2, August 1951 Printed in U.S.A.
TRANSL UMBAR NEPHROCOLOPEXY FRANCISCO BARQUIN Prom the Department of Urology, JIIilitary Hospital, Havana, Cuba
The fact that a few of the cases operated on by us for nephroptosis returned complaining that they were not free of their symptoms, prompted us to carry out a more complete study in all these cases. In all suspected case of nephroptosis, we take a minute history; and, besides the routine urological examination, we do a gastro-intestinal series and barium enemas. vVe have observed that tbese patients are nervous individuals and their usual complaints are: loss of weight, gastric distress, constipation, and loss of appetite, besides the cardinal symptom of nephralgia. In this study vve observed tbat nephroptosis is not uncommonly associated with enteroptosis (Glenard's disease) or a displacement downward of the colon, particularly in women, in whom these conditions are more prevalent. This observation prompted us to devise the operation, translumbar nephrocolopexy. The technique is the usual lumbar incision and the Lowsley ribbon gut technique is carried out for the nephropexy (figs. 1 to 5). Following tbis procedure, the peritoneum is opened, the appendix is removed, the anterior band of the ascending colon is identified and is followed upwards the distance of 6 to 8 inches to the point where it turns, which corresponds with the hepatic flexure of the colon (fig. 6). The anterior band at the level of the hepatic angle is sutured, using State suture material, to the superior angle of the peritoneal wound and to the ribbon gut at the inferior pole of the kidney. In the past 4 years, we have performed this operation on 67 cases, all of them women between the ages of 20 and 45 years, and weighing between 80 and 110 pounds. All were improved clinically, and the gain in weight ranged between 11 and 45 pounds. I ·wish to present for your consideration some illustrations of these cases, before and after the operation (figs. 7 to 12). SUMMARY
It has been shown by the postoperative study presented that the kidney and hepatic angle of the colon have been restored to their normal anatomical position by the technique of transl um bar nephrocolopexy. The observation has been tbat patients' general health improves as shown the gain in weight of 11 to 45 pounds, and the fact that these patients have been free of symptoms while we have had them under observation. Coincidentally, it has been shown that nephroptosis is frequently associated with a displaced colon; and that this condition is more prevalent in women. Read at annual meeting, Southeastern Section, American Urological Association, Gulfport, Miss., February 3, 1950. 173
174
FRANCISCO BARQUIN
11\h.rib
Skm 1nc1s1on
Fm. 1. Nephropexy using chromicized ribbon gut. 1, Lumbar skin incision. 2, Kidney has been mobilized and delivered. Incising fibrous capsule of kidney. 3, Freeing capsule so as to expose about one sixth of renal surface. (From Lowsley and Kirwin: Clinical Urology. Baltimore: Williams & Wilkins, 1944.)
TRANSLUMBAR NEPHROCOLOPEXY
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175
-
lnci
Tirawi1:~ ribb
thru
lnCIS10!1'$
in capeule
Fm. 2. 1 to 4, Making incisions in fibrous capsule, at upper and lower poles, to hold ribbon gut in position. 5, Chromic ribbon gut with needle attached. 6, Ribbon gut in position about lower pole. Drawing gut through incisions in upper pole. (From Lowsley and Kirwin.)
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Fm. 3. Showing ribbon gut in position about two poles of kidney. One of strand about upper pole is tied to free end of strand about lower pole to hold two slings firmly in position when tension is made. (From Lowsley and Kirwin.)
Fm. 4. Needle studded end of upper sling of ribbon gut has been inserted through twelfth intercostal space, drawing kidney with its partly denuded cortex upward; it has then been firmly tied, so that the kidney is held in high position. Needle-studded end of lower sling is being drawn through quadratus lumborum muscle. (From Lowsley and Kirwin.)
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Fm. 5. Operation completed. Kidney drawn upward and outward, with urete · free and straight. (From Lowsley and Kirwin.)
Fm. 6. A, peritoneum is opened and appendix removed; B, anterior band of ascending colon is followed to hepatic flexure and sutured to superior angle of peritoneal wound and to ribbon gut at inferior pole of kidney; C, nephrocolopexy has been ended.
