title: Ureteropelvic junction obstruction in children by polar vessels. Is laparoscopic vascular hitching procedure a good solution? Single center experience on 35 consecutive patients.
abstract: OBJECTIVE
  We report the results of laparoscopic vascular hitching (LVH) in a series of children with ureteropelvic junction obstruction (UPJO) owing to aberrant lower polar crossing vessels (CV). Our aim is to confirm if LVH associated with intraoperative diuretic test (DT) represents a good procedure to treat extrinsic-UPJO by CV. In order to confirm the relief of the obstruction we suggest performing an intraoperative DT.
  
  
  METHODS
  In our department from 2006 to 2014, 120 patients were treated for both extrinsic and intrinsic-UPJO. 85 (30 females, 55 males) presented an intrinsic obstruction and underwent dismembered pyeloplasty (AHDP), 61 open, 16 laparoscopic, 8 retroperitoneoscopic. 35 (23 males, 12 females) were studied for a suspected extrinsic-UPJO: 30 were treated with LVH (modified Hellström vascular hitch). Intraoperative-DT was performed in all patients before and after vessel transpositions confirming the UPJO and eventual relief after the procedure. We included in the study only patients with suspicion of vascular extrinsic-UPJO. Average age at surgery was 7.5years. Symptoms of presentation were recurrent abdominal/flank pain and hematuria. All patients presented ultrasound (US) detection of hydronephrosis. Preoperative diagnostic studies include: US/doppler scan, MAG3 renogram, urography, functional magnetic resonance urography (fMRU) and CT scan.
  
  
  RESULTS
  28 out 35 patients had a correct preoperative diagnosis, and the remaining needed an intraoperative diagnosis confirmation. All 35 patients had an intraoperative-DT: 30 patients underwent LVH (positive-DT); 3 patients (negative-DT) underwent laparoscopic-AHDP for intrinsic-UPJO; two with positive-DT and nonobstructive CV, had no surgical treatment. Median operating time was 95min; mean hospital stay was 4days. At 12-84months follow-up 29 patients remained symptoms-free, one needed after two years a laparoscopic-AHDP.
  
  
  CONCLUSIONS
  According our experience, LVH associated with intraoperative-DT may be considered a safe procedure to treat extrinsic-UPJO by CV in carefully selected patients. In particular, the very low incidence of relapse suggest that in suspicion of extrinsic-UPJO, performing intraoperative-DT after CV transposition allows to exclude intrinsic-UPJO confirming that the LVH-procedure has relieved the pelvic obstruction, precluding the need for AHDP.
authors.affiliation: Department of Pediatric Surgery, San Bortolo Hospital, Vicenza, Italy. Electronic address: fabio.chiarenza@ulssvicenza.it.
authors.forename: Salvatore Fabio
authors.initials: SF
authors.lastname: Chiarenza
authors.affiliation: Department of Pediatric Surgery, San Bortolo Hospital, Vicenza, Italy. Electronic address: cosimo.bleve@ulssvicenza.it.
authors.forename: Cosimo
authors.initials: C
authors.lastname: Bleve
authors.affiliation: Department of Pediatric Surgery, San Bortolo Hospital, Vicenza, Italy.
authors.forename: Lorella
authors.initials: L
authors.lastname: Fasoli
authors.affiliation: Department of Pediatric Surgery, San Bortolo Hospital, Vicenza, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Battaglino
authors.affiliation: Department of Pediatric Surgery, San Bortolo Hospital, Vicenza, Italy.
authors.forename: Valeria
authors.initials: V
authors.lastname: Bucci
authors.affiliation: Department of Pediatric Surgery, San Bortolo Hospital, Vicenza, Italy.
authors.forename: Steven
authors.initials: S
authors.lastname: Novek
authors.affiliation: Department of Pediatric Surgery, San Bortolo Hospital, Vicenza, Italy.
authors.forename: Elisa
authors.initials: E
authors.lastname: Zolpi
mesh_terms: D000293:Adolescent; D001808:Blood Vessels / Q000002:abnormalities*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D006869:Hydronephrosis / Q000209:etiology; D007223:Infant; D007682:Kidney Pelvis / Q000098:blood supply* / Q000601:surgery; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D061646:Operative Time; D012008:Recurrence; D014513:Ureter / Q000098:blood supply* / Q000601:surgery; D014517:Ureteral Obstruction / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D014656:Vascular Surgical Procedures / Q000379:methods
keywords: Laparoscopy; Lower pole crossing vessels; Pelvi-ureteric junction obstruction; Vascular hitch