RU2528642C2 - Method of treating patients with nephroptosis combined with renal rotation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, specifically to surgery. A kidney is mobilised from a lumbotomy approach. An upper pole of the kidney is pre-fixed with a muscle flap from a psoas muscle. It is delivered in a subcapsular tunnel formed in the upper pole of the kidney. The flap is sutured to a renal capsule. The muscle flap is cut out of the psoas muscle. The subcapsular tunnels are formed on posterior and anterior surfaces of a lower pole of the kidney. The muscle flap is delivered in the tunnels. The flap is sutured to the renal capsule.

EFFECT: method provides maintaining the physiological mobility in treating the patients with a flail kidney in a combination with the rotation.

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Description

The invention relates to medicine, namely to surgery and urology, and can be used in the treatment of patients with a pathologically mobile kidney, in combination with rotation, to maintain physiological mobility, on the one hand, which is necessary for normal kidney function, on the other hand, fixation upper pole, prevents the rotation of the kidney.

There are several types and modifications of nephropexy - fixation of the kidney with its pathological mobility. Currently, the method of fixing the kidney with the help of a muscle flap cut from the lumbar muscle has found wide application [Urology, Moscow, 1997, edited by N. A. Lopatkina, p. 143]. In the patient’s position on a healthy side with an extended hypochondrium, a lumbotomy is performed according to Fedorov, retroperitoneal space is exposed in layers. The kidney is bluntly and sharply freed from planar adhesions and adhesions. The kidney is exposed and carefully mobilized. After this, the kidney is pushed back and thrown back medially, exposing its posterior surface. At the level of the middle part of the kidney, a renal capsule is incised in the transverse direction, 2-2.5 cm long, and with a direct instrument they form a tunnel to the lower pole. In the region of the lower pole at the end of the tunnel formed along the back surface, a capsule is also cut 2-2.5 cm long, from which a tunnel is formed like the first, but along the front surface, ending slightly lower than the middle part of the kidney. Thus, a hook-shaped tunnel is formed in the subcapsular space of the kidney. From the medial part of the lumbar muscle, a flap on a leg is cut out with a width of 1-1.5 cm and a length of 8-10 cm. A muscle flap is crossed at the level of transition of the muscle into the tendon component. The free distal end of the muscle flap is ligated with catgut thread and inserted into the tunnel under the fibrous capsule along the posterior surface of the kidney, around the lower pole and out through the hole in the fibrous capsule along the front surface. A muscle flap is attached to the kidney capsule with sutures from absorbable suture material, on both sides of all incisions applied to the capsule.

The disadvantages of the method: there is a likelihood of a relapse of nephroptosis; the possibility of rotation of the kidney in the frontal plane is not excluded, which causes "twisting" of the vascular pedicle with subsequent ischemia and atrophy of the organ in 5-8% of cases [Shpilenya ES Surgical treatment of nephroptosis. - Abstract. dis. Cand. honey. sciences. L., 1988]; when combined with kidney rotation, it is possible to maintain violations of the urodynamics of the upper urinary tract (UMP), which is the cause of recurrent pyelonephritis, leads to the development of urolithiasis, the preservation of pain. In the postoperative period, hypertension often persists.

Modifications of the nephropexy method according to Rivoir-Pytel-Lopatkin are known. One of the modifications is the method in which a polypropylene mesh is used [Meshkov S.V., Polutin B.V. Patent for invention No. 2411916 RU, published on 04/20/2004]. A synthetic implant is sewn at one end to the lumbar muscle, then the lower pole of the kidney is wrapped and the free end of the tape is fixed to the front surface of the kidney. However, when using this material there are a number of disadvantages. The use of a polypropylene prosthesis leads to the formation of a dense infiltrate in the fixation zone with an outcome in a coarse deforming scar. The contact of the lumbar muscles with the polypropylene network causes a dense fusion of muscle fibers with synthetic material, which leads to a violation of their function. In addition, the mesh implant, having a different thickness due to the intersection of individual threads, has a traumatic effect, which can be compared with the effect of a “grater” that damages the kidney capsule in the fixation zone. This leads to compression, disrupts blood circulation, is accompanied by the development of chronic inflammation and the threat of malignancy.

Another known modification is a method of treating nephroptosis by suturing the prerenal fascia to the square lumbar muscle with the formation of a suspension [Deming, Urologic surgery. Editor J.F. Glenn. Third edition, 1983, P.253-254]. The essence of the method consists in performing a lumbar incision, exposing a kidney and reponing it in an orthotopic position. Sutures in an amount of 5 to 8 fix the prerenal fascia to the square lumbar muscle.

However, this method has a significant drawback, namely, that its implementation does not provide sufficient efficiency of nephropexy in the orthotopic position, since inertial overloads on the mating edges of the muscle and fascia during caudal or rotational displacements of the kidney can exceed acceptable values and cause relapse of nephroptosis or obstructive uropathy, which leads to the formation of hydronephrosis. The above method of nephropexy can cause pathological rotation of the kidney, since there is no suture fixation mechanism with a uniform load distribution on the front surface of the kidney.

