Article

Lower pole vessels in children with pelviureteric junction obstruction: Laparoscopic vascular hitch or dismembered pyeloplasty?

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Abstract

Objective: To choose between laparoscopic "vascular hitch" (VH) and dismembered pyeloplasty (DP) in treatment of aberrant lower pole crossing vessels potentially responsible for pelviureteric junction obstruction (PUJO) in older children. Patients and methods: Retrospective study of 19 patients treated laparoscopically for PUJO. Based on videos of the procedures, we studied the anatomical relationship between the renal pelvis, the pelviureteric junction, and the aberrant vessels. Results: Eight patients had laparoscopic VH and 11 had DP. All patients with DP needed drainage. In the VH group, 7/8 patients were asymptomatic and had decreased pelvic dilation. Half of them accepted MAG3 scintigraphy, and in these patients the obstructive syndrome disappeared completely. The last patient in this group was lost to follow-up. We observed three anatomical variations in the location of polar vessels: type 1 (in front of the dilated pelvis), type 2 (in front of the pelviureteric junction), type 3 (under the pelviureteric junction, resulting in ureteral kinking). Conclusion: Laparoscopic VH is a simple technique involving no urinary anastomosis or drainage, but we cannot guarantee that the crossing vessels are the sole etiology for PUJO. Following our experience, only patients with type 3 anatomical variations and with a normal pelviureteric junction should be proposed for VH.

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... Vascular compression in these cases is not in the UPJ but in the proximal ureter. Therefore, the junction is certainly healthy, and correcting the herniation is all that is needed (8,11,20). This observation is supported by histological analysis of the UPJ and CV. ...
... Lower pole vessels may predispose the UPJ to the narrowing that favours infection or inflammatory episodes, or that causes tension and ischemia, thus resulting in fibrosis and stenosis of the urothelium. The presence of this UPJ fibrosis could be one cause of hypothetical failure of the VH-procedure (8)(9)(10)(11), even though there is no evidence to suggest that the fibrosis is progressive. In addition, electron microscopy studies of extrinsically obstructed UPJ tissue demonstrate no significant structural changes in muscle or collagen content, or in nerve distribution, immunohistochemically, when compared to normal controls. ...
... Transl Pediatr 2016;5(4):256-261 tp.amegroups.com inserting percutaneously into the renal pelvis a fine-needle evaluating the ureteral opening pressure with a column device before and after the procedure was completed (1,8). ...
Article
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Background: Congenital hydronephrosis due to intrinsic or extrinsic uretero-pelvic-junction (UPJ) obstruction (UPJO) is a common problem in childhood UPJO may be caused by intrinsic disorganization or by extrinsic compression from crossing vessels (CV); extrinsic causes usually present symptomatically in older children. This report the large Italian experience in the treatment of children with extrinsic-UPJO by CV. Methods: We analyzed the data of 51 children (17 girls and 34 boys, median age 10, 7 years) affected by extrinsic-UPJO were treated in three Italian institutions with laparoscopic transposition of CV (Hellström Vascular Hitch modified by Chapman).The intraoperative diuretic-test was performed in all patients before and after the vessels transpositions confirming the extrinsic-UPJO. We included in the study only patients with suspicion of vascular extrinsic obstruction of the UPJ. Symptoms at presentation were recurrent abdominal/flank pain and haematuria. All patients presented intermittent ultrasound (US) detection of hydronephrosis (range, 18–100 mm). Preoperative diagnostic studies included: US/doppler scan, MAG3- renogram, functional-magnetic-resonance-urography (fMRU). Results: Median operative time was 108 minutes; median hospital stay: 3, 4 days. Unique complications: a small abdominal wall hematoma and higher junction-translocation without obstruction. During follow-up (range, 12–96 months) all patients reported resolution of their symptoms, a decrease in the hydronephrosis grade and improved drainage on diuretic renogram. Conclusions: We believe that Vascular Hitch is less technically demanding than laparoscopic pyeloplasty, resulting in a lower complication rate and a significantly reduced hospitalization. The results of our study allow us to conclude that laparoscopic VH may be a safe, feasible, and attractive alternative to treat obstructed hydronephrosis due to CV presenting a useful alternative to AHDP in the management of symptomatic children where CV are deemed the sole aetiology. We recommend careful patient selection based on preoperative clinical and radiologic findings that are diagnostic of extrinsic-UPJO, combined with intraoperative-DT to confirm the appropriate selection of corrective procedure.
... Several groups reported successful treatment of UPJO by upward transposition and fixation of LPCV ranging from 96% to 100% when applying the patient selection criteria discussed above. [15][16][17][18][19][20][21] Schneider et al [22] conducted intra-operative diuretic testing in addition to the criteria mentioned above and opted for hitching of the LPCV in 8 of 19 (42%) patients with UPJO caused by LPCV. In all patients, hydronephrosis had resolved at postoperative follow-up; in 1 patient who was lost to follow-up, this could not be confirmed. ...
... In all patients, hydronephrosis had resolved at postoperative follow-up; in 1 patient who was lost to follow-up, this could not be confirmed. [22] Similarly, Parente et al [23] extended the known criteria for patient selection by an intra-operative test with retrograde catheter insertion into the UPJ zone for balloon dilation in order to identify internal causes of UPJO. The authors stipulated that development of a "waist" in the UPJ zone after inflating the balloon under a pressure of 8 to 12 atm. ...
... According to the literature, the proportion of patients with UPJO due to LPCV treated successfully with upward transposition of LPCV ranges from 42% and 94%. [5,14,16,22] The advantages of LPCV transposition over Anderson-Hynes pyeloplasty with resection of the UPJ in LPCV-induced UPJO include preservation of the integrity of the urinary tract as well as blood supply and innervation of the UPJ zone. In addition, time of surgery and LOS are significantly shorter than those associated with pyeloplasty. ...
Article
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Chapman and Hellstrom techniques are typically employed to transpose renal lower pole crossing vessels (LPCVs). Both procedures have certain limitations. We investigated the midterm outcomes in pediatric patients in whom LPCV-induced ureteropelvic junction obstruction was treated with either dismembered Anderson-Hynes pyeloplasty or upward transposition coupled with a new technique to fix the LPCV.We retrospectively compared Anderson-Hynes pyeloplasty to the new technique in terms of outcome. LPCV transposition was considered feasible in patients in whom the diuretic loading test revealed a decrease in the pelvic volume after correction of vascular compression as well as absence of structural changes in the ureteropelvic junction (UPJ) and hemodynamic compromise of the lower renal pole. The fascial flap was passed below the LPCV to form a "hammock". The free edge of the flap was sutured to its base.Group 1 consisted of 102 (69.9%) patients (median age: 7.9 years) undergoing dismembered Anderson-Hynes pyeloplasty, while group 2 included 44 (30.1%) patients (median age: 8.4 years) treated with upward transposition and the new technique to fix the LPCV. No intra-operative complications or conversions occurred in either group. Redo-pyeloplasty was performed in 3 (2.9%) children of group 1 and 1 (2.3%) child of group 2. Renal ultrasonography conducted 12 months after surgery revealed similar anteroposterior diameters of the renal pelvis in groups 1 (7.9 ± 8.1 mm) and 2 (6.0 ± 2.9 mm). Patients in both groups showed a non-significant median increase in differential renal function at follow-up after at least 1 year after surgery (group 1: 36% [33.3; 40.5] vs 36.5% [35.3; 41.0]; group 2: 41% [37.5; 46.0] vs 43% [39; 46]).In our patients, the new technique for laparoscopic or open fixation of the obstructing vessel after transposition was effective, reproducible, and devoid of limitations typical for the Chapman and Hellstrom techniques. We recommend Anderson-Hynes pyeloplasty in children with a history of hydronephrosis diagnosed antenatally, recurrent abdominal pain, intra-operative absence of peristalsis across the UPJ, high location of the UPJ at the renal pelvis, or intra-operative absence of volume reduction of the renal pelvis upon furosemide testing.
... This technique was later modified by Chapman, who proposed moving the CV more cranially within a wrap of the anterior wall of the redundant pelvis, without vascular adventitial sutures [15]. According to Schneider et al. the only situation in which a VH has to be performed is when the vessels are under the UPJ, resulting in ureteral kinking (defined as a ureteral curl or bend around the polar vessels similar to a swanneck ureter) [16]. Some authors reported good results also by performing a non-dismembered pyeloplasty (Y-V Foley) (NDP), especially in those patients with a small-sized renal pelvis, a long narrow ureteric segment or a high insertion of the ureter [17]. ...
... Open Anderson-Hynes DP has always been considered the gold standard both for intrinsic and extrinsic UPJO with success rates of more than 90% [10]. In the last decade, many authors have wondered whether Hellstrom VH can be considered a valid alternative to DP in presence of CV [12,16,24,25], considering the advantages of this technique: surgical repair without opening the collecting system, leaving the UPJ intact, eliminating the risk of leakage or urinoma and preserving the pyelo-ureteral motility peristalsis. This procedure avoids the technical challenge of pelvi-ureteric anastomosis with a low complication rate and operative time [25,26]. ...
... In literature, the success rate of VH has been reported in a range of 92-100% [24,25,29], even if a careful preoperative and intra-operative functional and anatomical assessment is crucial to guide the choice between VH and DP [24]. Schneider and colleagues identified three different types of intraoperative anatomical relationship between the lower pole CV, the renal pelvis, the PUJ, and the ureter and only Schneider type 3situation with ureteral kinking and normal junction should be proposed for VH [16]. In our experience, the laparoscopic VH success rate was 90.3% and we agree with other authors that VH may be a safe, feasible, and attractive alternative to treat obstructed hydronephrosis due to polar CV [16,24,25,29]. ...
Article
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Purpose Uretero-pelvic junction obstruction is the most common cause of prenatal hydronephrosis. It can be intrinsic, extrinsic due to crossing vessel (CV) or mixed. This paper aims to present the surgical outcome in a single pediatric third-level center. Methods A retrospective analysis of all children operated between 2011 and 2018 was conducted. Demographic information, pre-operative pelvic antero-posterior diameter (APD), intra-operative parameters, hospital stay and follow-up were considered. Re-do operations and success rate for Vascular Hitch (VH), open and laparoscopic pyeloplasties were recorded. Results 128 patients were included. The mean pre-operative APD was 30 mm. The etiology was intrinsic in 71.9%, extrinsic in 25.0% and mixed in 3.1%. The median age between intrinsic and extrinsic groups was statistically different. Thirty-one VH, 88 dismembered and 9 non-dismembered pyeloplasties were performed. The median hospital stay was 2 days for VH and 6 for pyeloplasties. The median hospital stay was statistically longer in open pyeloplasties compared to laparoscopic. The mean post-operative APD was 14 mm. The success rate after VH was 90.3%, after open pyeloplasties 97.9% and after mini-invasive pyeloplasties 91.8%. Conclusions VH could be a good option in the treatment of hydronephrosis due to CV, laparoscopic pyeloplasties have equivalent success rate and shorter hospital stay than open pyeloplasties.
