Pelviureteric junction obstruction and crossing vessels: pro "vascular hitch"

Abstract

The vascular hitch procedure for pelviureteric junction obstruction caused by crossing lower-pole vessels is a controversial treatment option. Since this minimally-invasive technique has been introduced in patients with aberrant lower-pole vessels, multiple publications have reported successful short, intermediate and long-term outcomes. Success rates of > 90 % are similar to those of Anderson-Hynes pyeloplasty. In general, an associated intrinsic stenosis seems to be rare. Histological evidence of muscular hypertrophy may simply indicate a compensatory mechanism and may be reversible to a certain degree. To differentiate between those patients who are eligible for a vascular hitch procedure and those who should receive an initial Anderson-Hynes pyeloplasty, an intraoperative diuretic test should be performed (volume bolus plus intravenous administration of furosemide). An associated intrinsic stenosis seems to be unlikely in a funnel-like and otherwise normal-looking pelviureteric junction, decreasing hydronephrosis after mobilisation of renal pelvis and crossing vessels and effective peristalsis of the renal pelvis after intraoperative diuretic testing. The vascular hitch technique is less demanding than laparoscopic Anderson-Hynes pyeloplasty and less time-consuming with regard to the duration of the surgical procedure and anaesthesia. Further advantages are: no risk of urinary leakage or anastomotic stricture and no need for intra-luminal stenting. Therefore, in a selected group of patients with solely extrinsic pelviureteric junction obstruction, the vascular hitch procedure is a valuable alternative to classic Anderson-Hynes pyeloplasty with seemingly long-term efficiency.