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Pelvi-ureteric junction obstruction with crossing renal vessels: A case report of failed laparoscopic vascular hitch
Journal of Pediatric Urology (2009) 5, 147e150
CASE REPORT
Pelvi-ureteric junction obstruction with crossing renal vessels: A case report of failed laparoscopic vascular hitch R.B. Nerli a,*, V. Rama Jayanthi b, Mallikarjun Reddy a, Ashish Koura a a b
Department of Urology, KLES Kidney Foundation, Belgaum 590010, India Nationwide Children’s Hospital, Columbus, OH, USA
Received 17 May 2008; accepted 30 September 2008
KEYWORDS Pelvi-ureteric junction obstruction; Pyeloplasty; Vascular hitch; Laparoscopy
Abstract Introduction: 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. Case report: 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. Conclusion: 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. ª 2008 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction Pelvi-ureteric junction obstruction (PUJO) occurs in all pediatric age groups, but there tends to be a clustering in the neonatal period because of the detection of antenatal hydronephrosis, and again later in life because of symptomatic occurrence. The precise cause of obstruction
* Corresponding author. E-mail address: [email protected] (R.B. Nerli).
remains elusive despite investigation. Intrinsic causes such as interruption in the development of the circular musculature of the PUJ, or an alteration of the collagen fibers and composition between and around the muscle cells may lead to muscle fibers becoming widely separated and attenuated, leading to a functional discontinuity of the muscular contractions and ultimately to insufficient emptying [1]. An aberrant, accessory or early branching lower pole vessel is the most common cause of extrinsic PUJO [1]. These vessels pass anteriorly to the PUJ or proximal ureter and contribute to mechanical obstruction. Reported incidences of crossing
1477-5131/$34 ª 2008 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2008.09.009
148 renal vessels have varied between 15% and 52% [2]. Whether the aberrant vessel causes obstruction or is a co-variable that exists along with an intrinsic narrowing is unclear [3]. The debate centres on whether these vessels are merely an anatomical variation with no pathological significance or whether they play a role in the pathogenesis of PUJO. We report a case of PUJO with crossing lower pole vessels managed initially by laparoscopic transposition of these vessels and later by laparoscopic dismembered pyeloplasty for persistence of PUJO.
Case report A 9-year-old girl presented to us with history of intermittent left loin pain, occasional vomiting and fever. On examination the child had tenderness in the left loin. Ultrasonography imaging revealed a dilated left pelvicalyceal system. Color Doppler studies revealed crossing of lower pole renal vessels at the PUJ. CT angiography confirmed the presence of the lower pole vessels and also delineated the same in detail (Fig. 1). DTPA renogram revealed a dilated and obstructed left pelvicalyceal system. The child was taken for laparoscopy using three ports: a 5-mm port at the umbilicus for the endoscope and two other 3-mm ports for instrumentation. The PUJ was approached through the mesentery and the ureter identified. The ureter was traced up to the PUJ. The crossing lower pole vessels were identified. The vessels were lifted off the PUJ and emptying of the pelvis was seen promptly. Simultaneous fluoroscopy revealed emptying of the pelvis on lifting the vessels off the PUJ. A decision to perform laparoscopic transposition of lower pole vessels was made. The lower pole vessels were then pexed in a cephalad position well away from the region of the PUJ by suturing the pelvis on either side of the vessels with two-to-three absorbable sutures without tension. No double J (DJ) stent was inserted. The child was catheterized for 24 h and started feeding orally within 12 h.
Figure 1 Angiogram showing left-sided crossing lower pole renal vessels.
R.B. Nerli et al. The child presented again to us a week later with pain in the abdomen, vomiting and mild grade fever. Ultrasonography revealed the left-sided pelvicalyceal system to be dilated. The child was stented with a DJ stent and discharged after 24 h. Post stenting the dilatation of the pelvicalyceal system had reduced. The DJ stent was left in place for 12 weeks and then removed. Repeat DTPA renogram done a week later (Fig. 2) revealed persistence of PUJO and split renal function of 30% on the left side. A decision was made to re-operate. Laparoscopy was done through the transperitoneal route. Transmesenteric approach was made to identify the left ureter. As it was impossible to adequately dissect anteriorly, attention was shifted posteriorly. The posterior renal pelvis was relatively unscarred and easier to mobilize. A small adynamic segment was identified and an uneventful pyeloplasty with 5-0 PDS and 4-Fr DJ stent was performed. Oral feeds were started within 24 h. The child was discharged after 72 h. The DJ stent was removed after 6 weeks and repeat DTPA scan done after 12 weeks. DTPA scan revealed improvement of renal function (Fig. 3). Split renal function of 40% was noted on the left side. The drainage improved and post-Lasix emptying of the pelvicalyceal system was noted. The child is under regular follow up.
