Transposition and fixation of lower pole crossing vessel in children with ureteropelvic junction obstruction

Abstract

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.

What is the role of crossing vessel and how to treat it?

“…Balloon dilatation shows a 'waist type' appearance in the PUJ zone, which represents a combination of extrinsic and intrinsic causes of PUJO; endoscopic surgery can examine the intraluminal condition of the PUJ; intraoperative diuretic testing can determine whether there is dynamic obstruction of the PUJ [2].…”

“…As for laparoscopic dismembered pyeloplasty, based on location and course of the CV, upward transposition or backward transposition can be chosen [1,2]. As disconnection of the CV can result in partial loss of renal function, the crossing artery is usually preserved [3].…”

“…There are no unified intraoperative standards to select appropriate patients for VH. A laparoscopic VH is given priority in patients with CV-induced PUJO excluding intrinsic causes under the following conditions: (i) normal colour of renal lower pole tissue after CV cephalad translocation; (ii) PUJ located at the bottom of the renal pelvis; (iii) lack of visible PUJ changes; (iv) observation of PUJ peristalsis after mobilising the CV; (v) decrease of the renal pelvis volume upon intraoperative diuretic testing; (vi) measurement of renal pelvic pressure; (vii) normal intraluminal condition identified by endoscopic procedure [2,3].…”