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FRANCISCO BARQUIN
Frn. 7. Case 1. A, preoperative vertical film. Marked ptosis of right kidney. B, hepatic angle of colon in iliac fossa. C, postoperative film, vertical position. Right kidney of hepatic angle of colon in normal position. Case 2. A, preoperative vertical film. Right renal pelvis at level of body of fourth lumbar vertebra. Hepatic angle of colon, full of gas, over iliac crest. B and C, postoperative films, vertical position. Right kidney in normal position. Hepatic angle of colon, full of gas, over lower third of anterior aspect of kidney.
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Fm. 8. Case 3. A, preoperative vertical film. Mild ptosis of right kidney. B, hepatic angle of colon under right iliac crest. C, postoperative film, vertical position. Right renal pelvis in normal position, but not so hepatic angle of colon, which was fixed a little low during colopexy. Case 4. A, preoperative vertical film. Lower pole of kidney just above iliac crest. B, hepatic angle of colon just above iliac crest. C, postoperative film, vertical position. Right kidney and hepatic angle of colon both in normal position.
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FRANCISCO BARQUfN
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Fm. 9. Case 5. A, preopenit1ve vertical film. Marked ptosis of right kidney. Hepatic angle of colon above iliac crest. B, postoperative film, vertical position. Right kidney and hepatic angle of colon in normal position. Case 6. A, preoperative vertical film. Inferior pole of right renal silhouette touching iliac crest. Transverse colon and its hepatic angle, both full of barium, very ptotic at bottom of pelvic vone. B, postoperative vertical film. Transverse colon and its hepatic angle quite elevated, especially at angle, which is ampl:i, in contact with rear aspect of kidney. C, no change in film taken 6 months later.
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Fm. 10. Case 7. A, preoperative vertical film. Marked ptosis of right kidney and hepatic angle of colon. B, postoperative film, vertical position. Right kidney and its hepatic angl0 in normal position. Case 8. A, preoperative vertical film. Mild ptosis of right kidney. B, postoperative film, vertical position. Right kidney and hepatic angle considerably raised. C, film taken 23 days after discharge of patient. Colon and right kidney still in normal position.
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FRANCISCO BARQUIN
Fm. 11. Case 9. A, preoperative vertical film. Right renal pelvis at level of body of fourth lumbar vertebra. B, lower pole of right kidney at iliac crest; hepatic angle of colon in right iliac fossa. C, postoperative film, vertical position. Right kidney in normal position. Hepatic angle of colon above anterior aspect of kidney. Case 10. A, preoperative vertical film. Right renal pelvis, slightly ptotic, at level of body of third lumbar vertebra. On left side, marked ptosis of kidney. Transverse colon (indicated by arrows) on floor of pelvis. B, film taken 10 hours after ingestion of barium show ing same result. C, postoperative film, vertical position. Right kidney only slightly raised. Hepatic angle of colon correctly sutured to middle section of anterior aspect of kidney. 0
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Fm. 12. Case 11. A, preoperative vertical film. Bilateral renal ptosis and kink of left ureter. B, transverse colon, hammock fashion, on floor of pelvis. Hepatic angle at level of iliac crest together with kidney. C, postoperative vertical film. Good result, right kidney being fixed high at level of third lumbar vertebra. D, hepatic angle of colon, high above iliac crest, fixed at middle section of anterior aspect of right kidney.
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FRANCISCO BARQUIN
REFERENCES BANET, V.: Clinica y Terapeutica Quirugicas. Havana, 1938, pp. 123-131. DoDSON, A. I.: Urological Surgery. St. Louis: C. V. Mosby Co., 1944, pp. 239-'240. GAzzoLo, J. J.: Trat. de las Enf. Genitourinarias, 1944, pp. 948-960. HERMAN, L.: The Practice of Urology. Philadelphia: W. B. Saunders Co., 1945, pp. 179-18R. LowsLEY, 0. S. AND Krnwrn, T. J.: Clinical Urology. Baltimore: Williams & Wilkins, 1944, . vol. 1, pp. 141-149; vol. 2, pp. 339-472, 682. MARION, G.: Tecnica Quirurgica. 1932, vol. 2, pp. 188-193. PELOUZE, P. S.: Office Urology. Philadelphia: W. B. Saunders Co., 1941, pp. 518-520.