Discussion PUJO secondary to vessels presents particular clinical and imaging features within the spectrum of congenital hydronephrosis. Its intermittent nature may explain why it is detected later in life [2,4]. The overall incidence of PUJO caused by lower pole crossing renal vessels was 18.5% in the series reported by Rigas et al. [5], which was similar to that reported by Pesce et al. [6]. However, amongst symptomatic children the proportion of those with PUJO caused by extrinsic pressure from crossing renal vessels was significantly higher, reaching 30e50% [4,7]. The traditional surgical technique for PUJO is the dismembered pyeloplasty, which may be either open, laparoscopic [8] or robotically assisted [9,10]. Hellstrom
Figure 2 DTPA renogram following laparoscopic transposition of the crossing vessels shows persistence of PUJO.
Pelvi-ureteric junction obstruction with crossing renal vessels
Figure 3 DTPA renogram dismembered pyeloplasty.
following
left
laparoscopic
first described the technique of relocation of the lower pole vessel in PUJO [11]. This technique has also been reported in children [6] by the open approach and laparoscopically in adults combined with an endopyelotomy [12] with good results. Godbole et al. [13] reported their series of 13 children with a mean age of 10.2 years (range 7e16) who 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. Twelve children showed good drainage on the postoperative MAG3 renogram and improvement in ultrasound appearance. One child had recurrent symptoms requiring insertion of a DJ stent. This child underwent further laparoscopic exploration; a kink at the PUJ was released and a vertical pyelotomy was closed transversely over a DJ stent. The authors concluded that the technique was simple, requiring less operating time. No anastomosis or temporary DJ stent was required. Early results were encouraging with no serious complications. The child in our case presented with history of intermittent pain and occasional vomiting, similar to the children in Godbole’s series. The diagnosis of crossing renal vessels was confirmed on CT angiography. The vascular hitch was performed as described by Godbole et al. [13]. However, the postoperative outcome was not encouraging. There could be several factors responsible for this outcome. One cannot rule out a concurrent intrinsic factor along with crossing renal vessels with certainty. Histological examination of the resected specimens of the PUJ where lower pole vessels were deemed to be the etiology showed evidence of inflammation and fibrosis [13]. These findings can be secondary to intermittent obstructive episodes leading to inflammatory changes and subsequent fibrosis. Another factor which could be responsible for poor outcome following laparoscopic transposition of crossing renal vessels could be premature undoing of the sutures used to pex the vessel in a cephalad position. Kinking of the PUJ following laparoscopic transposition of the vessels could also result in persistence of obstruction following surgery, similar to the child in Godbole’s series. Patient selection for this procedure should be on the basis of a high index of suspicion of the lower pole vessels
149 accounting for the PUJO. PUJO secondary to crossing renal vessels should be suspected in older children presenting with recurrent renal colics. Good renal function is expected in most children, despite their age, because the vascular obstruction is intermittent. Though a number of imaging modalities have been able to identify the crossing renal vessels, none are able to pinpoint whether the crossing renal vessels are obstructive or are just incidental findings. Intraoperatively the PUJ must be carefully inspected for any intrinsic stenosis, and peristalsis across it. In cases of doubt, the pelvis must be distended with saline to assess drainage across the PUJ. An intraoperative Whitaker’s test would be ideal to identify an intrinsic component of PUJO. For full appraisal of this technique of laparoscopic transposition e the vascular hitch e long-term follow up is required. Until then, one should advocate this surgery with caution.
Conclusions Though numerous imaging methods have been described for preoperative detection of crossing lower pole renal vessels, none of these can identify an intrinsic component in PUJO. Though laparoscopic transposition of vessels is a simple procedure, not involving anastomosis or insertion of temporary DJ stent, it must be used as an option with caution.
