• Vascular hitch; Crossing vessel; Ureteropelvic junction obstruction

Jaafar F, Youssef M, Anass M, Ilyass Z, Amine S, et al. (2024) Vascular Hitch: An Alternative for Dismembered Pyeloplasty in Extrinsic Ureteropelvic Junction Obstruction. J Urol Res 11(1): 1145.

DP: Dismembered Pyeloplasty: UPJO: Ureteropelvic Junction Obstruction: VH: Vascular Hitch; CV: Crossing Vessel; UPJ: Ureteropelvic Junction LP: Laparoscopic Pyeloplasty; OP: Open Pyeloplasty

Since it was first described by Anderson and Hynes, dismembered pyeloplasty (DP) has been the gold standard treatment for hydronephrosis caused by ureteropelvic junction obstruction (UPJO), either by open or laparoscopic surgery [1,2]. This procedure is frequently performed for UPJO in children and adult patients. This procedure has recently incorporated the use of robotic surgery. The development of UPJO is attributed to both intrinsic stenosis as well as extrinsic compression caused by crossing vessels. An alternative method for treating pure extrinsic PUJO was described by Hellström et al. in 1949, which involved moving the lower pole vessels upwards and fastening them to the front pelvic wall with vascular adventitial sutures [3]. Chapman later modified this technique, securing a higher location of the lower pole vessels within an anterior redundant pelvic wall wrap without using vascular adventitial sutures [4]. This low-invasive technique is preferred for its effectiveness and lower risk of complications.

The technique of lower pole crossing vessel transposition, commonly referred to as the “vascular hitch,” presents a relatively less complex alternative compared to laparoscopic pyeloplasty in avoiding medical intervention on the urinary excretory system. Gundeti et al. [5,6], are credited with pioneering this procedure which has since seen notable success rates observed across various centers [7]; some studies have reported up to 95% satisfaction among patients even over extended periods.

We report a case of an 18-year-old female patient with ureteric pelvic junction obstruction treated with a laparoscopic vascular hitch. The case reported was managed by the authors in an academic hospital and written in line with the SCARE criteria [8].

E.F., an 18 y.o. female patient presented by herself to the emergency department with a history of intermittent left lower back pain evolving for 5 years. The patient was afebrile and the physical examination was poor. A blood sample was taken and the serum renal tests were at normal values (creatinine: 5.9 mg/L; Urea: 0.27 g/L).

The patient was hospitalized and a contrast-enhanced URO-CT was performed (Figure 1) to determine the cause of the complaints. This examination revealed left pelvicalyceal system dilatation and ipsilateral UPJ obstruction due to a lower pole crossing vessel.

Figure 1: Uro-CT showing crossing vessel responsible of UPJO.

The patient underwent laparoscopic surgery electively. Under general anesthesia, the patient was placed in the left semilateral position. A 12-mm trocar was inserted at the umbilicus via the open Hasson method for a 12-mm, 0° rigid scope. Pneumoperitoneum was established and two additional ports were then inserted under laparoscope inspection: a 5-mm port below the xiphoid for the operator’s left hand and a 5-mm port at the middle lower abdomen for the operator’s right hand. The dilated right pelvis and crossing vessel were detected after the ascending colon was dissected and mobilized (Figure 2).

Figure 2:; Crossing vessel responsible of dilated renal pelvis.

The crossing vessel was dissected and the ureter was recognized due to its peristalsis. The pelvis was mobilized in the caudal direction and its anterior wall wrapped the crossing vessel using two interrupted sutures of 3–0 non-absorbable monofilament (Figure 3). No stent catheter was inserted in the ureter. There were no intraoperative or postoperative complications.

Figure 3: Crossing vessel suspension on the pelvis anterior wall.

The follow-up CT scan showed no evidence of hydronephrosis with a normal renal excretion at the late phase.

An aperistaltic dysplastic section of the UPJ is typically the etiology of UPJO. Apart from this inherent etiology, external variables such abnormal lower pole CV could be the cause. CV are thought to cause from 40% to over 50% of extrinsic-UPJO in adults, they are more frequently found ventrally to the UPJ than dorsally. These abnormal vessels are typically lower pole segment normal morphologic vessels, which are separated into accessory renal arteries that originate from aortic branches and additional renal arteries that arise from the aorta [9].

