Long-term results with the laparoscopic transposition of renal lower pole crossing vessels

Uretero-pelvic junction obstruction in children: Is vascular hitch an effective and safe solutions in very long term outcome? Report of 25 years follow-up

Vascular (VH) according to Hellstrom-Chapman technique is considered a safe and effective alternative approach to pure extrinsic Ureteropelvic Junction Obstruction (UPJO) with good results in short and medium term, but few data are available on long and verylong term outcomes. Our aim is to evaluate VH long and very-long term outcomes in patients treated in pediatric age focusing on relapse, development of hypertension and/or inferior polar kidney hypotrophy during puberty and adulthood. From 1990 to 2015 in our Department 76 children were treated by open or laparoscopic VH for pure extrinsic-UPJO. We were able to contact 54 of 76. 41 patients (25 males, 16 females) accepted to be studied. Mean follow- up time was 12.7 years (range 6-27 years); mean age at the assessment was 22.2 years. We excluded patients who were younger than 13 (if females) or 14 (if males) at the assessment (upper limits of physiological puberty onset). Patients were followed with US, MAG-3-scan and arterial blood pressure measurement. Collected data were compared with the preoperative ones by Student t-test. 95% of US images and MAG-3-scan reports were compatible with complete resolution of obstruction with good renal functionality. 87% of patients were completely healthy. We recorded 3 cases of hypertension (7%) not secondary to renovascular origin; 2 cases with recurrent flank pain (5%) with slightly dilated pelvis at the US and sub-obstructive pattern at MAG-3-scan with preserved renal function. Our experience confirms that VH, (open/laparoscopic) is a safe and effective procedure with good outcomes at very longterm follow-up. No patients at puberty and in adulthood required reoperation or presented polar hypotrophy and related vascular hypertension. VH is an alternative approach to pure extrinsic-UPJO. There were few data about long and very-long term outcomes in patients after this kind of surgery. We followed-up 41 patients confirming that VH (open/laparoscopic) is safe and effective with good long-term outcomes.

Transposition and fixation of lower pole crossing vessel in children with ureteropelvic junction obstruction: A STROBE-compliant study

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.

Minimally invasive vascular hitch to treat pediatric extrinsic ureteropelvic junction obstruction by crossing polar vessels: A systematic review and meta-analysis

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 2783 titles/abstracts screened, 43 full-text articles were analyzed. Twelve studies on laparoscopic VH (298 pts) reported 98.3% success rate, with 1.3% intra-operative complications. Meta-Analysis - Five studies compared laparoscopic VH versus laparoscopic DP (277 pts). Operative time was reduced in VH (102.5 ± 47.5min) compared to DP (165.7 ± 53.7min; p < 0.00001). Complications were similar (VH 4/119 pts, 3.4 ± 1.2% versus DP 15/158 pts, 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; Summary Figure). The success rate was comparable (VH 115/118 pts, 97.5 ± 1.6% versus DP 157/158 pts, 99.4 ± 0.5%; p = ns). Two prospective studies compared robot-assisted VH to laparoscopic VH (53 pts). No differences were found among complications (robot-assisted VH 0/13 pts, 0% versus laparoscopic VH 1/40 pts, 2.5%; p = ns) and success rate (robot-assisted VH 13/13 pts, 100% versus laparoscopic VH 39/40 pts, 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.

Laparoscopic Vascular Hitch for Polar Vessels in Pyeloureteric Junction Obstruction: Medium-Term Follow-up of a Monocentric Experience

INTRODUCTION

 To evaluate medium-term results of the management of patients with pyeloureteric junction obstruction (PUJO) secondary to lower pole vessels managed by a laparoscopic vascular hitch technique.

MATERIALS AND METHODS

 We performed a retrospective monocentric study of all patients who were operated using this technique, transperitoneal laparoscopy (TL) or robotic surgery (RS), from 2011 to 2018. Description of the initial population, pre- and postoperative data was collected and analyzed.

RESULTS

 During the study period, 25 patients (11 males and 14 females) with a mean age of 11.1 years were managed. Initial symptoms leading to the diagnosis were present in 21 children (lumbar pain 17, high blood pressure 1, and infection 3). Four patients were diagnosed incidentally (three) or following a prenatal screening (one). The diagnostic has been confirmed in all patients by ultrasound scan completed by computed tomography or magnetic resonance imaging scans. Twenty-one patients were operated by TL and four by RS. Mean operating time was 90.2 minutes. Three immediate postoperative complications were noticed including one urinary tract infection, one urinary tract rupture, and one postoperative massive dilatation. After a mean follow-up of 3 1.5 years, 17 patients remain asymptomatic. Mean pelvic diameter was preoperatively 35 mm and postoperatively 10.5 mm (p < 0.005). Of the eight remaining patients, six required reoperation (pyeloplasty) and two remained symptomatic with recurrent flank pain.