References [1] Carr MC, El-Ghoneimi A. Anomalies and surgery of the ureteropelvic junction in children. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. CampbelleWalsh urology. 9th ed. Philadelphia: Saunders; 2007. [2] Lowe FC, Marshal SF. Ureteropelvic junction obstruction in adults. Urology 1984;23:331e5. [3] Stephens FD. Ureterovascular hydronephrosis and the aberrant renal vessels. J Urol 1982;128:984. [4] Rooks VJ, Lebowitz RL. Extrinsic ureteropelvic junction obstruction from a crossing renal vessel. Demography and imaging. Pediatr Radiol 2001;31:120. [5] Rigas A, Karamanolakis D, Bogdanos I, Stefanidis A, Androulakakis PA. Pelvi-ureteric junction obstruction by crossing renal vessels: clinical and imaging features. BJU Int 2003;92:101. [6] Pesce C, Campobasso P, Costa L, Battaglino F, Musi L. Ureterovascular hydronephrosis in children: is pyeloplasty always necessary? Eur Urol 1999;36:71. [7] Ross JH, Kay R, Knipper NS, Streem SB. The absence of crossing vessels in association with ureteropelvic junction obstruction detected by prenatal ultrasonography. J Urol 1998;160:973. [8] Tan HL. Laparoscopic AndersoneHynes dismembered pyeloplasty in children. J Urol 1999;162:1045. [9] Gettman MT, Neururer R, Bartsch G, Peschel R. Andersone Hynes dismembered pyeloplasty performed using the da Vinci robotic system. Urology 2002;60:509. [10] Palese MA, Stifelman MD, Munver R, Sosa RE, Phillips CK, Dinlenc C, et al. Robot assisted laparoscopic dismembered pyeloplasty: a combined experience. J Endourol 2005;19: 382. [11] Meng MV, Stoller ML. Hellstrom technique revisited: laparoscopic management of ureteropelvic junction obstruction. Urology 2003;62:404.
150 [12] Nagai A, Nasu Y, Hashimoto H, Tsugawa M, Yasui K, Kumon H. Retroperitoneoscopic pyelotomy combined with the transposition of crossing vessels for ureteropelvic junction obstruction. J Urol 2001;165:23.
R.B. Nerli et al. [13] Godbole P, Mushtaq I, Wilcox DT, Duffy PG. Laparoscopic transposition of lower pole vessels e the vascular hitch: an alternative to dismembered pyeloplasty for pelvi-ureteric junction obstruction in children. J Pediatr Urol 2006;2:285.
CASE REPORT
Pelvi-ureteric junction obstruction with crossing renal vessels: A case report of failed laparoscopic vascular hitch R.B. Nerli a,*, V. Rama Jayanthi b, Mallikarjun Reddy a, Ashish Koura a a b
Department of Urology, KLES Kidney Foundation, Belgaum 590010, India Nationwide Children’s Hospital, Columbus, OH, USA
Received 17 May 2008; accepted 30 September 2008
KEYWORDS Pelvi-ureteric junction obstruction; Pyeloplasty; Vascular hitch; Laparoscopy
Abstract Introduction: 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. Case report: 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. Conclusion: 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. ª 2008 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction Pelvi-ureteric junction obstruction (PUJO) occurs in all pediatric age groups, but there tends to be a clustering in the neonatal period because of the detection of antenatal hydronephrosis, and again later in life because of symptomatic occurrence. The precise cause of obstruction
* Corresponding author. E-mail address: [email protected] (R.B. Nerli).
remains elusive despite investigation. Intrinsic causes such as interruption in the development of the circular musculature of the PUJ, or an alteration of the collagen fibers and composition between and around the muscle cells may lead to muscle fibers becoming widely separated and attenuated, leading to a functional discontinuity of the muscular contractions and ultimately to insufficient emptying [1]. An aberrant, accessory or early branching lower pole vessel is the most common cause of extrinsic PUJO [1]. These vessels pass anteriorly to the PUJ or proximal ureter and contribute to mechanical obstruction. Reported incidences of crossing
1477-5131/$34 ª 2008 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2008.09.009
148 renal vessels have varied between 15% and 52% [2]. Whether the aberrant vessel causes obstruction or is a co-variable that exists along with an intrinsic narrowing is unclear [3]. The debate centres on whether these vessels are merely an anatomical variation with no pathological significance or whether they play a role in the pathogenesis of PUJO. We report a case of PUJO with crossing lower pole vessels managed initially by laparoscopic transposition of these vessels and later by laparoscopic dismembered pyeloplasty for persistence of PUJO.
