1
|
Sizonov VV, Shidaev AHA, Mayr JM, Kogan MI, Kagantsov IM, Rostovskaya VV. Transposition and fixation of lower pole crossing vessel in children with ureteropelvic junction obstruction: A STROBE-compliant study. Medicine (Baltimore) 2021; 100:e28235. [PMID: 34941091 PMCID: PMC8701445 DOI: 10.1097/md.0000000000028235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 11/24/2021] [Indexed: 01/05/2023] Open
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.
Collapse
Affiliation(s)
| | - Askhab H.-A. Shidaev
- Rostov State Medical University, Department of Urology and Human Reproductive Health, Rostov-on-Don, Russia
| | - Johannes M. Mayr
- University Children's Hospital Basel, Spitalstrasse 33, Basel, Switzerland
| | | | - Ilya M. Kagantsov
- Research Institute of Surgery of Congenital and Hereditary Pathology Institute of Perinatology and Pediatrics, Federal State Budgetary Institution “Almazov National Medical Research Center”, Saint Petersburg, Russia
| | - Vera V. Rostovskaya
- First Moscow State Medical University, Department of Pediatric Surgery and Urology-Andrology, Moscow, Russia
| |
Collapse
|
2
|
Liu J, Zhang J, Chen W, Xiong L, Huang X, Ye X. Crossing vessels with suspension versus transposition in laparoscopic pyeloplasty of patients with ureteropelvic junction obstruction: a retrospective study. BMC Urol 2021; 21:77. [PMID: 33957905 PMCID: PMC8101153 DOI: 10.1186/s12894-021-00846-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/26/2021] [Indexed: 01/13/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Jun Liu
- Urology and Lithotripsy Center, Peking University People's Hospital, Peking University, 133 Fuchengmen Inner Street, Xicheng District, Beijing, 100034, People's Republic of China.,Peking University Applied Lithotripsy Institute, Peking University, Beijing, 100034, China
| | - Jingjun Zhang
- Department of Urology, Peking University BinHai Hospital (Fifth Tianjin Central Hospital), Tianjin, 300450, China
| | - Weinan Chen
- Urology and Lithotripsy Center, Peking University People's Hospital, Peking University, 133 Fuchengmen Inner Street, Xicheng District, Beijing, 100034, People's Republic of China.,Peking University Applied Lithotripsy Institute, Peking University, Beijing, 100034, China
| | - Liulin Xiong
- Urology and Lithotripsy Center, Peking University People's Hospital, Peking University, 133 Fuchengmen Inner Street, Xicheng District, Beijing, 100034, People's Republic of China.,Peking University Applied Lithotripsy Institute, Peking University, Beijing, 100034, China
| | - Xiaobo Huang
- Urology and Lithotripsy Center, Peking University People's Hospital, Peking University, 133 Fuchengmen Inner Street, Xicheng District, Beijing, 100034, People's Republic of China.,Peking University Applied Lithotripsy Institute, Peking University, Beijing, 100034, China
| | - Xiongjun Ye
- Urology and Lithotripsy Center, Peking University People's Hospital, Peking University, 133 Fuchengmen Inner Street, Xicheng District, Beijing, 100034, People's Republic of China. .,Peking University Applied Lithotripsy Institute, Peking University, Beijing, 100034, China.
| |
Collapse
|
3
|
Kim JK, Keefe DT, Rickard M, Milford K, Lorenzo AJ, Chua ME. Vascular hitch for paediatric pelvi-ureteric junction obstruction with crossing vessels: institutional analysis and systematic review with meta-analysis. BJU Int 2021; 129:679-687. [PMID: 33463000 DOI: 10.1111/bju.15342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 01/05/2021] [Accepted: 01/14/2021] [Indexed: 11/28/2022]
Abstract
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.