CONCLUSION

 In our experience, PUJO managed by the vascular hitch technique is associated with a 68% success rate after a 3-year follow-up. These results are different from the current literature which reported success rate of 96% after 52 months. It leads us to question the efficiency of this technique in the long term in our hands both concerning the indications and the surgical procedure itself. Further studies are required to collect data concerning the evolution of our patients during adulthood to compare their evolution to classic pyeloplasty.

Crossing vessels with suspension versus transposition in laparoscopic pyeloplasty of patients with ureteropelvic junction obstruction: a retrospective study

Purpose

To compare the effects of two different methods of laparoscopic pyeloplasty for the treatment of crossing vessels.

Methods

From January 2016 to August 2019, 33 patients with ureteropelvic junction obstruction (UPJO) underwent laparoscopic pyeloplasty at our center, including 21 men and 12 women, ranging from 14 to 66 years of age. There were 20 and 13 cases on the left and right sides, respectively. Patients underwent laparoscopic pyeloplasty (Anderson-Hynes operation). During the operation, either a Hem-o-lok clip suspension or transposition was used to treat the crossing vessels. The double-J stent was removed 8 weeks after the operation. The clinical data of patients were collected and follow-ups were regularly performed after the operation.

Results

All the crossing vessels were successfully preserved, and none of them were severed during the operation. The average operation time was 210.6 ± 58.9 min in this group and the average time to manage the crossing vessel was 8.0 ± 3.5 min, 5.9 ± 1.4 min in the suspension group, and 11.7 ± 3.0 min in the transposition group. The dilation of the affected side was 4.8 ± 1.5 cm before operation and 1.2 ± 1.3 cm 3 months after operation. The difference was statistically significant (P < 0.05). Follow-up to February 2020 showed no significant changes in the kidney size in all patients and hydronephrosis was relieved.

Conclusion

For UPJO patients with crossing vessel compression, the method of Hem-o-lok suspension or vascular transposition can be used to relieve crossing vascular compression and improve the success of pyeloplasty.

Vascular hitch for paediatric pelvi-ureteric junction obstruction with crossing vessels: institutional analysis and systematic review with meta-analysis

OBJECTIVE

To compare the outcomes for laparoscopic vascular hitch (VH) and dismembered pyeloplasty in patients with pelvi-ureteric junction obstruction (PUJO) secondary to crossing vessels (CV).

PATIENTS 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 the absence of intrinsic obstruction by assessing resolution of hydronephrosis after cranially displacing the CV away from the PUJ, followed by intraoperative fluid bolus and diuretic test. In addition, a systematic search and meta-analysis were performed in June 2020 (International Prospective Register of Systematic Reviews [PROSPERO] ID CRD42020195833).

RESULTS

A total of 20 patients underwent VH and 74 dismembered pyeloplasty. On multivariate analysis, VH was associated with: shorter operative time (P = 0.001; odds ratio [OR] 0.455, 95% confidence interval [CI] 0.294-0.705) and length of stay (P = 0.012; OR 0.383, 95% CI 0.183-0.803), 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). From our literature search, 194 records were identified and 18 records were included (three comparative and 16 non-comparative). Meta-analysis of the comparative studies and our institutional data showed similar success rates (relative risk [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 (standardised mean difference [SMD] -1.65, 95% CI -2.58 to -0.72 h) and hospital stay (SMD -1.41, 95% CI -2.36 to -0.47 days). The VH success rates ranged from 87.5% to 100% in the identified studies. Failure of VH was associated with unrecognised concomitant intrinsic obstruction in addition to CV.

CONCLUSIONS

A VH, for well-selected patients with CV without concomitant intrinsic obstruction, offers a high success rate with shorter operative times.

