Laparoscopic transposition pyelo-pyelostomy for repair of adult uretero-pelvic junction obstruction secondary to lower pole crossing vessels: a novel technique.

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.