Horseshoe Nephrectomy

Horseshoe kidney is a congenital disease, which means that the lower or upper poles of the two kidneys fuse together in the midline to form a horseshoe-shaped abnormality. The fusion part constitutes the isthmus, and the isthmus may be renal parenchyma or fibrous connective tissue. Horseshoe kidney is the most common type of kidney fusion, about 90%. The isthmus is located in front of the third lumbar vertebrae aorta and inferior vena cava, and the ureter spans in front of the horseshoe kidney isthmus. Horseshoe kidney often combined with other congenital malformations of the kidney, such as polycystic kidney disease, poor kidney rotation, malformation of blood vessels, etc., can cause ureteral obstruction, poor urine drainage, urine deposition, causing hydronephrosis and urinary stone formation. Hydronephrosis and urinary calculi are easy to cause urinary tract infections. The clinical manifestations of the patient are secondary lesions of the horseshoe kidney and compression of the vascular plexus. When young, the patient is asymptomatic. In adulthood, the patient may have symptoms of urinary tract infection such as lumbar pain, frequent urination, urgency, dysuria, pyuria, and some may find a lower abdominal mass. Some patients have gastrointestinal dysfunction, similar to ulcer disease, biliary calculi, as well as abdominal discomfort, lower abdomen or umbilical pain, depressed edema of lower limbs. Abdominal X-ray film and intravenous urography showed that the two kidneys were fused in front of the spine, the kidney axis was inverted, and the renal pelvis and renal pelvis were abnormally rotated, and the two kidneys were in a low position. Ultrasonography, radionuclide renal scan is helpful for diagnosis, and bilateral retrograde pyelography can be performed if necessary. Clinically, not only to diagnose whether it is horseshoe kidney, but more importantly, to pay attention to whether combined with urinary tract obstruction such as hydronephrosis, urinary stone formation, other congenital malformations such as polycystic kidney disease, isolated cysts and presence or absence of tumors. Asymptomatic and uncomplicated horseshoe kidneys are in urgent need of treatment. If the patient's symptoms are severe, complications may be considered for ureteral release, isthmus separation or resection, and renal pelvis, ureteral plastic surgery and renal fixation. If necessary, the severely damaged side of the kidney or partial nephrectomy. Horseshoe and kidney isthmus resection is the most commonly used surgical method for the treatment of horseshoe kidney. Treating diseases: horseshoe kidney Indication 1. Horseshoe kidney isthmus causes obvious symptoms of retroperitoneal compression, which is severely painful and affects work and life. 2. Due to ureteral obstruction, complications such as hydronephrosis, infection, and stones need to be treated. Contraindications Asymptomatic and complications of horseshoe kidney. Preoperative preparation 1. Before surgery, you should know in detail whether the horseshoe kidney is complicated with hydronephrosis, urinary tract infection, stones, and whether there are other congenital malformations and kidney tumors. 2. Understand the function of the kidneys, in order to facilitate the treatment. The imaging examination data should be carefully analyzed before surgery, including intravenous urography, retrograde pyelography and CT, renal angiography, etc., to determine the horseshoe kidney surgery plan, isthmus incision site, and choose the appropriate surgical incision. 3. Apply antibiotics to prevent infection before surgery. 4. Prepare a certain amount of whole blood. Surgical procedure Incision selection If the horseshoe kidney only causes unilateral complication, or if it is decided to perform only a horseshoe and kidney stenosis before surgery, it is more suitable to use a lumbar incision. Because the horseshoe kidney is 90% of the lower pole fusion, the position is low, and the 12th rib incision is used. The incision is longer than the normal nephrectomy incision to the midline of the abdomen. If the horseshoe kidney causes bilateral complication, it is necessary to expose the kidneys. It is advisable to use the middle or middle mid-abdominal incision to facilitate the simultaneous treatment of bilateral lesions. The surgical approach reveals the kidney through the abdomen. The surgical procedure of the horseshoe kidney isthmus resection is described below with a lumbar incision. 2. Incision The 12th rib incision revealed the kidney. 3. Reveal After exposing the kidneys, the kidney and the upper ureter are properly dissociated to reveal the isthmus and the ureter is pulled outward. Horseshoe kidney deformity vagus blood vessels are quite common, and attention should be kept as much as possible when handling these blood vessels. 4. Free isthmus There is a small amount of adhesion between the isthmus of the horseshoe and the surrounding tissue, and the finger can be used for blunt separation. If necessary, the adhesion tissue is clamped and cut and ligated, and the thicker blood vessels should be retained. The free isthmus is to cross the midline, making subsequent isthmus removal and suturing easy. 5. Processing the isthmus After freeing the isthmus, carefully check the isthmus. If the isthmus is a fiber cord, it is easy to handle, that is, it can be clamped, cut, and ligated after separation, and the symptoms of compression can be relieved. If the isthmus is a renal parenchyma, it can be seen that the joint of the two kidneys has a depressed interstitial, which can be used as a cutting site. If there is no such groove, the appropriate cutting site can be selected according to the preoperative examination data. Cut and cut with a large right angle clamp at the cutting site, or cut off a section of the isthmus according to the situation. The cut surface should be carefully examined for communication with the renal pelvis. If it is connected to the renal pelvis, the channel is closed with a 3-0 absorbable line. The renal parenchyma section was sutured with an absorbable thread, and the stump kidney capsule was sutured continuously with absorbable lines. 6. Close the incision After the surgical wound is to be inspected without oozing, the incision is sutured layer by layer according to the level of the surgical incision. If the surgical wound seeps more, a rubber tube can be placed for drainage. complication Bleeding Occurred 5 to 7 days after surgery, due to intraoperative hemostasis or tissue necrosis and infection. Postoperative patients should stay in bed for 1 to 2 weeks. Secondary bleeding can be treated by the application of hemostatic drugs, antibiotics, etc. Repeated severe bleeding is sometimes forced to undergo surgery again. Urinary fistula Mostly caused by intraoperative injury of renal pelvis without corresponding treatment. Prevent the renal pelvis injury when cutting the isthmus during surgery. If there is damage, repair with 3-0 absorbable line in time, if necessary, cover with free omentum. If urinary fistula occurs, the stent tube can be inserted through the ureter to drain the urine and promote the healing of the urinary fistula. Urinary fistula that has not healed for a long time should be identified and treated accordingly. 3. Infection Horseshoe kidney often has urinary tract infections, and intraoperative urine contaminates the wound, which can lead to infection. Postoperative drainage and antibiotics can be used to control infection.