Laparoscopic Management of Extrinsic Ureteropelvic Junction Obstruction (UPJO) by Crossing Vessels

Abstract

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.