... Many authors expect renal function to be good in the presence of CV compared to antenatally detected cases as the obstruction is expected to be intermittent [3,5,9]. However, Hacker et al. [6] reported a slightly lower differential renal function in children with CV (38.9% AE 1.7 SD) compared to the group without CV (42.4% AE 11.2 SD). ...
... They also mention a 13-year-old boy with UPJO with function <10% and CV who underwent nephrectomy during the study period. In Schneider's series of 19 patients, five (26%) had impaired function on DMSA scan [3]. In Calisti's series, 18 patients (21%) with CV had an initial function of 37.8 (SD 11.08) (range 12e50) [10]. ...
... Calisti et al. [10] reported lower polar CV in six out of 54 (11%) prenatally detected cases with a mean age of 3.5 months (SD 7.3) compared with 12 out of 30 (40%) symptomatic patients who had a mean age of 6.4 years (SD 3.1). In Schneider et al.'s [3] series, all children were above 2 years (age range 2e17.3 years) with a mean of approximately 10 years. Maheshwari et al. [11] in a series of 82 patients encountered CV in seven children (8.5%) with age ranging from 4 months to 15 years (mean 7.12 years). ...
Article
Pediatric ureteropelvic junction obstruction (UPJO) due to an extrinsic crossing vessel (CV) is rare and often remains undiagnosed preoperatively. Vascular hitch procedures are often performed as associated intrinsic obstruction is not expected. We compared data and intravenous urography (IVU) findings of patients with aberrant CV versus those with intrinsic UPJO, all undergoing open dismembered pyeloplasty. Primary objective: Is accurate pre-operative diagnosis of aberrant CV causing extrinsic UPJO possible? To assess differences in the demographic, clinical, radiological, intra-operative features and postoperative improvement after pyeloplasty between patients with a CV and those with only intrinsic UPJO. Prospective study of all children below 12 years with UPJO presenting to a tertiary referral centre and who underwent open Anderson - Hynes dismembered pyeloplasty between 2003 and 2013 was conducted. Pre-operative investigations included serial ultrasonography, renal dynamic [ethylene di-cysteine (EC)] scan and IVU. These were repeated 3 months after pyeloplasty. Pre-operative IVUs of children with CV were compared with the IVUs of an equal number of similar aged children, randomly selected from the intrinsic obstruction group. Pyeloplasty was performed in 643 children during the study period. Data of 33 children with aberrant CVs (mean age 6.99 years) were compared with the remaining 610 children (mean age 3.27 years) with only intrinsic obstruction. Highly significant associations of those with CV included age above 2 years, female gender, associated anomalies, abdominal pain in those above 2 years and poor preoperative function on IVU. Specific IVU features which were statistically highly significant in favor of presence of CV were small, intrarenal and globular flat bottomed pelvis. (Figure) Calyceal dilatation was also more prominent in the CV group. A funnel shaped, extrarenal pelvis was highly significant in favor of intrinsic obstruction. There was associated intrinsic obstruction in addition to CV obstruction in 8 children. All children symptomatically improved after pyeloplasty and did well on long term follow up. The majority showed improvement or stabilization of function on EC scan. With the advent of antenatal ultrasonography, most children with UPJO are detected early. Children with CV tend to present later. This is often detected during surgery. Color Doppler is useful but is operator dependant and not performed routinely. In this study, IVU showed the presence of obstruction and loss of function unlike color Doppler, but also revealed specific diagnostic features not previously reported in literature. This can help in accurate preoperative prediction and avoid endopyelotomy, or a dorsal lumbotomy/retroperitoneal approach. Renal function in CVs is expected to be good as the obstruction is thought to be intermittent. However, we noted delayed contrast uptake on IVU in 60.6% and differential renal function on EC scan below 40% in 17 patients (56.6%). These indicate the effect of the obstruction on the renal parenchyma and the importance of early detection. Higher association with other anomalies and higher incidence in females has also not been emphasized in the literature so far. We noted associated intrinsic obstruction in 24.24% patients which is highly significant. This category of patients is likely to be missed and inappropriately treated if a "vascular hitch procedure" is performed. None of our patients had postoperative complications. Characteristic features were seen on IVU helping in preoperative diagnosis which can be extrapolated to magnetic resonance urography. There is a higher association of CV in age above 2 years, females, associated congenital anomalies, delayed uptake on IVU and differential renal function below 40% compared to intrinsic obstruction. Associated intrinsic obstruction in 24% with no postoperative complications indicates the superiority of dismembered pyeloplasty over vasculopexy procedures. Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
... Independently from the approach, the vascular hitch was performed according to the Hellström-Chapman technique. UPJ intra-operative anatomical aspect and its relationship with the crossing vessels were reported according to Schneider classification [11] (Fig. 1). Further intra-operative evaluations regarding the UPJ appearance (stenotic, fibrotic, aperistaltic) and pelvic emptying, after vascular mobilization, were reported. ...
... On the other hand, series with good results from Hellström-Chapman procedure stressed on the pre and intra-operative patients' selection criteria [11,[14][15][16]. Among pre-operative evaluations, a detailed clinical history could be helpful to suspect extrinsic obstruction; antenatal diagnosis of urinary tract dilatation is suspicious for intrinsic obstruction, while late symptoms onset, intermittent or progressive pelvic dilatation and a stable SRF on functional studies are more suggestive for extrinsic causes. ...
... Our data showed a higher incidence of antenatal diagnosis (25%) not related with undiagnosed concomitant intrinsic UPJO; in fact, only 1 patient of 3 requiring secondary pyeloplasties, presented with antenatal diagnosis; a similar finding was reported by Villemagne [14], being 2 out of 3 cases of vascular hitch failures occurred in patients with antenatal diagnosis. Some Authors described a correlation between crossing vessels and age of symptoms onset: in Schneider and Menon' series [11,18], all patients treated by vascular hitch were older than 2 years, while Villemagne reported surgery in children older than 2 years in 91% of cases [14]. It was supposed that latency in symptoms onset might be related to differential growth between the aorta and renal length [18]. ...
Article
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Objective To assess the efficacy of the vascular hitch procedure in extrinsic ureteropelvic junction obstruction (UPJO) by crossing vessels in children, both by open and mini-invasive approach.Methods Retrospective analysis on patients treated by open or mini-invasive vascular hitch during the period 2006–2020. Preoperative imaging included renal ultrasound (US) and functional studies by magnetic resonance or renogram. Crossing vessels obstruction and UPJ anatomy were evaluated at surgery. Success was defined as the resolution of symptoms and improvement of hydronephrosis at US or functional studies.ResultsForty-eight patients were included with mean age at surgery of 7.6 years and 25% had an antenatal diagnosis. Aberrant vessels were suspected preoperatively in 72.9%; mean hydronephrosis and renal function were 30.9 mm and 38% respectively. Seven cases were treated by open approach, 37 by laparoscopy and 4 were robotassisted. Mean operative time was 58.3 min and mean hospital stay was 2 days. Mean follow-up was 16.9 months; success rate was 91.6% and 5 patients required secondary surgery.Conclusions Vascular hitch shows to be a safe, feasible and effective alternative to pyeloplasty. Careful pre and intra-operative patients’ selection is essential to exclude any intrinsic cause of UPJO. Mini-invasive surgery could be helpful for better evaluation of UPJ anatomy and its relationships with crossing vessels. Complications and secondary surgeries could be related to incorrect patients’ selection.
... From January 2007 and January 2014, 11 children (five boys and six girls) were included in this study. All anatomical relationships between lower pole crossing vessels and PUJ were classified according to Schneider et al. 10 Surgical indications included two or more of the following conditions: presence of meaningful clinical symptoms, obstruction on diuretic renogram (diethylenetriaminepentacetate [DTPA]), decrease on relative renal function (dimercaptosuccinic acid), or worsening of hydronephrosis on follow-up. The median age at presentation was 96 months (range, 36-168 months). ...
... 9 Vascular compression in these cases is not in the PUJ but in the proximal ureter (Fig. 3), creating an ureteral bend like a swan-neck ureter. 10 Therefore, the junction is certainly healthy, and correcting the herniation is all that is needed. 10,12,13 This observation is supported by histological analysis of the PUJ and crossing vessels. ...
... 10 Therefore, the junction is certainly healthy, and correcting the herniation is all that is needed. 10,12,13 This observation is supported by histological analysis of the PUJ and crossing vessels. Normal muscle density was found and suggests an inherently different PUJ configuration between intrinsic and extrinsic obstruction. ...
Article
Full-text available
To report a series of children with pelviureteric junction obstruction (PUJO) due to lower polar crossing vessels who underwent laparoscopic vascular transposition. In order to confirm the relief of the obstruction and avoid unnecessary additional procedures, we suggest performing an intraoperative measure of the ureteral opening pressure. From January 2007 and January 2014, 11 children underwent laparoscopy to treat well-documented PUJO by polar vessels. In the first 7 cases, children underwent a careful dissection of the polar vessels that were transposed cranially in the pelvis. In the last 4 cases, a percutaneous needle was inserted into the renal pelvis, and the ureteral opening pressure was obtained intraoperatively, before and after the vascular hitch procedure, in 3 cases. No vascular relocation was necessary except in 1 case with a polar vessel unrelated to the obstruction. The laparoscopic procedure was feasible in all cases. Median operative time was 90 minutes without intraoperative complications. In the last 3 cases, a decrease in the renal pelvic pressure was demonstrated just after releasing the ureter from the polar vessels, confirming the extrinsic obstruction. In 1 case, the intraoperative pelvic pressure measurement showed that there was no vascular compression but that obstruction was due to renal rotation. During follow-up (range, 12-96 months) all patients reported resolution of their symptoms, nine children showed a decrease in the hydronephrosis grade, and all but one with poor function had improved drainage on diuretic renography. Intraoperative measurement of ureteral opening pressure may help to confirm that the vascular hitch procedure has relieved the pelvic obstruction, precluding the need for dismembered procedures. We believe that in some doubtful cases, with the addition of intraoperative pelvic pressure measurement, vascular hitch may be considered a safe procedure to treat selected cases of PUJO in children.
... Meta-Analysis -Five retrospective studies comparing laparoscopic VH versus laparoscopic DP were included (277 patients, with 119 VH and 158 DP) [1,4,5,9,20]. Operative time was significantly reduced in VH (102.5 AE 47.5min) compared to DP (165.7 AE 53.7min; p < 0.00001, MD -48.89, 95% CI -56.66 to À41.12, I 2 Z 77%; Fig. 2a). ...
... All but two studies included in the meta-analysis were retrospective observational studies [1,4,5,9,20]. Two studies reported on prospectively followed-up cohort of patients [2,6]. ...
