HISTORY OF NEPHROPTOSIS
WHY WAS NEPHROPTOSIS ONE OF THE MOST CONTROVERSIAL CONDITIONS IN UROLOGY?
The term nephroptosis was first described by Glenard in 1885, with nephropexy for nephroptosis being one of the most common surgical procedures a urologist would perform in the 19th century.  Due to the popularity of nephropexy surgery, over one hundred and seventy surgical techniques have been described in an effort to fixate the kidney.  With such a large variation of experimental surgical techniques, inconsistency for a standard procedure for fixation of the kidney, and high post-operative morbidity and mortality rates associated with open surgery in these times, patient satisfaction levels in terms of symptom relief were usually low. In addition, poor patient selection also affected these outcomes due to the inconsistency of diagnosis and wrongly attributed symptoms such as gastrointestinal problems, anxiety and even hysteria.  As a result, some urologists even doubted the belief in the condition as a clinical entity and performing nephropexy for individuals with suspected nephroptosis led to divided opinions between urologists. In 1882 Lawson Tait stated, “In fact, I have no belief in its existence as a pathological incident.” 
By the end of the 19th and early 20th century, with the continued poor reputation associated with nephropexy surgery, by the 1920’s the general medical profession came to deny surgery to sufferers with nephroptosis. Due to this, the procedure was more or less abandoned by the 1970’s and 80’s in the UK and US.  Stated by McWhinnie and Hamilton in 1984 “Nephropexy for nephroptosis is listed among other ineffective treatments for imaginary diseases.”  Although, many urologists have still fought against the majority of opinions and incredulousness towards nephroptosis and nephropexy over the years.
In more recent times, with the use of modern techniques such as isotope renography and more specific diagnostic requirements, diagnosing patients with symptomatic nephroptosis has become much more successful. The first case report of laparoscopic nephropexy was performed by Urban in 1993, using capsular silk sutures to attach the kidney to the fascia of the quadratus lumborum.  With the combination of more careful patient selection and minimally invasive laparoscopic techniques, laparoscopic nephropexy has resulted in excellent outcomes in terms of symptom relief and successful results when achieving reattachment of the ptotic kidney.
Although a standardised approach has not yet been ultimately defined in terms of fixation of the kidney, numerous studies     have demonstrated far more successful results than previously achieved by open nephropexy surgery associated with the past. Due to the minimally invasive laparoscopic procedures which can now be performed, patients are at less risk of surgical complications, experience less postoperative pain and have a much quicker recovery. Although more expensive than laparoscopic surgery, with the introduction of The da Vinci Surgical System in the new millennium, a robotic assisted nephropexy can now also be performed. An advantage of this type of surgery can make intraoperative suturing much easier and the system can provide tri-dimensional magnified viewing and enhanced surgical dexterity.  As only individual case studies appear to have been published on robotic assisted nephropexy,    further research and comparative studies with a greater number of individuals could arise in the future.
Author: Caitlin La
MSc Medical Art 2020
University of Dundee
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