Ureteropelvic junction obstruction: does CT angiography allow better selection of therapeutic modalities and better patient outcome?

PURPOSE: To determine whether preoperative helical CT angiography (CTA) with three-dimensional (3D) reconstructed images improves outcome in patients with ureteropelvic junction obstruction (UPJO) by identifying crossing vessels that may lead to surgical failure. PATIENTS AND METHODS: Twenty-five patients with UPJO underwent imaging with CTA to identify crossing vessels. Patients with crossing vessels or severe hydronephrosis underwent laparoscopic dismembered pyeloplasty. In the absence of crossing vessels, and with >25% renal function on MAG-3 scan, the patient underwent an endopyelotomy. Procedures were assessed as successful by resolution of patient symptoms as well as relief of obstruction on renal scintography. RESULTS: Twenty-seven procedures (14 laparoscopic dismembered pyeloplasties [9 in the setting of a crossing vessel], 11 ureteroscopic endopyelotomies, and two antegrade endopyelotomy procedures) were performed. Follow-up ranged from 2.4 to 40 months (mean 21.6 months). Twenty-three of the primary procedures (92.0%) were successful. Primary laparoscopic pyeloplasty was successful in 100% of patients, while primary endopyelotomy had a success rate of 83.3%. Both secondary procedures were successful rendering the patients unobstructed and pain free. No complications occurred. The sensitivity and specificity of CTA in determining crossing vessels was 78% and 40%, respectively. CONCLUSIONS: Helical CT angiography with 3D reconstructed images provides valuable preoperative information in patients with UPJO scheduled for surgical intervention. This study may be used in selecting patients for proper operative intervention according to the anatomy of crossing vessels to attain high treatment success rates.