... None of the papers provided sample size calculations as well as none reported a blinded evaluation of objective endpoints. Moreover, only one study have reported with regards to the loss to follow-up [5]. Furthermore, follow-up periods were appropriate to the aim of the [1,4], thanks to a long-term follow-up period (i.e. with a mean or median follow-up of !3 years). ...
Article
INTRODUCTION Vascular hitch (VH) gained an increasing success in treating ureteropelvic junction obstruction (UPJO) by crossing vessels (CV) in pediatrics. AIMS OF THE STUDY We aimed: (i) to compare laparoscopic VH versus laparoscopic dismembered pyeloplasty (DP) to treat UPJO by CV; (ii) to review possible amelioration given by a robot-assisted procedure. METHODS Using defined search strategy, three investigators identified all studies on laparoscopic VH. Those studies comparing VH versus DP or versus robot-assisted VH were included in the meta-analysis. The meta-analysis was conducted using RevMan 5.3. Data are mean±SD. RESULTS Systematic review - Of 2,783 titles/abstracts screened, 43 full-text articles were analyzed. Twelve studies on laparoscopic VH (298pts) reported 98.3% success rate, with 1.3% intra-operative complications. Meta-Analysis - Five studies compared laparoscopic VH versus laparoscopic DP (277pts). Operative time was reduced in VH (102.5±47.5min) compared to DP (165.7±53.7min; p<0.00001). Complications were similar (VH 4/119pts, 3.4±1.2% versus DP 15/158pts, 9.5±6.8%; p=ns). Hospital stay was shortened in VH (1.1±0.9dd) versus DP (3.3±3.2dd; p<0.0001; Figure). The success rate was comparable (VH 115/118pts, 97.5±1.6% versus DP 157/158pts, 99.4±0.5%; p=ns). Two prospective studies compared robot-assisted VH to laparoscopic VH (53pts). No differences were found among complications (robot-assisted VH 0/13pts, 0% versus laparoscopic VH 1/40pts, 2.5%; p=ns) and success rate (robot-assisted VH 13/13pts, 100% versus laparoscopic VH 39/40pts, 97.5%; p=ns). DISCUSSION Several studies have been reported long-term results of laparoscopic VH in children. However, few papers demonstrated its superiority over laparoscopic DP to treat extrinsic UPJO. In the present study, we found similar incidence of complications and success rates when comparing VH versus DP. Nonetheless, the operative time and the length of hospital stay were significantly reduced in VH compared to DP. An increasing number of surgeons performed robotic-assisted VH, reporting promising outcomes. However, only a couple of studies compared robot-assisted VH to laparoscopic VH, with a similar incidence of complications and success rate in both procedures. The main limitations of the study were related to the slight number of papers included and to their quality, since all of them were retrospective studies or prospectively followed-up cohort of patients. CONCLUSIONS Laparoscopic VH seems to be a safe and reliable procedure to treat UPJO by CV. The procedure appeared quicker than laparoscopic DP, with shortened hospital stay. Further studies are needed to corroborate these results and to establish amelioration given by a robot-assisted procedure.
... Основной причиной врожденного гидронефроза считается внутренняя патология стенки мочеточника, которая проявляется дисплазией и образованием зоны стеноза в области пиелоуретерального сегмента. Но в последнее время все большее внимание уделяется наиболее частой и спорной внешней причине гидронефрозаналичию аберрантного сосуда [1][2][3][4]. ...
... Диагностика В педиатрической практике УЗИ считается методом выбора для первичной диагностики патологий мочевыделительной системы. С помощью УЗИ можно определить степень расширения коллекторной системы почки, оценить состояние паренхимы почки, в режиме доплерографии исследовать почечный кровоток и подсчитать индекс резистентности [4,20,21]. ...
... в 2011 г. [52]. Относительная простота выполнения при правильном отборе пациентов сделали эту операцию популярной среди многих зарубежных хирургов [4,12,[51][52][53]. По мнению авторов, методика показана пациентам с клиникой перемежающегося гидронефроза начиная с подросткового возраста. ...
Article
A review of the domestic and foreign scientific literature is devoted to an actual problem of pediatrics — congenital hydronephrosis, the cause of which is an aberrant vessel. The features of the diagnosis of the vessel and methods of surgical treatment are considered. The technique and indications for non-dismembered pyeloplasty “vascular hitch” are analyzed in detail.
... 16 SCHNEIDER a apporté une classification anatomique peropératoire basée sur les rapports du VPI avec la JPU, le pyélon et l'uretère. Il distingue ainsi 3 types : Image 2. Classification de Schneider : Type 1 : VPI au-dessus de la JPU ; Type 2 : VPI en regard de la JPU ; Type 3 : VPI au-dessous de la JPU, ce qui prédispose à un kinking de l'uretère Selon l'expérience du centre de Strasbourg, seul le type 3 avec une JPU normale est une indication au VH [8]. ...
... La durée de l'intervention en moyenne est de 122 min (104-148min), ce qui rejoint la durée opératoire de la série de VILLEMAGNE [7], mais représente le double de temps de l'équipe de STRASBOURG [8]. La durée opératoire de LVH est plus courte que celle de la résection- ...
... Chapman [24] later modified this technique by enclosing the vessels in an overlapping tunnel of pelvic tissue without the need for adventitial sutures. The major advantage of any vessel transposition technique over dismembered pyeloplasty is to allow surgical repair without opening the collecting system, leaving the PUJ intact, avoiding the technical challenge of pelviureteric anastomosis, and presumably reducing the complication rate and operative time [11,12]. In 2006, Godbole et al. first reported the use of laparoscopy for vascular relocation of LPCV in the paediatric population, and their promising results were confirmed in 2008 [5] with a successful outcome in up to 95% of 20 patients, after a follow-up of 22 months. ...
... The question of durability of improvement of hydronephrosis after transposition of LPCV has previously been studied and reported, with mean follow-up from 12 to 52 months [1,5,11]. Based on the intraoperative findings at redo surgery of failed cases, which always showed dense postoperative adhesions and fibrosis of the pelvis surrounding the vessels, it seems unlikely that the mobilized pelvis eventually moves back and, thus, a recurrence of PUJ vascular obstruction occurs. ...
Article
Summary Purpose Laparoscopictranspositionoflower-polecrossingvessels (LPCV) has been described as an effective alternative to dismembered pyeloplasty in selected indications of hydronephrosis, with purely extrinsic vascular PUJ obstruction. We hypothesized that the initial good results of laparoscopic transposition of LPCV in children presenting with pure extrinsic PUJO were sustained at puberty when these children go through statural growth, without inducing significant changes in systemic arterial blood pressure. Hence, we analysed the long-term follow-up of adolescents successfully treated with this technique during childhood, reviewed after they have reached puberty, focusing on the incidence of recurrent symptoms, renal dilatation, and systemic hypertension.
... Chapman [24] later modified this technique by enclosing the vessels in an overlapping tunnel of pelvic tissue without the need for adventitial sutures. The major advantage of any vessel transposition technique over dismembered pyeloplasty is to allow surgical repair without opening the collecting system, leaving the PUJ intact, avoiding the technical challenge of pelviureteric anastomosis, and presumably reducing the complication rate and operative time [11,12]. In 2006, Godbole et al. first reported the use of laparoscopy for vascular relocation of LPCV in the paediatric population, and their promising results were confirmed in 2008 [5] with a successful outcome in up to 95% of 20 patients, after a follow-up of 22 months. ...
... The question of durability of improvement of hydronephrosis after transposition of LPCV has previously been studied and reported, with mean follow-up from 12 to 52 months [1,5,11]. Based on the intraoperative findings at redo surgery of failed cases, which always showed dense postoperative adhesions and fibrosis of the pelvis surrounding the vessels, it seems unlikely that the mobilized pelvis eventually moves back and, thus, a recurrence of PUJ vascular obstruction occurs. ...
Article
Purpose: Laparoscopic transposition of lower-pole crossing vessels (LPCV) has been described as an effective alternative to dismembered pyeloplasty in selected indications of hydronephrosis, with purely extrinsic vascular PUJ obstruction. We hypothesized that the initial good results of laparoscopic transposition of LPCV in children presenting with pure extrinsic PUJO were sustained at puberty when these children go through statural growth, without inducing significant changes in systemic arterial blood pressure. Hence, we analysed the long-term follow-up of adolescents successfully treated with this technique during childhood, reviewed after they have reached puberty, focusing on the incidence of recurrent symptoms, renal dilatation, and systemic hypertension. Patients and methods: Early 2015, among a cohort of 70 patients prospectively followed-up since they had undergone laparoscopic transposition of LPCV during childhood (2005-2012), we performed systematic clinical assessment of the 33 adolescent patients (16 years; range 12-22) who had reached puberty age. Assessment focused on clinical examination, arterial blood pressure measurements, and renal ultrasonography (Table). Results: The median delay since surgery was 67 months (31-113 months). Arterial blood pressure adjusted for age and height was within normal range in all patients. Three patients had occasional episodes of abdominal pain: two of them had normal US (including during pain episodes), one had persistent extra-renal dilated pelvis with no calyceal dilatation. None of them showed obvious clinical characteristics linking the pain to a renal origin. Renal US showed residual SFU grade 2 pelvicalyceal dilatation in 2/33 asymptomatic patients; SFU grade 1 extra-renal pelvis dilatation in 3, and was normal in the remaining. When Doppler analysis was performed, there was no evidence of lower-pole parenchyma perfusion defect. Discussion: In adolescents successfully treated during childhood with transposition of LPCV, there seemed to be no impact of this procedure on systemic arterial blood pressure in adolescents after puberty, nor any evidence of late recurrence of symptoms or hydronephrosis. The main limitation of the present study relies in its retrospective nature, the limited sample size, and the obvious difficulty in adequate selection of candidate patients to this technique. The present experience however reinforces the hypothesis that a vast majority of children can be definitely cured with transposition of LPCV when they represent the sole aetiology of obstruction. Conclusion: In the long-term follow-up, most adolescents successfully treated during childhood by laparoscopic transposition of LCPV for PUJ extrinsic obstruction remain asymptomatic, with normal arterial blood pressure, and normal renal ultrasound when they reach puberty.
... Chapman [24] later modified this technique by enclosing the vessels in an overlapping tunnel of pelvic tissue without the need for adventitial sutures. The major advantage of any vessel transposition technique over dismembered pyeloplasty is to allow surgical repair without opening the collecting system, leaving the PUJ intact, avoiding the technical challenge of pelviureteric anastomosis, and presumably reducing the complication rate and operative time [11,12]. In 2006, Godbole et al. first reported the use of laparoscopy for vascular relocation of LPCV in the paediatric population, and their promising results were confirmed in 2008 [5] with a successful outcome in up to 95% of 20 patients, after a follow-up of 22 months. ...
