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[Pelviureteric junction obstruction and crossing vessels: pro "vascular hitch"]
Katrin Zahn1, Nina Friederike Younsi1, Raimund Stein1
1Universitätsmedizin Mannheim, Zentrum für Kinder-, Jugend- und rekonstruktive Urologie, Mannheim.
Insights
The vascular hitch procedure offers a minimally invasive, effective alternative for pelviureteric junction obstruction caused by crossing vessels, with success rates comparable to traditional methods. An intraoperative diuretic test helps select suitable candidates for this less demanding technique.
Area of Science:
- Urology
- Minimally Invasive Surgery
- Pediatric Surgery
Background:
- Pelviureteric junction (PUJ) obstruction due to crossing lower-pole vessels is a common condition.
- The vascular hitch procedure is a minimally invasive surgical option, but its efficacy compared to Anderson-Hynes pyeloplasty remains debated.
- Aberrant lower-pole vessels are frequently implicated in PUJ obstruction, necessitating effective treatment strategies.
Purpose of the Study:
- To evaluate the efficacy and outcomes of the vascular hitch procedure for PUJ obstruction caused by crossing lower-pole vessels.
- To compare the success rates of the vascular hitch procedure with the traditional Anderson-Hynes pyeloplasty.
- To identify criteria for patient selection for the vascular hitch procedure versus Anderson-Hynes pyeloplasty.
Main Methods:
- Review of publications reporting outcomes of the vascular hitch procedure for PUJ obstruction.
- Analysis of success rates (short, intermediate, and long-term) and comparison with Anderson-Hynes pyeloplasty.
- Discussion of the role of intraoperative diuretic testing (volume bolus plus furosemide) in patient selection.
Main Results:
- Success rates for the vascular hitch procedure are reported as >90%, comparable to Anderson-Hynes pyeloplasty.
- Intrinsic stenosis appears rare; muscular hypertrophy may be a compensatory and reversible mechanism.
- Intraoperative diuretic testing can help differentiate eligible patients, identifying those with a normal-appearing, funnel-shaped PUJ and effective renal pelvis peristalsis.
Conclusions:
- The vascular hitch procedure is a valuable, less demanding alternative to Anderson-Hynes pyeloplasty for selected patients with extrinsic PUJ obstruction.
- The technique offers advantages including reduced surgical time, anesthesia duration, and absence of urinary leakage or anastomotic stricture risks.
- Long-term efficiency of the vascular hitch procedure is suggested, making it a viable option for specific patient groups.
Abstract:
The vascular hitch procedure for pelviureteric junction obstruction caused by crossing lower-pole vessels is a controversial treatment option. Since this minimally-invasive technique has been introduced in patients with aberrant lower-pole vessels, multiple publications have reported successful short, intermediate and long-term outcomes. Success rates of > 90 % are similar to those of Anderson-Hynes pyeloplasty. In general, an associated intrinsic stenosis seems to be rare. Histological evidence of muscular hypertrophy may simply indicate a compensatory mechanism and may be reversible to a certain degree. To differentiate between those patients who are eligible for a vascular hitch procedure and those who should receive an initial Anderson-Hynes pyeloplasty, an intraoperative diuretic test should be performed (volume bolus plus intravenous administration of furosemide). An associated intrinsic stenosis seems to be unlikely in a funnel-like and otherwise normal-looking pelviureteric junction, decreasing hydronephrosis after mobilisation of renal pelvis and crossing vessels and effective peristalsis of the renal pelvis after intraoperative diuretic testing. The vascular hitch technique is less demanding than laparoscopic Anderson-Hynes pyeloplasty and less time-consuming with regard to the duration of the surgical procedure and anaesthesia. Further advantages are: no risk of urinary leakage or anastomotic stricture and no need for intra-luminal stenting. Therefore, in a selected group of patients with solely extrinsic pelviureteric junction obstruction, the vascular hitch procedure is a valuable alternative to classic Anderson-Hynes pyeloplasty with seemingly long-term efficiency.
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