Meta-Analysis of the Efficacy of Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction via Retroperitoneal and Transperitoneal Approaches

Objective: This study aimed to evaluate the clinical efficacy of laparoscopic pyeloplasty (LP) for ureteropelvic junction obstruction (UPJO) via retroperitoneal and transperitoneal approaches. Method: A systematic literature search on keywords was undertaken using PubMed, Cochrane Library, Embase, China Nation Knowledge (CNKI), and Wanfang. The eligible literature was screened according to inclusion and exclusion criteria. Meta-analysis was performed by using RevMan 5.0 software. Results: According to the inclusion and exclusion criteria, 12 studies were identified with a total of 777 patients. Four hundred eight patients were treated with retroperitoneal laparoscopic pyeloplasty (RLP), and 368 patients were treated with transperitoneal laparoscopic pyeloplasty (TLP). The meta-analysis results showed that the two approaches were similar in terms of presence of postoperative hospital stay, postoperative complication, the rate of conversion, and recurrence (p > 0.05). The operative time in the TLP group was significantly shorter than the RLP group (MD = 16.6; 95% CI, 3.40-29.80; p = 0.01). The duration of drainage was significantly shorter (MD = -1.06; 95% CI, -1.92 to -0.19; p = 0.02), and the score of postoperative visual analog score (VAS) was significantly lower in the RLP group than in the TLP group (MD = -0.52; 95% CI, -0.96 to -0.08; p = 0.02). Conclusion: Both approaches have good success rates and low postoperative complication rates. RLP provides a shorter duration of drainage and lower VAS score, but it takes more operative time than TLP.

Searching for the Least Invasive Management of Pelvi-Ureteric Junction Obstruction in Children: A Critical Literature Review of Comparative Outcomes

Introduction: To review the published evidence on the minimally invasive pyeloplasty techniques available currently with particular emphasis on the comparative data about the various minimally invasive alternatives to treat pelvi-ureteric junction obstruction and gauge if one should be favored under certain circumstances. Materials and Methods: Non-systematic review of literature on open and minimally invasive pyeloplasty including various kinds of laparoscopic procedures, the robotic-assisted laparoscopic pyeloplasty, and endourological procedures. Results: Any particular minimally invasive pyeloplasty procedure seems feasible in experienced hands, irrespective of age including infants. Comparative data suggest that the robotic-assisted procedure has gained wider acceptance mainly because it is ergonomically more suited to surgeon well-being and facilitates advanced skills with dexterity thanks to 7 degrees of freedom. However, costs remain the major drawback of robotic surgery. In young children and infants, instead, open surgery can be performed via a relatively small incision and quicker time frame. Conclusions: The best approach for pyeloplasty is still a matter of debate. The robotic approach has gained increasing acceptance over the last years with major advantages of the surgeon well-being and ergonomics and the ease of suturing. Evidence, however, may favor the use of open surgery in infancy.

Medusa's Curls: Ureteropelvic Junction Obstruction Secondary to Multiple Long Intraluminal Polyps

Fibroepithelial polyps represent a rare cause of intrinsic ureteropelvic junction obstruction in the pediatric population, accounting for less than 5% of cases. Herein, we present this peculiar case of a 10-year-old boy with multiple large intraluminal FEPs resembling Medusa's hair and the challenges associated with its subsequent treatment plan.

Hydronephrosis in Children Caused by Lower Pole Crossing Vessels-How to Choose the Proper Method of Treatment?

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.

Is there a difference in the number of interstitial cells, neurons, presence of fibrosis and inflammation in ureteropelvic junction tissues of patients with ureteropelvic junction obstruction with and without crossing vessels?

OBJECTIVE

We compared the number of interstitial cells (ICs), nerves, presence of fibrosis and inflammation at the level of full-thickness human ureteropelvic junction (UPJ) tissues obtained from normal subjects, and patients with UPJ obstruction with and without crossing vessels.

MATERIAL AND METHODS

Normal UPJ tissues (n=12) histopathologically confirmed to be without tumor involvement were obtained from subjects who underwent radical nephrectomy for kidney mass. Additional UPJ tissues were obtained from patients who underwent pyeloplasty due to UPJ obstruction. Crossing vessel was identified in 17 patients. In 57 patients, no crossing-vessel was noted. ICs were stained immunohistochemically with anti-human CD117 (c-kit) antibody. Neural tissue was stained with S-100. The numbers of ICs and neurons were compared between the groups: controls with normal UPJ (Group I), Ureteropelvic junction obtruction (UPJO) with crossing vessel (Group II) and UPJ obstruction without crossing vessel (Group III). Groups were also compared in terms of the presence of fibrosis and inflammation.

RESULTS

The mean age of total population included in the study was 30.5±18.5 years. No significant differences were detected between the three groups regarding mean and median numbers of ICs at the level of UPJ (lamina propria and muscle layer) and mean and median numbers of neurons at the level of lamina propria (p>0.05). Likewise, no significant differences were detected between the three groups regarding the presence of fibrosis and inflammation (p>0.05).

CONCLUSION

Number of ICs, neurons, presence of fibrosis and inflammation seem to be similar in the intact UPJ and UPJ with obstruction with and without crossing vessel. Cellular function rather than the number ICs might play a role that warrants further research.

