UPJ obstruction and lower pole crossing vessels: further experience with the laparoscopic vascular hitch

Abstract

Purpose The transposition of lower pole crossing vessels has been reported as an alternative technique to dismembered pyeloplasty for the treatment of ureterovascular ureteropelvic junction (UPJ) obstruction. We report a multi-institutional experience with laparoscopic transposition in children with intermediate follow-up. Material and Methods Candidate patients were selected on the basis of clinical history, renal ultrasonography, MAG-3 renal scan, and magnetic-resonance angiography. Selection criteria included presence lower-pole crossing vessels with moderate hydronephrosis, poor renal drainage, and intraoperative normal ureter with UPJ peristalsis. All children were followed clinically with renal ultrasonography and postoperative MAG-3 renal scan. Success was defined by symptoms resolution with improvement in hydronephrosis and drainage. Results 36 children (21 boys- 15 girls) presenting with flank pain, hydronephrosis SFU grade 1 or 2, impaired drainage on MAG-3 and crossing vessels at a mean age of 11.5 years (range 3.5-16) were selected. Operations were performed through transperitoneal laparoscopy (n = 33) or robotic assisted (n = 3). The mean operative time was 95 min. (47-137), and length of hospital stay was 2 nights (1-3). With a follow-up of 20 months (3-42), outcome was successful in 34/36 patients (94%), with resolution of symptoms in all, improved hydronephrosis and better drainage. There were 2 failures in children showing recurrent pain and worsened hydronephrosis, who initially required ureteral stent placement. One boy had intrinsic UPJ stenosis and was treated by dismembered pyeloplasty. In the remaining child, adhesions around the renal pelvis had caused kinking of the proximal ureter and extrinsic UPJ obstruction, and subsequently underwent Mikulitz UPJ incision and plasty. Conclusions At intermediate follow-up, the laparoscopic vascular hitch procedure has been successful in treating a selected group of children with obstructive crossing vessels, and represents a safe and reliable alternative to standard dismembered pyeloplasty.