... The question of durability of improvement of hydronephrosis after transposition of LPCV has previously been studied and reported, with mean follow-up from 12 to 52 months [1,5,11]. Based on the intraoperative findings at redo surgery of failed cases, which always showed dense postoperative adhesions and fibrosis of the pelvis surrounding the vessels, it seems unlikely that the mobilized pelvis eventually moves back and, thus, a recurrence of PUJ vascular obstruction occurs. ...
Article
Full-text available
Objectifs La transposition des vaisseaux polaires inférieurs (VPI) laparoscopique a été décrite comme une alternative efficace à la pyéloplastie classique dans les cas d’obstruction de la jonction pyélo-urétérale purement extrinsèque. Nous rapportons le suivi à long terme des enfants traités par cette technique pendant l’enfance et revus à la puberté, en analysant la survenue de symptômes, la persistance d’une hydronéphrose et la pression artérielle (PA) Méthodes Au début de l’année 2015, parmi une cohorte de 70 enfants ayant eu une transposition des VPI laparoscopique, nous avons évalué les 33 atteignant l’âge de la puberté (16 ans [12–22]). L’évaluation a porté sur: Un examen clinique relevant la fréquence des épisodes douloureux et d’infection, la mesure de la PA comparée aux normes ajustées à l’âge et à la taille, une échographie rénale (grade SFU) pour 21/33 patients. Résultats Le suivi médian après chirurgie était de 69 mois [13–113]. L’échographie rénale retrouvait une hydronéphrose de grade 2 SFU chez 2 patients asymptomatiques (10 %), de grade 1 extrasinusale chez 3 patients (14 %) et était normale chez les autres. Les PA étaient dans la fourchette normale des valeurs ajustées à l’âge et à la taille. Trois patients présentaient des douleurs épisodiques: deux avaient une échographie normale (notamment durant les épisodes douloureux) et un gardait une dilatation pyélique extrasinusale (31 mm vs > 60 mm préopératoire en percritique) sans dilatation calicielle. Aucune douleur ne montrait de caractéristiques cliniques pouvant la relier à une origine rénale. Une adolescente a présenté un épisode infectieux fébrile à 18 ans (8 ans postopératoire) en gardant une échographie normale et sans hypertension artérielle. Conclusion À très long terme, la grande majorité des adolescents traités dans l’enfance d’une transposition laparoscopique des VPI pour obstruction extrinsèque de la JPU restent asymptomatiques, avec une PA normale et une échographie normale à la puberté.
... The incidence of the CV causing obstruction of the UPJ in children increases with age. [14][15][16] Crossing vessels are very rarely noticed in newborns and infants. Similarly, the analyzed material did not show this pathology in any child under 1 year of age. ...
... 14 In the study by Schneider et al., all CV patients were over 2 years of age, with an average age of 10 years (from 2 to 17.3 years). 15 Maheshwari et al. in a group of 82 patients showed CV in 7 (8.5%) with an average age of 7.12 years (from 4 months to 15 years). 16 In adults, the proportion of patients with CV is around 39-71% of all patients with UPJO. ...
Article
Full-text available
Background: A bundle of crossing vessels (CV) supplying the lower pole of the kidney and causing mechanical obstruction of the ureteropelvic junction (UPJ) has been the subject of many discussions. During pyeloplasty, it is possible to overlook the CV. This may result in recurrent dilatation of the kidney and the need for re-surgery. Objectives: To compare the detection rate of CV in UPJ obstruction (UPJO) depending on the operational access applied (transperitoneal laparoscopy (LAP) vs open lumbotomy (OPEN)). Assessment of features that could indicate the presence of CV. Material and methods: Two hundred and forty-six pediatric pyeloplasties were performed between January 2006 and July 2017 in the Department of Pediatric Surgery and Urology at the Wroclaw Medical University, Poland - 111 out of them by LAP and 135 by OPEN, on 98 girls and 148 boys. A retrospective analysis of the patient records for the detection of CV and characteristics of the CV before surgery was performed. Results: Intraoperative CV causing obstruction of the UPJ in the LAP group were recognized in 34.2% (n = 38) of the patients, and within the OPEN group in 12.5% (n = 17) (p < 0.0001); 90% (n = 27) of patients with the diagnosed CV did not show congenital hydronephrosis. In 68% (n = 21) of the patients there were cases of recurrent renal colic. The presence of CV was suspected in 7.2% of kidney ultrasounds and in 12.5% in computed tomography (CT) urograms. Conclusions: The detection rate of CV in UPJO is statistically higher in LAP access than in open retroperitoneal lumbotomy. The distinguishing features of patients with CV are the lack of prenatal diagnosis for hydronephrosis and the presence of pain in the lumbar region.
... There were 327 search results identified in the database search with 18 studies meeting inclusion criteria [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26]. The search results and reasons for study exclusion are summarized in Fig. 1. ...
... The latest development has been the robotic AHDP which has been envisaged to demonstrate promising results. As an alternative approach, [12,16]. ...
Article
Full-text available
Objective This systematic review aimed to determine the overall success rate for vascular hitch (VH) procedures in patients with pelvi-ureteric junction obstruction (PUJO) due to lower pole crossing vessel (LPCV) and with the laparoscopic approach. Materials and methods The review based on PRISMA guidelines was performed using the PubMed, SCOPUS and Google scholar databases searches till September 2020. Baseline characteristics, number of patients undergoing VH procedure, mode of surgery, patient mean age, clinical presentation, mean operative duration, use of intraoperative diuretic test, use of suture material, mean length of postoperative hospital stay, use of JJ stent, comparison of pre- and post-operative renal pelvis anteroposterior diameter, comparison of pre- and post-operative renograms, mean follow-up, outcomes of the procedures, recurrence and post-operative complications were studied. The results were pooled to determine overall success rate for VH procedures in patients with PUJO due to LPCV. Results The initial search led to identification of 327 articles, of which 18 studies met the inclusion criteria. VH was performed in 77.57% PUJO patients that presented with LPCV. Furthermore, 92.57% of these patients with detailed data available were included in the study. The pooled success rate of VH was 94% in patients with LPCV (95% CI 91–97, I² = 40.6%, n = 18 studies). Mean operating time ranged from 45–164 min. An overall recurrence was noted in 27 (5.8%) patients, majority (67%) of which later underwent a dismembered pyeloplasty. Conclusion VH for well-selected patients with LPCV, without concomitant intrinsic obstruction, offers a high success rate with shorter operating time, a lower rate of complication and significantly reduced hospitalization time. The results of this study also concludes that laparoscopic VH may be a safe, feasible, and effective alternative to treat obstructed hydronephrosis due to CV. Recurrent PUJO after VH can be attributed improper patient selection.
... Other authors assume that there is no imaging method with which the obstructive effect of a vessel on the pyeloureteral junction can be detected because despite detaching and lifting of the vessel (no cutting) with subsequent fixation above the pyeloureteral junction (so-called vascular hitch [30]), the obstruction can remain [31], or because there are cases in which an aberrant vessel is obstructive in the sense of an extrinsic stenosis but there are also histological changes in the pyeloureteral junction that indicate an intrinsic stenosis [32]. These authors therefore recommend performing an intraoperative water load test following immobilization and clamping of the vessel before and after lifting of the vessel to differentiate an extrinsic stenosis caused by the vessel from a stenosis caused by intrinsic factors [32,33] At present, MAG3 scintigraphy is the gold standard for functional preoperative evaluation of an obstruction and was therefore used in our patient group. ...
... Other authors assume that there is no imaging method with which the obstructive effect of a vessel on the pyeloureteral junction can be detected because despite detaching and lifting of the vessel (no cutting) with subsequent fixation above the pyeloureteral junction (so-called vascular hitch [30]), the obstruction can remain [31], or because there are cases in which an aberrant vessel is obstructive in the sense of an extrinsic stenosis but there are also histological changes in the pyeloureteral junction that indicate an intrinsic stenosis [32]. These authors therefore recommend performing an intraoperative water load test following immobilization and clamping of the vessel before and after lifting of the vessel to differentiate an extrinsic stenosis caused by the vessel from a stenosis caused by intrinsic factors [32,33] At present, MAG3 scintigraphy is the gold standard for functional preoperative evaluation of an obstruction and was therefore used in our patient group. This method entails radiation exposure and should be perspectively replaced by an adequate functional MRI examination via which the urodynamics of the urinary system can also be evaluated [29]. ...
Article
Purpose: To determine the importance of MRI with contrast-enhanced MRA for the detection or exclusion of aberrant or obstructing renal arteries in ureteropelvic junction obstruction in children. Materials and Methods: Key word-based search in RIS database (ureteropelvic junction obstruction/ MRI) and retrospective comparison of arterial findings from preoperative contrast -enhanced MRA and intra-operative inspection. From 2007 to 2013, 19 children with ureteropelvic junction obstruction underwent contrast-enhanced MRA. Based on the results of the MRI scan and MAG3 scintigraphy, the children were referred to surgery (Anderson-Hynes-pyeloplasty). Results: An aberrant renal artery was diagnosed with MRI in 14 of 19 children, and intra-operative inspection confirmed 13 of those 14. In the remaining 5 children, no aberrant vessel could be observed in MRI and this was confirmed intra-operatively in 3 of the 5 cases, while in the remaining 2, an aberrant vessel was found. Of the 14 children with aberrant vessels, 12 underwent surgery due to assumed ureteral obstruction, which was confirmed by surgery in 11 cases. In one case, an aberrant artery was found intra-operatively, but obstruction could not be confirmed. In one of the 14 children, the vessel was found in MRI, but its obstructing character was negated via MRA, which was confirmed intra-operatively. In the diagnosis of aberrant and obstructing renal arteries, contrast-enhanced MRA presents 85 % sensitivity and 80 % specificity, with a positive predictive value of 0.8. Conclusion: MRI with contrast-enhanced MRA is suitable to detect aberrant and obstructing renal arteries. An obstructive effect of the aberrant vessel is to be assumed if the vessel has a close relationship to the ureteropelvic junction and if it is linearly stretched. Key Points: • MRI with contrast-enhanced MRA is a sure method for the detection of aberrant renal arteries in children with ureteropelvic junction obstruction • the obstructive effect of the aberrant vessel can be derived from the close proximity of the vessel to the ureteropelvic junction and from the streched course of the vessel Citation Format: • Ritter L, Götz G, Sorge I et al. Significance of MR Angiography in the Diagnosis of Aberrant Renal Arteries as the Cause of Ureteropelvic Junction Obstruction in Children. Fortschr Röntgenstr 2015; 187: 42 – 48
... While pyeloplasty represents the surgical approach the most commonly used to treat PUJ obstruction, the exclusive transposition of crossing vessels initially developed by Hellström et al. has been proposed as a therapeutic alternative and has proved efficiency in selected cases [32][33][34][35][36]. Compared to pyeloplasty, the technique has the advantage to be less technically challenging, to require minimal suturing and no need for incising the renal pelvis leaving the collecting system intact [34]. ...