Collapse
Affiliation(s)
- Jin K Kim
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Daniel T Keefe
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mandy Rickard
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Karen Milford
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Armando J Lorenzo
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Michael E Chua
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON, Canada.,Institute of Urology, St. Luke's Medical Center, Quezon City, NCR, Phillipines
| |
Collapse
|
4
|
Polok M, Toczewski K, Borselle D, Apoznański W, Jędrzejuk D, Patkowski D. Hydronephrosis in Children Caused by Lower Pole Crossing Vessels-How to Choose the Proper Method of Treatment? Front Pediatr 2019; 7:83. [PMID: 30941339 PMCID: PMC6433871 DOI: 10.3389/fped.2019.00083] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 02/26/2019] [Indexed: 11/24/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Marcin Polok
- Department of Pediatric Surgery and Urology, Wroclaw Medical University, Wroclaw, Poland
| | - Krystian Toczewski
- Department of Pediatric Surgery and Urology, Wroclaw Medical University, Wroclaw, Poland
| | - Dominika Borselle
- Department of Pediatric Surgery and Urology, Wroclaw Medical University, Wroclaw, Poland
| | - Wojciech Apoznański
- Department of Pediatric Surgery and Urology, Wroclaw Medical University, Wroclaw, Poland
| | - Diana Jędrzejuk
- Department of Endocrinology, Diabetology and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Dariusz Patkowski
- Department of Pediatric Surgery and Urology, Wroclaw Medical University, Wroclaw, Poland
| |
Collapse
|
5
|
Panthier F, Lareyre F, Audouin M, Raffort J. Pelvi-ureteric junction obstruction related to crossing vessels: vascular anatomic variations and implication for surgical approaches. Int Urol Nephrol 2018; 50:385-394. [DOI: 10.1007/s11255-017-1771-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 12/08/2017] [Indexed: 11/24/2022]
|
6
|
Madec FX, Faraj S, Villemagne T, Fourcade L, Lardy H, Leclair MD. Laparoscopic transposition of lower-pole crossing vessels: Long-term follow-up of 33 patients at puberty. J Pediatr Urol 2016; 12:226.e1-6. [PMID: 27238751 DOI: 10.1016/j.jpurol.2016.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 03/21/2016] [Indexed: 10/21/2022]
Abstract
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.
Collapse
Affiliation(s)
- François-Xavier Madec
- Paediatric Surgery and Urology Department, Children University Hospital, Nantes, France
| | - Sébastien Faraj
- Paediatric Surgery and Urology Department, Children University Hospital, Nantes, France
| | - Thierry Villemagne
- Paediatric Surgery and Urology Department, Children University Hospital, Nantes, France; Paediatric Surgery Department, University Hospital, Tours, France
| | - Laurent Fourcade
- Paediatric Surgery Department, University Hospital, Limoges, France
| | - Hubert Lardy
- Paediatric Surgery Department, University Hospital, Tours, France
| | - Marc-David Leclair
- Paediatric Surgery and Urology Department, Children University Hospital, Nantes, France.
| |
Collapse
|
7
|
Long-term results with the laparoscopic transposition of renal lower pole crossing vessels. J Pediatr Urol 2015; 11:174.e1-7. [PMID: 26139159 DOI: 10.1016/j.jpurol.2015.04.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 04/25/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND 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. PURPOSE To report on the long-term follow-up of children after laparoscopic transposition of LPCV. METHODS 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. RESULTS 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. DISCUSSION 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. CONCLUSION 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.
Collapse
|
8
|
Damasio MB, Costanzo S, Podestà E, Ghiggeri G, Piaggio G, Faranda F, Degl'Innocenti ML, Jasonni V, Magnano GM, Buffa P, Montobbio G, Mattioli G. Magnetic resonance urography and laparoscopy in paediatric urology: a case series. Pediatr Radiol 2013; 43:1516-27. [PMID: 23900764 DOI: 10.1007/s00247-013-2724-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 02/08/2013] [Accepted: 04/03/2013] [Indexed: 12/21/2022]
Abstract
Paediatric urology often presents challenging scenarios. Magnetic resonance urography (MRU) and laparoscopy are increasingly used. We retrospectively studied children affected by a disease of the upper urinary tract who after MRU were elected for laparoscopic treatment. This pictorial essay draws on our experience; it illustrates some specific MRU findings and highlights the usefulness of MRU for the diagnosis of upper urinary tract pathology in children. It also offers some examples of the potential additional diagnostic information provided by laparoscopy as well as its therapeutic role.
Collapse
|
9
|
Autorino R, Eden C, El-Ghoneimi A, Guazzoni G, Buffi N, Peters CA, Stein RJ, Gettman M. Robot-assisted and laparoscopic repair of ureteropelvic junction obstruction: a systematic review and meta-analysis. Eur Urol 2013; 65:430-52. [PMID: 23856037 DOI: 10.1016/j.eururo.2013.06.053] [Citation(s) in RCA: 137] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 06/26/2013] [Indexed: 12/15/2022]
Abstract
CONTEXT Over the last two decades, minimally invasive treatment options for ureteropelvic junction obstruction (UPJO) have been developed and popularized. OBJECTIVE To critically analyze the current status of laparoscopic and robotic repair of UPJO. EVIDENCE ACQUISITION 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. EVIDENCE SYNTHESIS 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. CONCLUSIONS 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.