Case report A 9-year-old girl presented to us with history of intermittent left loin pain, occasional vomiting and fever. On examination the child had tenderness in the left loin. Ultrasonography imaging revealed a dilated left pelvicalyceal system. Color Doppler studies revealed crossing of lower pole renal vessels at the PUJ. CT angiography confirmed the presence of the lower pole vessels and also delineated the same in detail (Fig. 1). DTPA renogram revealed a dilated and obstructed left pelvicalyceal system. The child was taken for laparoscopy using three ports: a 5-mm port at the umbilicus for the endoscope and two other 3-mm ports for instrumentation. The PUJ was approached through the mesentery and the ureter identified. The ureter was traced up to the PUJ. The crossing lower pole vessels were identified. The vessels were lifted off the PUJ and emptying of the pelvis was seen promptly. Simultaneous fluoroscopy revealed emptying of the pelvis on lifting the vessels off the PUJ. A decision to perform laparoscopic transposition of lower pole vessels was made. The lower pole vessels were then pexed in a cephalad position well away from the region of the PUJ by suturing the pelvis on either side of the vessels with two-to-three absorbable sutures without tension. No double J (DJ) stent was inserted. The child was catheterized for 24 h and started feeding orally within 12 h.
Figure 1 Angiogram showing left-sided crossing lower pole renal vessels.
R.B. Nerli et al. The child presented again to us a week later with pain in the abdomen, vomiting and mild grade fever. Ultrasonography revealed the left-sided pelvicalyceal system to be dilated. The child was stented with a DJ stent and discharged after 24 h. Post stenting the dilatation of the pelvicalyceal system had reduced. The DJ stent was left in place for 12 weeks and then removed. Repeat DTPA renogram done a week later (Fig. 2) revealed persistence of PUJO and split renal function of 30% on the left side. A decision was made to re-operate. Laparoscopy was done through the transperitoneal route. Transmesenteric approach was made to identify the left ureter. As it was impossible to adequately dissect anteriorly, attention was shifted posteriorly. The posterior renal pelvis was relatively unscarred and easier to mobilize. A small adynamic segment was identified and an uneventful pyeloplasty with 5-0 PDS and 4-Fr DJ stent was performed. Oral feeds were started within 24 h. The child was discharged after 72 h. The DJ stent was removed after 6 weeks and repeat DTPA scan done after 12 weeks. DTPA scan revealed improvement of renal function (Fig. 3). Split renal function of 40% was noted on the left side. The drainage improved and post-Lasix emptying of the pelvicalyceal system was noted. The child is under regular follow up.
Discussion PUJO secondary to vessels presents particular clinical and imaging features within the spectrum of congenital hydronephrosis. Its intermittent nature may explain why it is detected later in life [2,4]. The overall incidence of PUJO caused by lower pole crossing renal vessels was 18.5% in the series reported by Rigas et al. [5], which was similar to that reported by Pesce et al. [6]. However, amongst symptomatic children the proportion of those with PUJO caused by extrinsic pressure from crossing renal vessels was significantly higher, reaching 30e50% [4,7]. The traditional surgical technique for PUJO is the dismembered pyeloplasty, which may be either open, laparoscopic [8] or robotically assisted [9,10]. Hellstrom
Figure 2 DTPA renogram following laparoscopic transposition of the crossing vessels shows persistence of PUJO.
Pelvi-ureteric junction obstruction with crossing renal vessels
Figure 3 DTPA renogram dismembered pyeloplasty.
