Hydronephrosis: Comparison of extrinsic vessel versus intrinsic ureteropelvic junction obstruction groups and a plea against the vascular hitch procedure

• Published in: Journal of pediatric urology 2015-04, Vol.11 (2), p.80.e1-80.e6
• Main Authors: Menon, Prema, Rao, Katragadda L.N, Sodhi, Kushaljit S, Bhattacharya, A, Saxena, Akshay K, Mittal, Bhagwant R
• Format: Article
• Language: English
• Subjects: Child; Child, Preschool; Cohort Studies; Constriction, Pathologic; Dismembered pyeloplasty; Female; Follow-Up Studies; Humans; Hydronephrosis; Hydronephrosis - diagnostic imaging; Hydronephrosis - surgery; Intravenous urography; Kidney Pelvis - blood supply; Kidney Pelvis - pathology; Kidney Pelvis - surgery; Lower polar crossing vessel; Pediatrics; Preoperative Care - methods; Prospective Studies; Risk Assessment; Treatment Outcome; Ureteral Obstruction - diagnostic imaging; Ureteral Obstruction - surgery; Uretero-pelvic junction obstruction; Urography - methods; Urologic Surgical Procedures - methods; Urology; Vascular Malformations - diagnostic imaging; Vascular Malformations - surgery; Vascular Surgical Procedures - methods
• ISSN: 1477-5131; 1873-4898
• DOI: 10.1016/j.jpurol.2014.10.014

Summary Introduction Pediatric ureteropelvic junction obstruction (UPJO) due to an extrinsic crossing vessel (CV) is rare and often remains undiagnosed preoperatively. Vascular hitch procedures are often performed as associated intrinsic obstruction is not expected. We compared data and intravenous urography (IVU) findings of patients with aberrant CV versus those with intrinsic UPJO, all undergoing open dismembered pyeloplasty. Objective Primary objective: Is accurate pre-operative diagnosis of aberrant CV causing extrinsic UPJO possible? Secondary objective: To assess differences in the demographic, clinical, radiological, intra-operative features and postoperative improvement after pyeloplasty between patients with a CV and those with only intrinsic UPJO. Patients and methods Prospective study of all children below 12 years with UPJO presenting to a tertiary referral centre and who underwent open Anderson – Hynes dismembered pyeloplasty between 2003 and 2013 was conducted. Pre-operative investigations included serial ultrasonography, renal dynamic [ethylene di-cysteine (EC)] scan and IVU. These were repeated 3 months after pyeloplasty. Pre-operative IVUs of children with CV were compared with the IVUs of an equal number of similar aged children, randomly selected from the intrinsic obstruction group. Results Pyeloplasty was performed in 643 children during the study period. Data of 33 children with aberrant CVs (mean age 6.99 years) were compared with the remaining 610 children (mean age 3.27 years) with only intrinsic obstruction. Highly significant associations of those with CV included age above 2 years, female gender, associated anomalies, abdominal pain in those above 2 years and poor preoperative function on IVU. Specific IVU features which were statistically highly significant in favor of presence of CV were small, intrarenal and globular flat bottomed pelvis. (Figure) Calyceal dilatation was also more prominent in the CV group. A funnel shaped, extrarenal pelvis was highly significant in favor of intrinsic obstruction. There was associated intrinsic obstruction in addition to CV obstruction in 8 children. All children symptomatically improved after pyeloplasty and did well on long term follow up. The majority showed improvement or stabilization of function on EC scan. Discussion With the advent of antenatal ultrasonography, most children with UPJO are detected early. Children with CV tend to present later. This is often detected during surgery.