Collapse
Affiliation(s)
- Riccardo Autorino
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH, USA; Urology Service, Second University of Naples, Naples, Italy.
| | - Christopher Eden
- Department of Urology, Royal Surrey County Hospital, Guildford, UK
| | - Alaa El-Ghoneimi
- Department of Pediatric Surgery and Urology, Hôpital Robert Debré, Assistance Publique-Hopitaux de Paris, University of Paris Diderot, Paris, France
| | - Giorgio Guazzoni
- Department of Urology, Vita-Salute University, San Raffaele-Turro Hospital, Milan, Italy
| | - Nicolòmaria Buffi
- Department of Urology, Vita-Salute University, San Raffaele-Turro Hospital, Milan, Italy
| | - Craig A Peters
- Department of Pediatric Surgery, Children's National Medical Center, Washington, DC, USA
| | - Robert J Stein
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | | |
Collapse
|
10
|
Sameh W, Elgebaly OF. Laparoscopic transposition pyelo-pyelostomy for repair of adult uretero-pelvic junction obstruction secondary to lower pole crossing vessels: a novel technique. J Endourol 2011; 26:377-80. [PMID: 22192105 DOI: 10.1089/end.2011.0441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION An aberrant crossing vessel(s) (CV) is considered an important cause of uretero-pelvic junction obstruction (UPJO) in adults. Intrinsic defect at the uretero-pelvic junction (UPJ) is not necessarily present and so, dismembered pyeloplasty would not be necessary. We introduce in the present study a novel technique, laparoscopic transposition pyelo-pyelostomy (LTP) to treat UPJO caused by aberrant CV in adults. PATIENTS AND METHODS From July 2004 to August 2010, 21 adult patients were diagnosed as having UPJO secondary to aberrant CV and were treated laparoscopically by transposition pyelo-pyelostomy. The main presentation was pain in 13 patients, while 3 patients presented with fever. Five patients were accidentally discovered as having hydronephrosis in ultrasound (U/S). Preoperative intravenous urography and U/S revealed grade III hydronephrosis in 11 patients and grade IV in 10 patients. Diagnosis of CV was suspected preoperatively in the IVU in 15 patients and was confirmed by computed tomography. The remaining six patients were diagnosed intra-operatively. RESULTS The operative time ranged from 75 to 125 minutes with a mean of 93 minutes. The mean time for anastomosis was 12 minutes. No intra-operative complication was reported. Drain was removed after 48 hours, and mean hospital stay was 3 days. Symptom improvement was encountered in all symptomatic patients. Postoperative US done at 3 months revealed resolution of the hydronephrosis in 10 patients, and 11 patients had a residual grade I hydronephrosis. Diuretic renography at 1 year postoperatively revealed normal T1/2 in 19 patients. CONCLUSION LTP is a simple procedure that spares the normal UPJ and provides a wide, stentless anastomosis which nullifies the risk of re-stenosis and failure.
Collapse
Affiliation(s)
- Wael Sameh
- Department of Urology, Faculty of Medicin, Alexandria University, 50 Omar Lotfy Street, Alexandria, Egypt.
| | | |
Collapse
|
11
|
Nouralizadeh A, Simforoosh N, Basiri A, Tabibi A, Soltani MH, Kilani H. Laparoscopic management of ureteropelvic junction obstruction by division of the aberrant vein and cephalad relocation of the crossing artery: a long-term follow-up of 42 cases. J Endourol 2010; 24:987-91. [PMID: 20210527 DOI: 10.1089/end.2009.0524] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE It was intended to demonstrate the update report of our experience with laparoscopic management of ureteropelvic junction obstruction by division of the aberrant vein and cephalad relocation of the crossing artery in a large group of patients with long-term follow-up. PATIENTS AND METHODS Three hundred and twenty-nine patients were candidate to undergo laparoscopic transperitoneal ureteropelvic junction obstruction management from June 2001 to March 2009. Intraoperatively, lower pole crossing vessels were identified in 117 patients (35.5%). After division of the aberrant vein, the crossing artery was relocated cephalad and fixed to peripelvic tissue. Renal pelvic emptying with proper pyeloureteral peristalsis was considered in 71 patients, so neither pyeloplasty nor Double-J stent was fixed for them. Postoperative outcomes were assessed with intravenous urography and/or diethylene triamine pentaacetic acid-diuretic renal scan. RESULTS Of the 71 patients who underwent this laparoscopic approach, 42 were completely followed over a long-term period. The mean age of patients was 27 (7-69) years. The mean operative duration was 133 (55-185) minutes and blood loss was negligible. The mean hospital stay was 2.8 (1-7) days and mean follow-up was 29 (3-84) months. Overall success rate was 90% and recurrence of obstruction was noted in two patients. No significant complications were observed. CONCLUSION Cephalad relocation of the lower pole crossing artery after division of the crossing vein in selected cases could be an ideal alternative for dismembered pyeloplasty with noticeable outcomes in long-term follow-up.