Treatment options for crossing vessels vary in terms of surgery. In 1949, Hellström et al. [9], presented the Hellström surgery, which is regarded as the traditional way of treating UPJO brought on by crossing vessel compression. It was a vascular hitch operation. It is now known that Pesce et al. [10,11], continue to advise the laparoscopic Hellström procedure for UPJO with crossing vessels. It is assumed that the procedure is rather straightforward; nevertheless, depending on the extent of the blockage, it may determine whether to proceed with pyeloplasty. Furthermore, LP has the advantage of OP in that it can produce a more pleasing aesthetic result (a smaller scar) [12]. Zhang reported that eight successful patients of UPJO with crossing vessels received retroperitoneal laparoscopic Hellström operations [13]. The crossing vessels were secured on the anterior wall of the renal pelvis and embedded with 4-0 absorbable sutures after the blockage and complete dissection of the crossing vessels in the upper ureter. This surgical technique fixed the issue of external compression of the ureteropelvic junction and guaranteed the kidney’s blood supply. Notably, indications need to be strictly observed.

The first authors to disclose vascular relocation by laparoscopic method utilizing the Hellstrom technique were Meng and Stoller in 2003. They described this process in nine adult cases, all of which had resolutions. These authors noted that the obstruction was caused by the herniation and the ureteral kinking that followed, and they suggested that altering the geometry might be sufficient to remove the obstruction [14].

Careful pre- and intraoperative candidate selection is crucial to the success of the VH treatment. This technique can only treat patients with pure extrinsic-UPJO; any accompanying intrinsic UPJ abnormalities needs to be ruled out. According to certain authors, such as Janetscheck, in order to rule out such linked intrinsic malformations, which they record in as many as 33 percent of their patients, the UPJ should always be investigated via a longitudinal incision [15].

The vascular transposition method has been employed by several writers to address UPJO involving crossing vessels. 48 patients of UPJO with crossing vessels underwent laparoscopic pyeloplasty with robot aid, and 18 of those cases had successful transpositions, according to Boylu et al. [16]. The author believes that it is important to determine if crossing vessels actually squeeze the pelvic canal based on the state at the time of the procedure. Villemagne discovered that the furosemide challenge test is a workable technique for figuring out whether there is UPJO while the system is in use [7].

Regarding how to determine whether a crossing vessel is the direct cause of UPJO, Pesce [10] came to a conclusion. He made the decision to do the Hellström operation after observing the successful peristalsis of UPJ and the quick passage of urine from the renal pelvis in 111 patients during the procedure using a diuretic test. According to the paper, this procedure has a 98% success record, and the only patient who experienced a negative outcome from surgery suspension was that one. It is important to remember that there are other factors besides crossing vascular compression that might lead to UPJO. Resecting the blocked portion of the UPJ and rebuilding the junction are equally crucial. Reduced peristalsis function or ureteral stenosis typically occur in the compression segment. In the ureter, dynamic blockage persists even when the external force is released. The pathological traits of ureteral smooth muscle fibrosis, muscular hypertrophy, and inflammation did not significantly differ between UPJO patients with and without vascular compression, according to Ellerkamp’s study findings.

When considered as a whole, we propose that the location and orientation of the ectopic vessels should be taken into consideration when treating crossing vessels. To put it briefly, the blood vessel suspension approach can be used when the crossing vessels are near the renal hilus, or above the level of the kidney’s lower pole midline. The crossing vessel transposition procedure can be used when the crossing vessels are at the level of the kidney’s lower pole, or below the level of the kidney’s lower pole midline.

In summary, we think that Vascular Hitch requires less technical skill than laparoscopic pyeloplasty, which lowers the risk of complications and drastically lowers the length of hospital stay. In this series, very positive results were linked to the accurate anatomical localization of CV and UPJ offered by the laparoscopic method and a dynamic, objective evidence of pelvic emptying (diuretic-test). These results enable us to draw the conclusion that laparoscopic VH may represent a safe, practical, and appealing alternative to AHDP in the treatment of symptomatic patients where CV is determined to be the only etiology for blocked hydronephrosis [17].

In patients with UPJO as a result of extrinsic compression related to CV, laparoscopic VH might be a safe and useful substitute for laparoscopic dismembered pyeloplasty. Patients who are being evaluated for VH should use caution when identifying symptoms of concurrent intrinsic blockage.

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