Article
Full-text available
Pelvi-ureteric junction obstruction corresponds to an impairment of urinary transport that can lead to renal dysfunction if not treated. Several mechanisms can cause the obstruction of the ureter including intrinsic factors or extrinsic factors such as the presence of crossing vessels. The treatment of the disease relies on surgical approaches, pyeloplasty being the standard reference. The technique consists in removing the pathologic ureteric segment and renal pelvis and transposing associated crossing vessels if present. The vascular anatomy of the pelvi-ureteric junction is complex and varies among individuals, and this can impact on the disease development and its surgical treatment. In this review, we summarize current knowledge on vascular anatomic variations in the pelvi-ureteric junction. Based on anatomic characteristics, we discuss implications for surgical approaches during pyeloplasty and vessel transposition.
... Schneider et al. classified anatomically three types of CLPV by intraoperative location of the crossing vessel over the pelvis (Type 1), PUJ (Type 2), and upper ureter (Type 3). [12] They advocated standard pyeloplasty for types 1 and 2 and nondismembered techniques such as Hellstrom's vascular hitch for type 3, which they assumed to be a purely extrinsic obstruction. ...
Article
Full-text available
Introduction A crossing lower polar vessel (CLPV) is found in 11%–20% of children of pelviureteric junction obstruction (PUJO). Preoperative imaging (Doppler or magnetic resonance angiography (MRA)) may help but does not form a part of routine diagnostic workup. An attempt has been made here to evaluate clinical and imaging features (ultrasound and renal dynamic scan [RDS]) in children of PUJO with CLPV and define variables that could provide a diagnostic clue to its presence. Materials and Methods Records of children having PUJO with CLPV over 10 years (2006–2015) were reviewed retrospectively. Their demographic profile, clinical presentation, imaging features, management, and outcomes were evaluated. Results Of 372 children with PUJO, 21 (5.6%) had a CLPV. Median age at presentation was 7 years (range 4 months–11 years). Presenting features included pain (66.6%), urinary tract infection (14.3%), antenatally diagnosed fetal hydronephrosis (14.3%) and lump (4.8%). All had an obstructive drainage on RDS and mean split renal function (SRF) of the affected kidney was 32.5% ± 15.65%. The majority had mild-moderate hydronephrosis with intrarenal pelvis. None of the ultrasound images suggested the presence of a CLPV. Diagnosis of a CLPV was made intraoperatively in all. Dismembered pyeloplasty anterior to the vessel was done in the majority (80.9%). Mean SRF on postoperative RDS improved to 36.6% ±17.76% with nonobstructive drainage. All were asymptomatic at a mean follow-up of 34.5 ± 17.5 months (range 2–56 months). Conclusions Pain is the predominant presenting feature in these patients who present at an older age. Despite older age at presentation, these patients have well-preserved renal function and mild hydronephrosis. No specific RDS or ultrasound findings can predict the presence of a CLPV. As the incidence of CLPV is <10% and management is essentially same as PUJO with intrinsic obstruction, preoperative Doppler or MRA are extraneous.
... This technique involves mobilizing, moving, and securing the vessel to a more cephalad position on the renal pelvis so that the relocation alters the anatomic configuration and the pelvis does not obstruct. Only a few groups have performed and studied this procedure, the so-called vascular hitch (VH), using the laparoscopic approach115116117118119120121122123124125 (Table 9). Proper patient selection is crucial for success, and the intraoperative decision to perform the VH technique is usually based on the presence of the crossing vessels, a grossly normal appearance of the ureter and UPJ, and a small renal pelvis [115]. ...
Article
Over the last two decades, minimally invasive treatment options for ureteropelvic junction obstruction (UPJO) have been developed and popularized. To critically analyze the current status of laparoscopic and robotic repair of UPJO. A systematic literature review was performed in November 2012 using PubMed. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria. Multiple series of laparoscopic pyeloplasty have demonstrated high success rates and low perioperative morbidity in pediatric and adult populations, with both the transperitoneal and retroperitoneal approaches. Data on pediatric robot-assisted pyeloplasty are increasingly becoming available. A larger number of cases have also been reported for adult patients, confirming that robotic pyeloplasty represents a viable option for either primary or secondary repair. Robot-assisted redo pyeloplasty has been mostly described in the pediatric population. Different technical variations have been implemented with the aim of tailoring the procedure to each specific case. The type of stenting, retrograde versus antegrade, continues to be debated. Internal-external stenting as well as a stentless approach have been used, especially in the pediatric population. Comparative studies demonstrate similar success and complication rates between minimally invasive and open pyeloplasty in both the adult and pediatric setting. A clear advantage in terms of hospital stay for minimally invasive over open pyeloplasty was observed only in the adult population. Laparoscopy represents an efficient and effective less invasive alternative to open pyeloplasty. Robotic pyeloplasty is likely to emerge as the new minimally invasive standard of care whenever robotic technology is available because its precise suturing and shorter learning curve represent unique attractive features. For both laparoscopy and robotics, the technique can be tailored to the specific case according to intraoperative findings and personal surgical experience.
... CVs are very rarely noticed in newborns and infants. According to the literature, the average age of patients with a CV is between 7 and 11 years and is statistically higher than in patients with pure intrinsic obstruction (8)(9)(10)(11)(12). In our material, the median age at surgery was 6 years in both groups. ...
Article
Full-text available
Objectives: Assessment of the efficacy of intraoperative diagnosis between extrinsic and intrinsic UPJO in children. Assessment of the efficacy of laparoscopic vascular-hitch procedure in UPJO caused by lower pole crossing vessels (CV). Materials and Methods: Between 2008 and 2017, 47 laparoscopic procedures were performed with the CV discovered intraoperatively. CV were translocated cephalad, and the UPJ was carefully inspected. The Chapman's vascular hitch procedure was accomplished in the case of decreasing sizes of the pelvis and clear, visible peristalsis of the UPJ (31 patients). In the other cases, Anderson–Hynes (A-H) pyeloplasty with posterior translocation of the CV was performed (16 patients). Results: The median age at operation was 6 years (range 1–16) in VH and 6 years (range 2–17) in A-H (p = 0.4635). Prenatal dilatation of kidney was diagnosed in 18.7% of VH and 10% of A-H cases (p = 0.5474). Success was achieved in 16 (100%) patients in the A-H and in 29 (93.54%) in the VH groups. Two patients (6.5%) in VH required repeated surgery because of a misdiagnosed intrinsic obstruction. Median operation time in VH was 80 min (range 40–105) and was 105 (range 70–225) in A-H (p < 0.05). Conclusions: The intraoperative selection based on intraoperative pelvis and UPJ appearance after vessel transposition is sufficient in majority of cases. Laparoscopic vascular hitch seems to be effective and safe procedure, but can only be performed on carefully selected patients. In case of misdiagnosis, reoperation is possible with the same laparoscopic access.
... 22,23 However, since Hellström first described the "vascular hitch" in 1949, many surgeons prefer this method in adults and children. [24][25][26][27][28] Simforoosh et al. published his experience with cephalad translocation of the CVs in children and adults with good outcomes in more than 90% of cases. 16,29 Blanc et al. showed a 95% success rate for retroperitoneal LP with posterior transposition in pediatric patients. ...
Article
Background: Crossing vessels (CVs) are common in older children and adults with hydronephrosis but no gold standard exists on how to treat this condition. The final decision is made intraoperatively by the surgeon. Objectives: To assess the outcome of the laparoscopic dismembered pyeloplasty with translocation of the CVs in children and adults. Material and methods: Prospectively collected data from 3 departments was reviewed. Inclusion criteria were: 1) a transperitoneal laparoscopic approach; 2) dismembered pyeloplasty; and 3) the same operating pediatric urologist (RC) or urologist (TS). In the case of CVs, pyeloplasty with vessel transposition (children) or with cephalad translocation (adults) was performed. Forty-eight children and 41 adults met these criteria. Patients were divided into 4 groups: children with (group 1A) and without (group 1B) CVs, and adults with (group 2A) and without (group 2B) CVs. Any surgical reintervention at the uretero-pelvic junction (UPJ) was deemed a failure. Results: The overall reintervention rate was 3/48 (6.25%) in children and 2/41 (4.9%) in adults (p > 0.05), and involved the following: 4 endopyelotomies and 1 redo pyeloplasty. Crossing vessels were identified in 28/48 (58%) children and 12/41 (29%) adults. The mean operation time was 152 min in group 1A and 161 min in group 2A (p > 0.5). Reintervention was needed in 2/28 patients in group 1A and in 1/12 patients in group 2A (p > 0.05). There was no difference in the failure rate between group 1A and group 1B, nor between group 2A and group 2B (p > 0.05). Conclusions: Crossing vessels should be meticulously looked for during pyeloplasty in older children and adults. Dismembered laparoscopic pyeloplasty (LP) with dorsal transposition or cephalad translocation are comparable methods in terms of success rate for the treatment of UPJ obstruction in these patients.
... The incidence of colickly pain in pure extrinsic UPJHN has been reported as 71.8-100%, increasing with age (57-59). The average age of patients with a crossing vessel is between 7 and 11 years and is statistically higher than in patients with pure intrinsic obstruction (58)(59)(60)(61). An ultrasonography performed in the symptomatic period can prevent delay in diagnosis of extrinsic UPJHN due to crossing vessel. ...
Article
Full-text available
The most common cause of hydronephrosis in the pediatric age group is ureteropelvic junction-type hydronephrosis (UPJHN). Since the advent of widespread maternal ultrasound screening, clinical presentation of hydronephrosis associated with UPJ anomalies has changed dramatically. Today most cases are diagnosed in the prenatal period, and neonates present without signs or symptoms. For those who are not detected at birth, UPJHN eventually presents throughout childhood and even adulthood with various symptoms. Clinical picture of UPJHN highly depends on the presence and severity of obstruction, and whether it affects single or both kidneys. Abdominal or flank pain, abdominal mass, hematuria, kidney stones, urinary tract infections (UTI), and gastrointestinal discomfort are the main symptoms of UPJHN in childhood. Other less common findings in such patients are growth retardation, anemia, and hypertension. UTI is a relatively rare condition in UPJHN cases, but it may occur as pyelonephritis. Vesicoureteric reflux should be kept in mind as a concomitant pathology in pediatric UPJHN that develop febrile UTI. Although many UPJHN cases are known to improve over time, close clinical observation is critical in order to avoid irreversible kidney damage. The most appropriate approach is to follow-up the patients considering the presence of symptoms, the severity of hydronephrosis and the decrease in kidney function and, if necessary, to decide on early surgical intervention.
... Open pyeloplasty is still the standard of care as laparoscopic and robotic techniques though have comparable outcomes to the open technique, they are technically challenging and demanding [15]. Schneider et al [17] classified CLPV in to 3 based on intraoperative location, pelvis, PUJ and proximal ureter into class 1, 2 and 3 respectively. They advocated pyeloplasty for 1 and 2 and Hellstrom procedure for class 3 CLPV assuming the obstruction is primarily extrinsic. ...