The technical result is the development of a method to improve the reliability of nephropexy, to eliminate the likelihood of pathological rotation of the kidney while maintaining its physiological mobility.

The technical result is achieved by performing nephropexy according to Rivoir-Pytel-Lopatkin [Urology, Moscow, 1997, edited by N. A. Lopatkina, p.143] with the modifications developed by us.

Clinical experience suggests that patients with nephroptosis in combination with kidney rotation fixation using classical technology is not enough. We have developed an addition to the standard technology, which is the presence of a preliminary stage. For its implementation, fixation of the upper pole of the kidney is performed with a muscle flap on the leg. In this case, the flap is taken from the lumbar muscle, it is carried out in a subcapsular tunnel, previously formed in the upper pole of the kidney. The stage of additional fixation of the upper pole of the kidney that we developed is performed as follows.

First, from the lumbar muscle, a muscle flap is cut out on the leg, up to 1.5 cm wide and 8 cm long, FIGS. 1, 2 (1). In the region of the upper pole of FIGS. 1, 2 (2), a capsule is cut 2-2.5 cm long, from which a tunnel is formed that goes to the front surface of the kidney, reaching the border of the upper and middle third of the kidney of FIGS. 1, 2 (3) . The free distal end of the upper muscle flap is ligated with catgut thread and inserted into the tunnel under the fibrous capsule along the front surface of the upper pole of the kidney, bend around the upper pole and bring it out through the hole in the fibrous capsule along the front surface of FIG. 2 (9). The upper muscle flap is attached to the kidney capsule with sutures, on both sides of all incisions applied to the capsule using absorbable suture material.

At the end of the operation, the perimisium of the lumbar muscle is sutured with separate sutures from the absorbable suture material of FIG. 2 (7). Drainage into the retroperitoneal space is discharged through contraperture. After this, the wound is sutured tightly. The main condition for the success of the nephropexy operation is thorough hemostasis.

Thus, the kidney is, on the one hand, suspended, as in a hammock, and thereby maintains the physiological mobility that is necessary for normal kidney function, on the other hand, the fixation of the upper pole prevents the rotation of the kidney.

This method operated on 11 patients. During the operation, no technical difficulties were encountered (cutting out muscle flaps, rupture of capsular bridges (subcapsular tunnels), bleeding from the renal parenchyma, bleeding from the lumbar muscle). The postoperative period was uneventful in all patients (see table).

Table Comparative efficacy of methods for treating patients with nephroptosis combined with kidney rotation Parameter Known method The proposed method Complete and persistent relief of pain caused by treatment 90.9% one hundred% Preservation of arterial hypertension more than 140/90 mm Hg 27.3% * 9.1% Preservation of urodynamic disturbances (expansion of the pyelocaliceal system detected using ultrasonography performed 4-6 months after surgery) 18.2% 9.1% The recurrence rate of nephroptosis up to a year 18.2% * 0 Changes in urine tests - erythrocyturia, proteinuria, leukocyturia up to a year 18.2% 9.1% Exacerbation of pyelonephritis up to a year 18.2% * 0 * - reliability p≤0,05

Thus, we have developed a method that includes new technical steps: fixing the upper pole of the kidney with an additional muscle flap on a leg taken from the lumbar muscle, held in a subcapsular tunnel, which is preliminarily formed in the upper pole of the kidney. This fixation of the kidney increases depreciation to the caudal and rotational displacement of the organ in the vertical position of the body. The optimal location of the additional muscle flap in the upper pole excludes the rotation of the kidney and lateral displacements, thereby improving urodynamics, by protecting the pelvis-ureteric segment from kinks that can occur in the vertical position of the body.

The application of the developed method of nephropexy allows for more reliable fixation of the kidney, especially in the case of a combination of nephroptosis and rotation of the kidney, while maintaining its respiratory mobility, thereby improving treatment outcomes and socially rehabilitating patients with this disease. In addition, in patients operated on by our method, there was a complete absence of relapses during the first year after surgery and exacerbations of pyelonephritis.

Example 1: Patient V., 37 years old, was admitted to the Department of Urology with a diagnosis of Nephroptosis on the right 2 degrees, rotation of the right kidney. Chronic pyelonephritis, latent phase. On admission, pain in the projection of the right kidney, fluctuations in blood pressure, with rises up to 145/90 mm Hg were disturbed. The diagnosis is confirmed by ultrasound (hydrocalicosis up to 8–9 mm on the right), excretory urography performed in a wedge and otrostasis. The patient is shown surgical treatment - nephropexy on the right.

In a position on a healthy side with an extended hypochondrium, a lumbotomy was performed on the right according to Fedorov. The kidney is mobilized. A muscle flap was cut from a lumbar muscle on a leg, which was crossed at the level of muscle transition into a tendon component 1.5 cm wide and 8-10 cm long. The end of the flap was taken on a catgut holder. Subcapsular tunnels 2.0 cm wide were formed on the posterior and anterior surface of the kidney. A muscle flap was made into the tunnels formed, first on the posterior surface and then on the anterior surface of the kidney. The end of the flap was fixed to the kidney capsule with the ends of the catgut holder threads. Additionally, the flap was strengthened to the kidney capsule with PHA sutures No. 3 on both sides of all incisions applied to the capsule. Performed hemostasis. Sutured perimisium of the lumbar muscle. A drainage was installed in the retroperitoneal space, through contraception. Layered suture of the surgical wound. The postoperative period was uneventful, the intradermal suture was removed on the 9th day, the wound healed by first intention, and on the 10th day the patient was discharged from the ward.