Collapse
Affiliation(s)
- Akbar Nouralizadeh
- Urology and Nephrology Research Center, Shahid Labbafinejad Medical Center, Shahid Beheshti University, M.C., Tehran, Islamic Republic of Iran.
| | | | | | | | | | | |
Collapse
|
12
|
Singh RR, Govindarajan KK, Chandran H. Laparoscopic vascular relocation: alternative treatment for renovascular hydronephrosis in children. Pediatr Surg Int 2010; 26:717-20. [PMID: 20512343 DOI: 10.1007/s00383-010-2623-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2010] [Indexed: 10/19/2022]
Abstract
AIMS 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. METHODS 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. RESULTS 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. CONCLUSION 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.
Collapse
Affiliation(s)
- R R Singh
- Department of Paediatric Urology, Birmingham Children's Hospital, Birmingham, B4 6NH, UK.
| | | | | |
Collapse
|
13
|
Glodny B, Rapf K, Unterholzner V, Rehder P, Hofmann KJ, Strasak A, Herwig R, Petersen J. Accessory or additional renal arteries show no relevant effects on the width of the upper urinary tract: a 64-slice multidetector CT study in 1072 patients with 2132 kidneys. Br J Radiol 2010; 84:145-52. [PMID: 20223903 DOI: 10.1259/bjr/79479004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The aim of this study was to find out on an unselected patient group whether crossing vessels have an influence on the width of the renal pelvis and what independent predictors of these target variables exist. METHODS In this cross-sectional study, 1072 patients with arterially contrasted CT scans were included. The 2132 kidneys were supplied by 2736 arteries. RESULTS On the right side, there were 293 additional and accessory arteries in 286 patients, and on the left side there were 304 in 271 patients. 154 renal pelves were more than 15 mm wide. The greatest independent factor for hydronephrosis on one side was hydronephrosis on the contralateral side (p<0.0001 each). Independent predictors for the width of the renal pelvis on the right side were the width of the renal pelvis on the left, female gender, increasing age and height; for the left side, predictors were the width of the renal pelvis on the right, concrements, parapelvic cysts and great rotation of the upper pole of the kidney to dorsal. Crossing vessels had no influence on the development of hydronephrosis. Only anterior crossing vessels on the right side are associated with widening of the renal pelvis by 1 mm, without making it possible to identify the vessel as an independent factor in multivariate regression models. CONCLUSION The width of the renal pelvis on the contralateral side is the strongest independent predictor for hydronephrosis and the width of the renal pelvis. There is no link between crossing vessels and the width of the renal pelvis.
Collapse
Affiliation(s)
- B Glodny
- Department of Radiology, Innsbruck Medical University, Austria.
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Schuster TK, Jacobs BL, Gayed BA, Averch TD. Preliminary Experience with Laparoscopic Ureteropelvic Junction Release in the Treatment of Ureteropelvic Junction Obstruction. J Endourol 2010; 24:393-6. [DOI: 10.1089/end.2009.0194] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Tina K. Schuster
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Bruce L. Jacobs
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Bishoy A. Gayed
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Timothy D. Averch
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| |
Collapse
|
15
|
Further experience with the vascular hitch (laparoscopic transposition of lower pole crossing vessels): an alternate treatment for pediatric ureterovascular ureteropelvic junction obstruction. J Urol 2008; 180:1832-6; discussion 1836. [PMID: 18721979 DOI: 10.1016/j.juro.2008.05.055] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Indexed: 11/20/2022]
Abstract
PURPOSE 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. MATERIALS AND METHODS 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. RESULTS 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. CONCLUSIONS 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.
Collapse
|