following
left
laparoscopic
first described the technique of relocation of the lower pole vessel in PUJO [11]. This technique has also been reported in children [6] by the open approach and laparoscopically in adults combined with an endopyelotomy [12] with good results. Godbole et al. [13] reported their series of 13 children with a mean age of 10.2 years (range 7e16) who 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. Twelve children showed good drainage on the postoperative MAG3 renogram and improvement in ultrasound appearance. One child had recurrent symptoms requiring insertion of a DJ stent. This child underwent further laparoscopic exploration; a kink at the PUJ was released and a vertical pyelotomy was closed transversely over a DJ stent. The authors concluded that the technique was simple, requiring less operating time. No anastomosis or temporary DJ stent was required. Early results were encouraging with no serious complications. The child in our case presented with history of intermittent pain and occasional vomiting, similar to the children in Godbole’s series. The diagnosis of crossing renal vessels was confirmed on CT angiography. The vascular hitch was performed as described by Godbole et al. [13]. However, the postoperative outcome was not encouraging. There could be several factors responsible for this outcome. One cannot rule out a concurrent intrinsic factor along with crossing renal vessels with certainty. Histological examination of the resected specimens of the PUJ where lower pole vessels were deemed to be the etiology showed evidence of inflammation and fibrosis [13]. These findings can be secondary to intermittent obstructive episodes leading to inflammatory changes and subsequent fibrosis. Another factor which could be responsible for poor outcome following laparoscopic transposition of crossing renal vessels could be premature undoing of the sutures used to pex the vessel in a cephalad position. Kinking of the PUJ following laparoscopic transposition of the vessels could also result in persistence of obstruction following surgery, similar to the child in Godbole’s series. Patient selection for this procedure should be on the basis of a high index of suspicion of the lower pole vessels
149 accounting for the PUJO. PUJO secondary to crossing renal vessels should be suspected in older children presenting with recurrent renal colics. Good renal function is expected in most children, despite their age, because the vascular obstruction is intermittent. Though a number of imaging modalities have been able to identify the crossing renal vessels, none are able to pinpoint whether the crossing renal vessels are obstructive or are just incidental findings. Intraoperatively the PUJ must be carefully inspected for any intrinsic stenosis, and peristalsis across it. In cases of doubt, the pelvis must be distended with saline to assess drainage across the PUJ. An intraoperative Whitaker’s test would be ideal to identify an intrinsic component of PUJO. For full appraisal of this technique of laparoscopic transposition e the vascular hitch e long-term follow up is required. Until then, one should advocate this surgery with caution.
Conclusions Though numerous imaging methods have been described for preoperative detection of crossing lower pole renal vessels, none of these can identify an intrinsic component in PUJO. Though laparoscopic transposition of vessels is a simple procedure, not involving anastomosis or insertion of temporary DJ stent, it must be used as an option with caution.
References [1] Carr MC, El-Ghoneimi A. Anomalies and surgery of the ureteropelvic junction in children. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. CampbelleWalsh urology. 9th ed. Philadelphia: Saunders; 2007. [2] Lowe FC, Marshal SF. Ureteropelvic junction obstruction in adults. Urology 1984;23:331e5. [3] Stephens FD. Ureterovascular hydronephrosis and the aberrant renal vessels. J Urol 1982;128:984. [4] Rooks VJ, Lebowitz RL. Extrinsic ureteropelvic junction obstruction from a crossing renal vessel. Demography and imaging. Pediatr Radiol 2001;31:120. [5] Rigas A, Karamanolakis D, Bogdanos I, Stefanidis A, Androulakakis PA. Pelvi-ureteric junction obstruction by crossing renal vessels: clinical and imaging features. BJU Int 2003;92:101. [6] Pesce C, Campobasso P, Costa L, Battaglino F, Musi L. Ureterovascular hydronephrosis in children: is pyeloplasty always necessary? Eur Urol 1999;36:71. [7] Ross JH, Kay R, Knipper NS, Streem SB. The absence of crossing vessels in association with ureteropelvic junction obstruction detected by prenatal ultrasonography. J Urol 1998;160:973. [8] Tan HL. Laparoscopic AndersoneHynes dismembered pyeloplasty in children. J Urol 1999;162:1045. [9] Gettman MT, Neururer R, Bartsch G, Peschel R. Andersone Hynes dismembered pyeloplasty performed using the da Vinci robotic system. Urology 2002;60:509. [10] Palese MA, Stifelman MD, Munver R, Sosa RE, Phillips CK, Dinlenc C, et al. Robot assisted laparoscopic dismembered pyeloplasty: a combined experience. J Endourol 2005;19: 382. [11] Meng MV, Stoller ML. Hellstrom technique revisited: laparoscopic management of ureteropelvic junction obstruction. Urology 2003;62:404.
150 [12] Nagai A, Nasu Y, Hashimoto H, Tsugawa M, Yasui K, Kumon H. Retroperitoneoscopic pyelotomy combined with the transposition of crossing vessels for ureteropelvic junction obstruction. J Urol 2001;165:23.
R.B. Nerli et al. [13] Godbole P, Mushtaq I, Wilcox DT, Duffy PG. Laparoscopic transposition of lower pole vessels e the vascular hitch: an alternative to dismembered pyeloplasty for pelvi-ureteric junction obstruction in children. J Pediatr Urol 2006;2:285.