... A systematic description of three types of patients according to the different locations of UPJ and ventral CVs were summarized by A. Schneider et al. They suggested that AH pyeloplasty should be performed when the CVs are present anterior to the dilated pelvis or the UPJ with intrinsic stenosis site, while vascular suspension should be performed when the vessels are present posterior to the UPJ, resulting in ureteral kinking [18] . ...
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Background: To characterize the anatomical subtypes of ureteropelvic junction obstruction (UPJO) caused by crossing vessels (CVs) and demonstrate the Individualized operation procedures for these cases. Methods: From March 2015 to July 2019, 51 consecutive adult patients underwent treatment of primary UPJO via a retroperitoneal laparoscopic approach. The clinical data, iconography inspection results, and surgical procedures for each patient were retrospectively reviewed by our team. The diagnosis of etiological CV was confirmed during the operation in 13 patients (25.49%), which included 7 men and 6 women. Results: The mean surgical age was 30±11.66 years. The operating time was approximately 233±62.76 minutes, and there were one open conversions. In the follow-up period (mean, 27.23±15.46 months), all patients had a full recovery in the CV group. However, 3 patients without CV did not completely recover from uronephrosis, as determined on iconography inspection, and there was no improvement in the renal colic symptoms. In the CV group, none of the patients had lithiasis whereas 25% of the patients without CV had lithiasis. Conclusion: CV accounts for approximately 25.49% of the UPJO cases. Based on the anatomical position of the UPJ and CVs, we identified two types of abnormalities, and 84.62% of the CVs were located anterior to the UPJ. The retroperitoneal approach for treating CVs had particular advantages. A comprehensive understanding and interoperative analysis of the anastomosis between the CVs and UPJ is crucial for at least 4 individual treatments. After dismembered pyeloplasty, suspension of the CVs is recommended in approximately 40% of the cases. The follow-up showed good prognosis in the long term.
Article
In children, ureteropelvic junction obstruction (UPJO) is mostly caused by intrinsic factors (IUPJO); extrinsic UPJO are rare and often due to crossing vessels (CVs). We retrospectively reviewed all data of children with UPJO that underwent surgery in our institution from 2004 to 2011. Analyses included age at surgery, gender, preoperative and postoperative results of ultrasound and renal scans [differential renal function (DRF); signs of obstruction], and pathology reports. Available histological specimens of cases with CV were compared to a random selection of intrinsic cases in a blinded fashion. After additional Masson's trichrome staining, the specimens were scored for fibrosis, muscular hypertrophy, and chronic inflammation. Out of 139 patients with UPJO, 39 cases were associated with CV. Median age at surgery was 68 months (range 2-194) in the CV group and 11.5 months (range 0-188) in IUPJO group. Laparoscopic dismembered pyeloplasty (LDMP) was carried out in 134 and open DMP in five patients. Preoperative ultrasound identified 28/39 cases with CV. DRF below 40 % was more frequently seen in CV patients (p = 0.020). Histological analyses revealed no differences between the CV and IUPJO specimens in total. CV patients with higher grades of muscular hypertrophy had lower preoperative DRF, compared to those with higher preoperative DRF (p = 0.026). Functional recovery after (L)DMP was excellent in both groups. We could not find any significant histological differences between CV and IUPJO in children. To obtain excellent functional recovery, surgical procedures with a definite correction of the UPJ should be preferred in paediatric patients with CV.
Article
Les vaisseaux polaires inférieurs sont responsables d’une part importante des syndromes de la jonction pyélo-urétérale (JPU) y compris chez l’enfant. Si la classique pyéloplastie avec décroisement des vaisseaux reste la référence, certaines équipes ont remis au goût du jour la transposition des vaisseaux polaires dans cette indication, avec le développement de la chirurgie mini-invasive. Le but de notre étude était donc d’évaluer les résultats de la prise en charge des JPU pour vaisseaux polaires par cœlioscopie dans notre centre.
Article
Aims Ureteropelvic junction obstruction (UPJO) may originate from extrinsic or intrinsic causes in children. The aim of this study is to present preoperative and postoperative data of our patients operated for UPJO. Methods A total of 64 patients who underwent open pyeloplasty were investigated retrospectively. They were evaluated in terms of demographically, clinics, hydronephrosis, differential renal functions (DRFs), half-time tracer clearance (½TC), and histopathologic results. Patients’ numerical results were stated as mean ± standard deviation (SD). Results Male gender was more prevalent ( n = 47, 73.4%) and mean age at surgery was 46.87 months. UPJO was located at the left side in 56.3% ( n = 36), and at the right side in 39.1% ( n = 25) of patients. It was bilateral in 4.7% ( n = 3). Hydronephrosis was found antenatally in 68.8% ( n = 44) of patients. The mean preoperative DRF was 49.7% (21–78%) and mean postoperative DRF was 49.2% (20–56%). Mean renal scintigraphic t 1/2 was >20 min for all patients. The mean AP diameter was 21.58 mm (10–62 mm). Muscular hypertrophy was the most common pathological finding, mean length of excised segment was 10.26 mm (3–40 mm). Crossing vessel (CV) was detected in 17.18% ( n = 11). The CV was statistically associated with increased age of operation, left side, and female gender. Statistically significant hydronephrosis was found in non-CV patients. Re-operation was required in seven patients (7.8%). Conclusions Intrinsic pathologies are more seen in the etiology of UPJO patients with antenatal diagnosis and this group needs operation at an earlier age. However, CV is found more commonly in patients who are diagnosed and operated at older ages.
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For the treatment of ureterovascular pelviureteric junction obstruction (PUJO), transposition of lower pole crossing vessels (LPCV) has been described as an alternative to dismembered pyeloplasty. To report on the long-term follow-up of children after laparoscopic transposition of LPCV. A retrospective analysis of 70 children consecutively treated by laparoscopic transposition of LPCV. Candidate patients were selected on the basis of clinical history, renal ultrasound (US), and pre-operative mercaptoacetyltriglycine (MAG-3) scan. Selection criteria included: presence of LPCV with SFU Grade 1-2 hydronephrosis, impaired drainage on MAG-3 and intraoperative normal pelviureteric junction (PUJ) and ureter peristalsis. Thinned parenchyma, impaired renal function, or history of prenatal hydronephrosis were not considered as exclusion criteria. Children were clinically followed up with US and MAG-3 scan. Success was defined by symptom resolution with improvement in hydronephrosis. Seventy children, aged 8.3 years (range 2.75-16.0), were selected. Procedures were performed through transperitoneal laparoscopy (n = 42) or were robotic-assisted (n = 28). Operative time was 120 min and length of hospital stay was 2 days. The outcome was successful in 67/70 patients (96%), with a median follow-up of 52 months (range 13-114). There were three failures in children who eventually underwent dismembered pyeloplasty for a symptomatic, undiagnosed, intrinsic PUJ obstruction. Two of them had been postnatally followed for a resolving prenatally diagnosed hydronephrosis. Three children became free of symptoms, had improved hydronephrosis, but still showed impaired drainage on MAG-3 and are being closely followed up. Although this procedure proves to have long-term efficiency in selected indications, the main challenge is to intraoperatively ascertain the absence of associated intrinsic stenosis. Objective criteria remain difficult to establish, but intraoperative findings, including dependent, funnel-shaped, normal-looking PUJ with decreasing hydronephrosis after pelvis and LPCV mobilisation, and efficient peristalsis across the PUJ under intraoperative diuretic test, represent a low likelihood of associated intrinsic stenosis. Ipsilateral impaired renal function doesn't seem to be associated with an adverse outcome. In contrast, a prenatal history of mild or self-resolving hydronephrosis in a patient later presenting with intermittent dilatation, raises the suspicion of associated intrinsic PUJ obstruction, as it is associated with a higher risk of failure. With a long postoperative follow-up, the robotic-assisted or laparoscopic vascular hitch procedure has been successful in treating a selected group of children with obstructive LPCV, and represents a safe and reliable alternative to standard dismembered pyeloplasty in the absence of intrinsic PUJO suspected on prenatal US. Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Article
Ureteropelvic junction obstruction due to intrinsic causes is often diagnosed antenatally during routine ultrasonography. Cases of extrinsic obstruction often present later and symptomatically, during childhood. We describe the rare case of an 8-year-old boy with a 2-day history of severe left flank pain, no fevers, and Society of Fetal Urology grade 3 hydronephrosis on ultrasonography. Laparoscopic dismembered pyeloplasty revealed a left ureteropelvic junction obstruction secondary to a large fibroepithelial polyp in the proximal ureter with a concomitant anterior crossing vein. We also provide a focused review of the pertinent published literature. Copyright © 2015 Elsevier Inc. All rights reserved.
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Management of the asymptomatic ureteropelvic junction obstruction continues to challenge the pediatric urologist. Decisions as to appropriate and effective imaging, monitoring, and intervention remain unclear due to our inability to accurately define the potential risks of renal injury or clinical symptoms in a particular individual. While it has become well established that many of these children will resolve their apparent partial obstruction without sequelae, knowing who may be at risk remains uncertain. It is important to recognize the limitations in our ability to clinically assess UPJO and the variability of diagnostic testing, but we can develop pragmatic guidelines for care. These are based largely on a cautious approach to obstruction with the recognition that as long as there is a program of monitoring and the family is in agreement with such an approach, watchful waiting can be safe and effective. There are clear parameters to indicate the value of surgery such as reduced relative function, progressive dilation, or increasing washout times or symptoms. It is rare for function to be lost quickly in the older child so intervals of follow-up may be increased with time. Using pragmatic guidelines and a recognition of the limitations of current imaging technology, children with UPJO can be safely and efficiently managed with a largely watch-and-wait approach with operative intervention selectively.
Article
Congenital anomalies of the kidneys and urinary tract (CAKUT) encompass a spectrum of anomalies that result from genetic, epigenetic, environmental, and molecular signal aberrations at key stages of urinary tract development. CAKUT can be seen incidentally on cross-sectional imaging of the abdomen or can be a cause for adult-onset chronic kidney disease, posing new challenges for nephrologists, urologists, and radiologists. Awareness of CAKUT and familiarity with their imaging findings permit optimal patient management and thorough workup to prevent hypertension and progression from CAKUT to renal failure. The purpose of this article is to review the cross-sectional imaging findings of CAKUT that may present in adulthood.