During the follow-up examination after 6 months, the patient complained of periodic pulling pains in the projection of the right kidney, blood pressure 135-140 / 85-90 mm Hg, about which she was forced to take antihypertensive drugs. Blood and urine tests are normal. Ultrasound examination performed in the supine and sitting position showed the position and size of the kidneys within the normal range, no enlargement of the CLS was detected on the left, hydrocalicosis up to 7-8 mm on the right, respiratory mobility of the kidneys preserved. Dopplerographic examination of the kidneys revealed: a decrease in the diameter and lengthening of the renal artery and vein, an increase in the maximum pulse rate of blood flow in the distal and intraorgan branches of the renal artery, an increase in the maximum blood speed in the renal vein, and a relatively low resistance index.

Example 2. Patient P., 30 years old, was admitted to the Department of Urology No. 1 with a diagnosis of Nephroptosis on the right 2 degrees, rotation of the right kidney. Chronic pyelonephritis, latent phase. Upon admission, the patient was disturbed by pain in the projection of the right kidney, depriving the patient of working capacity, twice during the last year pyelonephritis attacks, periodically, after physical exertion, rises in blood pressure up to 140/85 mm Hg The diagnosis is confirmed by ultrasound, excretory urography performed in ortho- and clinostasis. The patient is shown surgical treatment - nephropexy on the right.

In a position on a healthy side with an extended hypochondrium, a lumbotomy was performed on the right according to Fedorov. The kidney is mobilized. From the lumbar muscle, a muscle flap was cut on a leg, 1 cm wide and 6-8 cm long, the base of the flap turned up. In the region of the upper pole, a 2 cm capsule was cut, from which a subcapsular tunnel was formed, going to the front surface of the kidney, reaching the border of the upper and middle third of the kidney. The free distal end of the muscle flap was ligated with catgut thread No. 5 and inserted into the tunnel under the fibrous capsule along the front surface of the upper pole of the kidney, circling the upper pole and leading it out through the hole in the fibrous capsule along the front surface. The superior muscle flap was attached to the kidney capsule with PHA sutures No. 3 on both sides of all incisions applied to the capsule.

A second flap was cut from the lumbar muscle, which was crossed at the level of muscle transition into the tendon component 1.5 cm wide and 8-10 cm long. The end of the flap was taken on a catgut holder. Subcapsular tunnels 2.0 cm wide were formed on the posterior and anterior surface of the kidney. A muscle flap was made into the tunnels formed, at the beginning on the posterior surface, and then on the anterior surface of the kidney. The end of the flap was fixed to the kidney capsule with the ends of the catgut holder threads. Additionally, the flap was strengthened to the kidney capsule with PHA sutures No. 3 on both sides of all incisions applied to the capsule. Performed hemostasis. Sutured perimisium of the lumbar muscle. A drainage was installed in the retroperitoneal space, through contraception. Layered suture of the surgical wound. The postoperative period was uneventful, the intradermal suture was removed on the 9th day, the wound healed by first intention, and on the 10th day the patient was discharged from the ward.

During the control examination after four months, pain in the projection of the kidneys does not bother, blood pressure 125/75 mm Hg, blood and urine tests are normal. An ultrasound examination of the kidneys performed in the supine and sitting position showed the position and size of the kidneys within the normal range, no enlargement of the heart rate was detected, respiratory mobility of the kidneys was within the physiological norms. Dopplerographic examination did not reveal significant deviations from the norm.

Description to drawings

Figure 1. The formation of muscle flaps and subcapsular tunnels

1 - upper muscle flap

2 - the upper pole of the kidney

3 - upper subcapsular tunnel

4 - lower subcapsular tunnel

5 - lower pole

6 - lower muscle flap

Figure 2. Fixation of the upper and lower poles of the kidney with muscle flaps

1 - upper muscle flap

2 - the upper pole of the kidney

3 - upper subcapsular tunnel

4 - lower subcapsular tunnel

5 - lower pole

6 - lower muscle flap

7 - sutured perimizium m.psoas

8 - lower muscle flap held in the lower subcapsular tunnel

9 - upper muscle flap held in the upper subcapsular tunnel

Claims (1)

A method of nephropexy with a combination of nephroptosis and kidney rotation, including exposing the retroperitoneal space with lumbotomic access, isolating and mobilizing the kidney, cutting out a muscle flap from the lumbar muscle, forming subcapsular tunnels on the posterior and anterior surfaces of the lower pole of the kidney and holding a muscle flap under it with fixation of its sutures to kidney capsule, characterized in that the fixation of the upper pole of the kidney is preliminarily performed with a muscle flap on a leg taken from the lumbar muscle, carried out in bkapsulyarnom tunnel, pre-formed in the upper pole of the kidneys, joints and fixed to the capsule of the kidney.

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