Introduction

Nephroptosis, also called hypermobile or floating kidney, is characterized by an abnormal caudal movement of the kidney by more than two vertebral bodies or 5 cm when the patient changes from the supine to the erect position.

Nephropexy, an organ-preserving modality, was first per-formed by Hahn in 1881, and was technically refined, innovated, and popularized by Edebohls, a gynecologist.

Nephroptosis, also called hypermobile or floating kidney, is characterized by an abnormal caudal movement of the kidney by more than two vertebral bodies or 5 cm when the patient changes from the supine to the erect position.

The condition was first described by Franciscus de Pedemantanus in the 14th century. Subsequently, Rayer described the characteristic symptoms attributable to a ptotic kidney in 1841(1). Historically, nephroptosis occurs more frequently in lean young females with a female-to-male ratio of about 5 to 10:1. The right kidney is affected in 70% of the cases. However, such data have to be evaluated cautiously because in approximately 20% of normal, asymptomatic females, the intravenous urogram was observed to have significant renal descent consistent with a diagnosis of nephroptosis (2,3). As such, from a practical standpoint, true symptomatic nephroptosis is a rare condition, and the diagnosis should be made with due circumspection.

The symptoms of nephroptosis usually include pain, which is exacerbated by sitting or standing. Sometimes, when the patient is upright, the kidney can be palpated in the lower abdomen. Nephroptosis may also present with pyelonephritis, renal calculi, hematuria, hypertension, and renal ischemia (2). The most severe presentation of nephroptosis is a syndrome of multiple symptoms including intermittent, severe colicky pain, nausea, tachycardia, oliguria, proteinuria, and/or hematuria, known as Dietl's crisis. On physical examination, the kidney may appear palpably enlarged and tender. The pain can be acutely relieved by upward manual reduction of the kidney into the renal fossa, with the patient in the supine position. Also the knee-chest or supine position assumed by the patient with the head down and feet elevated may help relieving the pain (4,5). Hypotheses for the pathogenesis of symptoms due to nephroptosis include kidney descent causing intermittent ureteral obstruction at the ureteropelvic junction with consequential hydronephrosis. Alternative explanations include traction on the renal pedicle combined with hilar vessel kinking leading to renal ischemia. Stretching of the peripelvic nerves is also considered to be a possible mechanism responsible for the pain.

Nephropexy, an organ-preserving modality, was first performed by Hahn in 1881 (6), and was technically refined, innovated, and popularized by Edebohls, a gynecologist.

Most of the proposed therapeutic options for nephroptosis are no longer popular because of their degree of invasiveness. In the 1870s, nephrectomy was advocated for the relief of symptomatic renal ptosis. However, such radical therapy was swiftly condemned due to its high mortality and lack of evidence of pathologic changes in the excised specimen (2).

Edebohls published a series of 12 cases in 1893, in which he described his technique comprising incision and back stripping of the renal capsule along the entire convexity of the kidney, and the placement of five or six deep sutures through the skin, the superficial fat, the tendons of the abdominal muscles, and the edges of the renal capsule and parenchyma (7).

Since then, a multitude of different procedures for symptomatic nephroptosis have been described including various "pexy" procedures, decapsulation of the kidney, and fixation of the kidney to the 12th rib. However, due to the lack of objective diagnostic studies and the lack of clear-cut indications for surgery, the diagnosis of nephroptosis and its surgical treatment have passed through cycles of intense popularity and equally intense disfavor during the past century (8).

In the last decade, the availability of laparoscopic surgery has led to a revival of interest in nephroptosis and nephropexy.

Urban et al. from the Washington University School of Medicine reported the initial laparoscopic nephropexy performed in a severely symptomatic woman with a palpable ptotic kidney and hydronephrosis in 1993 (9). Two years later, the same group updated their experience including five additional cases managed with laparoscopic nephropexy. The procedure was well tolerated with reported low morbidity, rapid recovery, and successful improvement of symptoms (10).

Blood Pressure Health

Blood Pressure Health

Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

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