Hydronephrosis and crossing vessels in children: Optimization of diagnostic-therapeutic pathway and analysis of color Doppler ultrasound and magnetic resonance urography diagnostic accuracy

INTRODUCTION

Ureteropelvic junction obstruction (UPJO) is one of the most frequent urological diseases affecting the pediatric population. It can be due to both intrinsic stenosis of the junction and extrinsic causes such as the presence of crossing vessels (CVs), which can be detected by color Doppler ultrasound (CD-US). Magnetic resonance urography (MRU) is a good alternative, but sedation and infusion of a contrast agent are required.

OBJECTIVE

The aim of this study was to analyze the diagnostic accuracy of CD-US and MRU in visualizing CVs in pediatric hydronephrosis, in order to decide the correct diagnostic pathway in the pre-operative phase.

MATERIAL AND METHODS

A retrospective review was performed of medical records for all patients who underwent surgical treatment for hydronephrosis from August 2006 to February 2016. Ultrasound and scintigraphy had been performed on all patients. Data about CD-US and MRU were collected. A high-level technology ultrasound scanner and a 1.5 T MR scanner were used. The presence of CVs at surgery was considered the gold standard. Sensitivity, specificity, positive and negative predictive values (NPV) were calculated and reported for both of the imaging techniques.

RESULTS

A total of 220 clinical charts were reviewed. Seventy-three CVs were identified at surgery (33.2% of UPJO). The median age was statistically higher in the group with CVs compared to the group without CVs (P < 0.001). The sensitivity and NPV of CD-US in detecting CVs were higher than MRU (sensitivity 93.3% vs. 71.7%, NPV 95.7% vs. 77.6%, respectively).

DISCUSSION

According to the data, CD-US had higher sensitivity and NPV than MRU, resulting in superior detection of CVs. It is important for a surgeon to know that a child has a CV, especially in older children in which the incidence of extrinsic UPJO is higher. The main limitation of this study was the presence of incomplete data, due to the retrospectivity.

CONCLUSIONS

In the pre-operative phase, the CD-US should be considered as the investigation of choice to detect CVs in children with hydronephrosis (Summary Fig). Moreover, CD-US has lower costs than MRU, and sedation with infusion of contrast agent is unnecessary. For the future, it could be useful to lead a prospective comparison between the two imaging techniques.

Minimally Invasive Treatment of Pediatric Extrinsic Ureteropelvic Junction Obstruction by Crossing Polar Vessels: Is Vascular Hitching a Definitive Solution? Report of a Multicenter Survey

BACKGROUND

This article aimed to evaluate the outcome of laparoscopic vascular hitch (VH) as an effective alternative to dismembered pyeloplasty in the treatment of children with extrinsic ureteropelvic junction obstruction (UPJO) by crossing vessels (CVs), by reporting the experience of three Italian centers of Pediatric Surgery.

METHODS

From 2006 to 2014, 54 children (18 girls and 36 boys, average age 10.7 years) affected by suspected extrinsic UPJO by CV were treated in three different institutions: 51 patients underwent laparoscopic VH, while 3 patients, in which a coexisting intrinsic etiology of UPJO was doubtful, underwent laparoscopic dismembered pyeloplasty. Preoperative diagnostic workup included: ultrasound (US)/Doppler scan, mercaptoacetyltriglycine (MAG3)-renal scan, and functional-magnetic-resonance-urography (fMRU). Symptoms at presentation were recurrent abdominal/flank pain and hematuria. All patients presented intermittent hydronephrosis (range 18-100 mm) on US and an obstructive pattern on MAG3 renogram.

RESULTS

Average operative time was 108 minutes, and average hospital stay was 1.8 days. As for complications, we reported a small abdominal wall hematoma and a high UPJ distortion without obstruction in 2 patients, not requiring reintervention (grade I Clavien-Dindo). At follow-up (range 12-96 months), all patients reported resolution of symptoms, decrease in the hydronephrosis grade, and improved drainage on MAG3 renogram.

CONCLUSIONS

Our results demonstrated the safety and efficacy of laparoscopic VH for treatment of extrinsic UPJO by CV, registering excellent outcomes in a very selected patient population. The careful selection of patients through intraoperative assessment of anatomical and functional aspects is a crucial step to confirm indications for VH and maintain a high success rate with the procedure. We believe that any concerns regarding the coexistence of intrinsic stenosis should certainly lead to opening the collecting system and to performing a classic dismembered pyeloplasty.

Laparoscopic transposition of lower-pole crossing vessels: Long-term follow-up of 33 patients at puberty

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.