Article
Purpose: We report the results of laparoscopic vascular hitching (LVH) in a series of children with ureteropelvic junction obstruction (UPJO) owing to aberrant lower polar crossing vessels (CV). Our aim is to confirm if LVH associated with intraoperative diuretic test (DT) represents a good procedure to treat extrinsic-UPJO by CV. In order to confirm the relief of the obstruction we suggest performing an intraoperative DT. Materials and methods: In our department from 2006 to 2014, 120 patients were treated for both extrinsic and intrinsic-UPJO. 85 (30 females, 55 males) presented an intrinsic obstruction and underwent dismembered pyeloplasty (AHDP), 61 open, 16 laparoscopic, 8 retroperitoneoscopic. 35 (23 males, 12 females) were studied for a suspected extrinsic-UPJO: 30 were treated with LVH (modified Hellström vascular hitch). Intraoperative-DT was performed in all patients before and after vessel transpositions confirming the UPJO and eventual relief after the procedure. We included in the study only patients with suspicion of vascular extrinsic-UPJO. Average age at surgery was 7.5years. Symptoms of presentation were recurrent abdominal/flank pain and hematuria. All patients presented ultrasound (US) detection of hydronephrosis. Preoperative diagnostic studies include: US/doppler scan, MAG3 renogram, urography, functional magnetic resonance urography (fMRU) and CT scan. Results: 28 out 35 patients had a correct preoperative diagnosis, and the remaining needed an intraoperative diagnosis confirmation. All 35 patients had an intraoperative-DT: 30 patients underwent LVH (positive-DT); 3 patients (negative-DT) underwent laparoscopic-AHDP for intrinsic-UPJO; two with positive-DT and nonobstructive CV, had no surgical treatment. Median operating time was 95min; mean hospital stay was 4days. At 12-84months follow-up 29 patients remained symptoms-free, one needed after two years a laparoscopic-AHDP. Conclusions: According our experience, LVH associated with intraoperative-DT may be considered a safe procedure to treat extrinsic-UPJO by CV in carefully selected patients. In particular, the very low incidence of relapse suggest that in suspicion of extrinsic-UPJO, performing intraoperative-DT after CV transposition allows to exclude intrinsic-UPJO confirming that the LVH-procedure has relieved the pelvic obstruction, precluding the need for AHDP.
Aims: Pelviureteric junction obstruction (PUJO) due to aberrant lower polar artery is conventionally managed with pyeloplasty. We present our experience of managing PUJO due to "vascular" anomalies-aberrant lower polar artery and vascular adhesions with simpler surgical options. Subjects and methods: This is a protocol based, retrospective study of PUJO. Preoperative investigations included ultrasonography (USG) and diuretic renogram. An intraoperative methylene blue test (MBT) assessed transit across the Pelviureteric junction (PUJ) after release of vascular compression. Surgical management included adhesiolysis for vascular adhesions and pyelopyelostomy anterior to the aberrant polar artery. Postoperative studies were repeated after 3 and 6 months. Results: Fourteen of 144 PUJO (9.7%) were "vascular" obstructions. Those with vascular adhesions (six) were largely infants with antenatal hydronephrosis. Children with aberrant lower polar artery (eight) were older, had fleeting symptoms, minimally increased pelvic diameter and subtle impairment on diuretic renogram. Majority were term males with urinary tract infection. The MBT showed normal transit across the PUJ in all. Postoperatively, there was progressive improvement on USG and diuretic renogram after 3 and 6 months. None had any complication or redosurgeries. At a mean follow-up of 41.2 months, all are asymptomatic. Conclusions: PUJO due to extrinsic vascular anomalies is rare. Intraoperative evaluation with the MBT ruled out associated intrinsic pathology. We describe two simple surgical alternatives preserving the normal PUJ - adhesiolysis for vascular adhesions and pyelopyelostomy for aberrant lower polar artery. The preliminary outcomes are comparable to conventional pyeloplasty.
Article
The traditional surgical technique for pelviureteric junction obstruction (PUJO) is the dismembered pyeloplasty which may be performed open, laparoscopic, or robotic assisted. In a select group of patients, aberrant lower pole crossing vessels may be responsible for an extrinsic compression of the pelviureteric junction. Relocation of the lower pole vessels can relieve the obstruction in such cases. This chapter focuses on the indications, contraindications, technical aspects, and postoperative management of the laparoscopic relocation of the lower pole vessels also known as the vascular hitch or pyelopexy.
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Aim To assess if calibration of the ureteropelvic junction (UPJ) using a high-pressure balloon inflated at the UPJ level in patients with suspected crossing vessels (CV) could differentiate between intrinsic and extrinsic stenosis prior to laparoscopic vascular hitch (VH). Materials and Methods We reviewed patients with UPJO diagnosed at childhood or adolescence without previous evidence of antenatal or infant hydronephrosis (10 patients). By cystoscopy, a high-pressure balloon is sited at the UPJ and the balloon inflated to 8-12 atm under radiological screening. We considered intrinsic PUJO to be present where a ‘waist’ was observed at the PUJ on inflation of the balloon and a laparoscopic dismembered pyeloplasty is performed When no ‘waist’ is observed we considered this to represent extrinsic stenosis and a laparoscopic VH was performed. Patients with absence of intrinsic PUJ stenosis documented with this method are included for the study. Results Six patients presented pure extrinsic stenosis. The mean age at presentation was 10.8 years. Mean duration of surgery was 99 min and mean hospital stay was 24 hours in all cases. We found no intraoperative or postoperative complications. All children remain symptoms free at a mean follow up of 14 months. Ultrasound and renogram improved in all cases. Conclusion When no ‘waist’ is observed we considered this to represent extrinsic stenosis and a laparoscopic VH was performed. In these patients, laparoscopic transposition of lower pole crossing vessels (‘vascular hitch’) may be a safe and reliable surgical technique.
Article
Objective: To compare the outcomes for laparoscopic vascular hitch (VH) and dismembered pyeloplasty in patients with ureteropelvic junction obstruction (UPJO) secondary to crossing vessel (CV). Materials and methods: Patients who underwent laparoscopic management of CV at our institution were identified between 2008 and 2020. Baseline characteristics and outcome measures were compared between those who underwent VH and those who underwent dismembered pyeloplasty. Those who underwent VH were selected intraoperatively by identifying CV in absence of intrinsic obstruction by assessing resolution of hydronephrosis after cranially displacing the CV away from the ureteropelvic junction, followed by intraoperative fluid bolus and diuretic test. In addition, a systematic search and meta-analysis was performed in June 2020 (PROSPERO ID CRD42020195833). Results: 20 patients underwent VH and 74 dismembered pyeloplasty. On multivariate analysis, VH was associated with: shorter operative time and length of stay (p=0.001, OR 0.455 [95%CI 0.294,0.705], p=0.012, OR 0.383 [95%CI 0.183,0.803], respectively), lower use of stents (p<0.001, OR 0.024 [95%CI 0.004,0.141]), and opioid administration (p=0.005, OR 0.157 [95%CI 0.044,0.567]). 194 records were identified from our literature search and 18 records were included (3 comparative, 16 non-comparative). Meta-analysis of the comparative studies and our institutional data showed similar success rates (RR 1.77 [95%CI 0.33,9.52]) and complication rates (RR 0.75 [95%CI 0.20, 2.82]). VH was associated with shorter operative time (SMD -1.65 [95%CI -2.58,-0.72]) and hospital stay (SMD -1.41, [-2.36,-0.47]). VH's success rates ranged from 87.5% to 100% in identified studies. Failure of VH was associated with unrecognized concomitant intrinsic obstruction in addition to CV. Conclusions: VH, for well selected patients with CV without concomitant intrinsic obstruction, offers high success rate with shorter operative times.
Chapter
Congenital hydronephrosis is the most common cause of a palpable neonatal abdominal mass, of which ureteropelvic junction (UPJ) obstruction is the most likely cause. UPJ stenosis is also the most common cause of antenatal hydronephrosis. The upper tract dilatation classification is useful to predict outcome and document follow-up. Fifty percent of UPJ stenoses are associated with other congenital urological abnormalities. UPJ stenosis is largely caused by an intrinsic aperistaltic segment of ureter; however, occasionally extrinsic and secondary causes are implicated. Not all UPJ stenoses (stenoses) requires surgery. Indications for surgery include a split function <40%, a decrease in split function by 10%, poor gravity-assisted drainage and delayed tissue transit time on renogram or the development of pain or infection. An open or laparoscopic dismembered pyeloplasty (Anderson-Hynes technique) offers excellent surgical outcomes. Endopyelotomy has inferior outcomes and increased complications when compared to pyeloplasty. Nephrostomy may be required if complicated by pyonephrosis, and nephrectomy is indicated only split function of less than 10%.
Chapter
Open or laparoscopic dismembered pyeloplasty (DP) is the gold standard procedure to treat UPJO since the procedure was first described by Anderson and Hynes (AHDP) in 1949 [1]. UPJO may be caused by intrinsic disorganization or by extrinsic compression from crossing vessels (CV); extrinsic causes often present symptomatically in older children. The association between UPJ obstruction and extrinsic aetiology by lower pole CV was first described by Von Rokitansky in 1842 [2]. UPJO due to CV, frequently observed in adults, is a rare condition in neonates and has a slight incidence in older children. An alternative approach to pure extrinsic UPJO was first described by Hellström [3] always in 1949; it involved displacing the lower pole vessels cranially and then anchoring them to the anterior pelvic wall using vascular adventitial sutures. Chapman [4] further modified this technique by securing a more superior position of the lower pole vessels within a wrap of the anterior redundant pelvic wall without the need for vascular adventitial sutures. This technique has since been described in children as an alternative to open DP, with the largest series reported in 1999 by Pesce [5]. Aberrant vessels usually cause intermittent UPJO. These cases present a normal perinatal history, followed by the subsequent onset of clinical signs and symptoms, often influenced by the child’s hydration status, characterized by intermittent hydronephrosis on imaging and normal kidney function. The CV typically cross over the UPJ to perfuse the lower pole of the affected kidney. Currently, there are no definitive imaging techniques or intraoperative procedures available to confirm the aetiology of UPJO. As noted by Schneider [6], frequently one encounters anatomic variability in the relationship between the renal pelvis and the lower pole vessels. Some authors have proposed DP to exclude intrinsic associated anomalies; others, in order to minimize technical difficulties and improve outcomes, have described simpler procedures that do not involve pyeloureteral anastomosis. We describe in this chapter the paediatric laparoscopic vascular hitch (LVH), a mini-invasive approach to UPJO by CV, suggesting a simple and uncomplicated intraoperative test, DT, to confirm the relief of the obstruction. This technique gives excellent results in our hands.
