Percutaneous endoscopic nephropexy with a percutaneous suture passed through the kidney

Abstract

Objectives: To report a technique of percutaneous endoscopic nephropexy, using a polyglactin suture passed through the kidney, in patients with nephroptosis.

Patients and methods: Four women presenting with symptomatic right nephroptosis underwent a percutaneous endoscopic nephropexy. An upper-pole calyx was accessed percutaneously and a 24-F working sheath was placed. Another needle access was made through a lower-pole calyx and a #2 polyglactin suture was passed into the renal pelvis. It was then pulled out through the upper-pole tract using the nephroscope. A retroperitoneoscopy was performed and the tip of the nephroscope was used to cause nephrolysis. After inserting the nephrostomy tube the polyglactin suture was passed into the subcutaneous tissue and then tied without too much tension, to avoid cutting the parenchyma.

Results: The operative duration was 33 min and the hospital stay after surgery was 3.5 days. The nephrostomy catheter was removed 5 days after surgery. There were no complications, especially no haemorrhagic, infectious, lithiasic or thoracic complications. The four patients were relieved of their initial symptoms, with a mean follow-up of 28 months. Ultrasonography and/or intravenous urography showed the kidney at a higher location with the patient standing.

Conclusions: This technique combines the nephrostomy tract used in percutaneous techniques with the suture and nephrolysis used in laparoscopic techniques. Moreover, this procedure seems to be safe, with satisfactory anatomical and clinical results and a lower morbidity. However, a larger series will be necessary to establish its long-term morbidity and success rate.

Keywords: Kidney; Lateral modified position; Nephropexy; Nephroptosis; Percutaneous surgery.

Figure 1

An upper-pole calyx is accessed via an intercostal route; the nephroscope is positioned in the renal pelvis. Another needle access was made through a lower-pole calyx, then a hydrophilic guidewire, and a 5- or 6-F PTFE dilator were inserted. Alternatively, the lower-pole calyx puncture could be made at the start, before upper-pole access.

Figure 2

A nephroscopic view; a two-prong forceps grasps the #2 polyglactin suture, which is passed into the renal pelvis via a 6-F PTFE dilator. The suture is pulled out through the upper-pole tract using the nephroscope.

Figure 3

(A) A retroperitoneoscopic view, after the Amplatz sheath and nephroscope were withdrawn in the percutaneous tract outside the retro-renal fascia. A space is developed outside the retro-renal fascia. The black hydrophilic guidewire and the purple suture are traversing the percutaneous tract gap. (B) The retro-renal fascia was traversed following the guidewire. A nephrolysis is developed, liberating the posterolateral aspect of the kidney, until reaching the lower pole access with the purple suture penetrating the renal capsule and parenchyma. (C) Sometimes a blunt dissection is performed with the help of the ‘opening and closing’ of a two-prong forceps.

Figure 4

The balloon of the nephrostomy Foley catheter was inflated with 3 mL of sterile water and contrast medium. A mild traction was placed on the kidney to bring it against the abdominal wall. The #2 polyglactin suture is passed into the renal collecting system between the lower and the upper calyx, in the subcutaneous tissue between the upper and lower skin punctures, and then tied in the upper skin incision.

Figure 5

(A) The 18-G diamond-tip needle is passed under the skin, from the upper to the lower puncture site, and passed through the lower skin puncture, alongside the suture. (B) The suture is introduced into the needle and pulled out in the upper skin incision.

Figure 6

(A) IVU before surgery, with the patient upright, shows descent and tilting of the right kidney, with a kink in the proximal ureter. (B) IVU at 40 months after surgery, with the patient upright, shows the right kidney in a higher position.