Crossing Vessels in Retroperitoneal Laparoscopic Pyeloplasty: Anatomy and Outcomes

Crossing vessels are commonly encountered during pyeloplasty for ureteropelvic junction obstruction (UPJO) and may influence surgical strategy. We aimed to describe the anatomical distribution of crossing vessels and their management options during retroperitoneal laparoscopic pyeloplasty (RLP) and report the long-term outcomes.

We retrospectively reviewed consecutive adult patients who underwent RLP for UPJO between 2006 and 2025 by a single surgeon. Preoperative computed tomography (CT) or magnetic resonance (MR) urography was routinely performed to assess vascular anatomy. Surgical technique emphasized identification of crossing vessels, routine UPJ reconstruction, mobilization and/or transposition of arteries, selective ligation of nonessential veins, and creation of a dependent tension-free anastomosis.

The study included 165 patients with mean age of 58.2 years. Crossing vessels were identified in 114 patients (69.1%), most commonly gonadal vein variants (45.6%) and accessory renal arteries (31.6%). Mean operative time was 175 minutes, with no conversions to open surgery. Only 19 (16.67%) patients required ureteral transposition. Postoperative Clavien-Dindo grade III complications occurred in 5 (3%) patients, with no grade IV or V events. With median follow-up of 64 months, overall success rate was 96.1%. None of the variables were statistically linked to failed pyeloplasty (P > .5 for all variables).

RLP with systematic identification of crossing vessels is associated with excellent long-term functional outcomes and low morbidity. Management of crossing vessels should be individualized according to the type and relation of the crossing vessel to the UPJ. Ureteral transposition should not be a routine part of RLP.