Article
The purpose of this article is to assess the immediate results of laparoscopic transposition of aberrant renal vessels as an effective alternative to pyeloplasty in the treatment of children with external obstruction of the pyeloureteral junction. Material and methods. The laparoscopic vascular transposition technique was used in 3 children with hydronephrosis caused by aberrant renal vessels. The preoperative diagnostic examination included: ultrasound / Doppler scanning, radioisotope renal scanning and contrast computed urography. Renoscintigraphy showed that all patients had intermittent hydronephrosis (24–36 mm) and an obstructive pattern. In order to select patients in whom vascular transposition is possible, the diuretic loading test was made at the beginning of the surgery. During the surgery, accessory renal vessels were mobilized and moved upward, where they were fixed by "wrapping" with renal pelvis tissue. Results. The median operative time was 59.0±10.2 minutes, and the median hospital stay was 3.6±0.5 days. There were no complications at the early observation period. At the follow-up (6.0–24.0 months), all patients showed a decrease in the degree of hydronephrosis and an improvement in excretory function at the renogram. Conclusion. Preliminary results of the study have demonstrated safety and efficacy of laparoscopic repositioning of aberrant renal vessels for the treatment of hydronephrosis. A careful selection of patients through intraoperative functional tests is an important step to confirm indications for this procedure and to maintain its high success rate. Any concerns about the presence of additional internal stenosis of the pyeloureteral junction, of course, should transform this surgical intervention into the classic pyeloplasty.
Article
The standard treatment for pelviureteric junction obstruction (PUJO) has been dismembered pyeloplasty. The open surgical, Hellström procedure in which crossing polar vessels are relocated, has been an option in adult urological practice. We present our experience with laparoscopic vascular relocation in children. Data were retrospectively gathered on all patients who underwent laparoscopic relocation of lower pole vessels (LRLPV) at our institution between July 2004 and March 2008. Follow-up ultrasounds and MAG3 were obtained. LRLPV was performed in 10 boys and 9 girls. Patients were between 5.8 and 15.25 years (median 9.9 years). They presented with recurrent abdominal pain (n = 17), urinary tract infections (n = 7) and haematuria (n = 3). On ultrasound, MAG3 and retrograde studies they had hydronephrosis, obstructed drainage and a normal calibre ureter with a sharp cut-off. They were further assessed at laparoscopy and were found to have aberrant lower pole crossing vessels. All underwent laparoscopic mobilization of the lower pole vessels from the region of the PUJ thereby freeing the junction and relocating them superiorly onto the anterior wall of the pelvis. The median operating time was 120 min (range 60-240 min). The median hospital stay was 2 days (range 1-3 days). They were followed up for a median period of 12 months (range 6-36 months). All patients have remained asymptomatic. Ultrasound done at 6 months showed decreased hydronephrosis. MAG3 study showed improved drainage in 17, while 1 had poor drainage. This patient remains symptom free and is under regular follow up. Laparoscopic vascular relocation is an unconventional technique in carefully selected patients with PUJO. It obviates disrupting an intrinsically normal PU junction and treats the cause rather than the effect. Our intermediate-term results are encouraging and further long-term assessment is needed.
Article
Dismembered pyeloplasty has been the traditional technique in the management of pelvi-ureteric junction obstruction (PUJO) secondary to crossing renal vessels in children. Laparoscopic transposition of lower pole vessels for PUJO has been described in children as well as adults. We report a child with PUJO secondary to lower pole renal vessels who underwent laparoscopic transposition of vessels. The child had persistent PUJO, which was later treated with laparoscopic dismembered pyeloplasty. Laparoscopic transposition of renal vessels is a simple technique, and requires less operating time. It involves no anastomosis or insertion of temporary DJ stent. However, as of now there are no imaging techniques or intraoperative procedures available to confirm that the crossing renal vessels are the sole etiology for PUJO. This option should therefore be used with caution.
Article
Dismembered pyeloplasty is the traditional technique in the management of ureterovascular pelvi-ureteric junction obstruction (PUJO) in children. Controversy remains regarding the role of lower pole vessels as the sole aetiology for PUJO. Endopyelotomy and concomitant laparoscopic transposition of lower pole vessels for PUJO has been described in adults. We describe our technique of laparoscopic transposition of lower pole vessels in children with PUJO, leaving the PUJ intact. Thirteen patients (seven boys and six girls) with a mean age of 10.2 years (range 7-16 years) underwent laparoscopic transposition of lower pole vessels. Surgery was indicated on the basis of intermittent pain and ultrasound/MAG3 appearance of obstruction with or without reduced function. The technique involved laparoscopic transperitoneal mobilization of the lower pole vessels from the region of the PUJ thereby freeing the junction and transposing them superiorly onto the anterior wall of the pelvis. The main outcome measures were relief of pain and improvement in ultrasound appearance or drainage parameters on a postoperative MAG3 renogram performed within 4-6 weeks of surgery. Median operating time was 92 min. All patients were discharged within 36 h of surgery. All patients remain pain free at a median of 6 months (range 3-18 months). Twelve patients showed good drainage on the postoperative MAG3 renogram and improvement in ultrasound appearance. One patient had recurrent symptoms requiring insertion of a JJ stent. She has undergone further laparoscopic exploration. The vessels were in their transposed position and there was a kink at the PUJ which was released. She had a vertical pyelotomy and transverse closure over the JJ stent with good results. This technique is simple and requires less operating time. No anastomosis or temporary JJ stent is required. Our early results are very encouraging with no serious complications.
Article
Standard treatment for ureterovascular ureteropelvic junction obstruction has been dismembered pyeloplasty. We previously reported the alternative technique of laparoscopic transposition of lower pole vessels (the vascular hitch) in pediatric patients. This report is an update of this select group of pediatric patients with intermediate followup. Patients underwent diagnostic renal sonography and (99m)technetium-mercaptoacetyltriglycine diuretic renography with additional magnetic resonance angiography in candidate patients. Radiographic criteria included moderate hydronephrosis with no caliceal dilatation and a well preserved cortex, poor renal drainage with preserved split function and lower pole crossing vessels. Intraoperative criteria included a normal ureter and ureteropelvic junction with peristalsis. Postoperatively patients were followed clinically, and with renal sonography and (99m)technetium-mercaptoacetyltriglycine renography at 1 and 2 months, respectively. Success was defined as symptom resolution with radiographic improvement in hydronephrosis and drainage with preserved renal function. Nine boys and 11 girls 7 to 16 years old (mean age 12.5) underwent laparoscopic transposition of crossing vessels, including 3 with da Vinci robot assistance. Mean operative time was 90 minutes (range 47 to 140). Median hospital stay was 24 hours. No ureteral stents or urethral catheters were placed intraoperatively. At a mean followup of 22 months (range 12 to 42) 19 of 20 patients (95%) had been successfully treated. One patient who had recurrent pain underwent successful laparoscopic pyeloplasty. At intermediate followup the laparoscopic vascular hitch procedure has been successful in treating patients with ureterovascular ureteropelvic junction obstruction. In these select patients this technique offers a feasible and durable alternative to standard dismembered pyeloplasty. Ongoing evaluation continues to ensure that the promising results endure.
Article
The pelvis, an angulated upper segment of the ureter and the lower anterior renal segmental vessels entangle to produce hydronephrosis. However, which of the 3 structures provokes obstruction is conjectural. The structural relations in this anomaly were compared to those of normal kidneys, hydronephroses from other causes and nonrotated kidneys. This anomaly was unique in that the pelvis and ureteropelvic junction bulged over the lower hilar segmental vessels instead of under as in other forms of hydronephrosis. Transient or permanent defects of medial rotation of the renal pelvis may account for the vulnerability of the ureteropelvic junction to obstruction by the lower anterior segmental branch of the renal artery, which was not aberrant in all the examples studied.
Article
To evaluate the efficacy of the vessel transposition technique in ureterovascular hydronephrosis in children. Over a 25-year period, we treated 111 patients with 112 instances of ureterovascular hydronephrosis. In order to determine the obstructive effect of the vessels, we performed an intraoperative diuretic test. Using this approach, 61 patients judged to have only vascular pyeloureteral junction obstruction underwent vessel transposition. However, 50 patients in whom the intraoperative diuretic test proved doubtful needed pyeloplasty. Surgical success was achieved in 98% of the patients. Only 1 child treated by vessel transposition had an unsatisfactory outcome which necessitated a subsequent pyeloplasty for persistent hydronephrosis. This was due to a previously unrecognized intrinsic pyeloureteral junction obstruction. Based on our clinical experience, the intraoperative diuretic test has proven to be a safe and effective diagnostic tool in children with ureterovascular hydronephrosis. Its use may contribute to treating some cases of ureterovascular hydronephrosis without resorting to pyeloplasty.
Article
Laparoscopic pyeloplasty must be compared with open surgery in terms of efficacy and with endopyelotomy in terms of morbidity. All of the series published so far show that the results of laparoscopic pyeloplasty equal those of open surgery. Laparoscopy is associated with a lower morbidity; therefore, it is preferable to open surgery. The morbidity of endopyelotomy is also low, at least when it is performed in a retrograde fashion. The results of endopyelotomy are poor if UPJ obstruction is caused by crossing vessels. In addition, endopyelotomy in this clinical setting carries the risk of hemorrhage. Most adults with symptomatic UPJ obstruction present with crossing vessels at the UPJ. These patients benefit from laparoscopy, and endopyelotomy should be reserved for patients with true intrinsic stenoses. For this reason, preoperative investigation using contemporary imaging techniques is of crucial importance to be able to select the most appropriate surgical method for a given patient. Laparoscopic dismembered pyeloplasty is technically feasible but difficult. The authors prefer nondismembered techniques that yield equally good results in selected patients. Nondismembered pyeloplasty as described by Fenger is easy to perform and well suited for laparoscopy.
Article
To determine whether prenatal sonography and early detection and correction of ureteropelvic junction obstruction (UPJO) has changed the incidence of crossing vessels as the etiology of obstruction in older children presenting with symptomatic UPJO. We reviewed the medical records of all children and adolescents who underwent pyeloplasty for symptomatic UPJO between 1986 and 1999, during the era of widespread use of prenatal sonography. Operative notes were used to determine which patients had obstruction due to lower pole crossing vessels. Thirty-eight patients were identified who underwent pyeloplasty for symptomatic UPJO. Lower pole vessels were identified in 22 (58%) of 38 patients (P <0.0001 compared with historical controls). All patients underwent dismembered pyeloplasty and remained asymptomatic after surgery, with renal scans demonstrating excellent drainage and preservation of function. Prenatal ultrasonography has increased the incidence of crossing vessels as the etiology of UPJO in young children and adolescents presenting with symptomatic UPJO compared with the historical incidence of 11% to 15%. This finding may impact treatment recommendations with respect to endourologic management of the obstruction in this patient population. Currently, we recommend open dismembered pyeloplasty for young children and adolescents presenting with symptomatic UPJO.
Symptomatic ureteropelvic junction obstruction in children in the era of prenatal sonography-is there a higher incidence of crossing vessels?.
  • Cain M.P.
  • Rink R.C.
  • Thomas A.C.
  • Austin P.F.
  • Kaefer M.
  • Casael A.J.
Ureterovascular hydronephrosis in children: is pyeloplasty always necessary?.
  • Pesce C.
  • Campbasso P.
  • Costa L.
  • Battaglino F.
  • Musi L.