1 Urology Journal UNRC/IUA Vol. 1, 1-4 Winter 2004 Printed in IRAN INTRODUCTION Aberrant vessels are considered as the extrin- sic cause of UPJ obstruction particularly in adults and it has an incidence of 15-52%. However, the exact role of aberrant vessels in ureteropelvic junction obstruction (UPJO) is still controversial. To date the generally accepted idea is that cutting, relocating the crossing vessels is not sufficient, and pyeloplasty is needed, as the obstruction is a primary intrinsic type due to a Original Article Laparoscopic Ureteropelvic Junction Decompression for the Management of Obstruction SIMFOROOSH N*, TABIBI A, NOORALIZADEH A, SHAYANI NASAB H Urology and Nephrology Research Center, Shaheed Labbafinejad Hospital, Shaheed Beheshti University of Medical Sciences, Tehran, Iran ABSTRACT Purpose: We reported the outcome and complications of laparoscopic aberrant ves- sels transposition without performing pyeloplasty in patients with ureteropelvic stenosis. Materials and Methods: A total of 10 patients with ureteropelvic stenosis accom- panying with aberrant vessels underwent laparoscopic transposition of vessels between June 2001 and March 2003. 4 of the cases were male and 6 were female, and 4 out of 10 had right side and 6 had left side involvement. The mean age was 31.9 (14 - 59). Reaction of aberrant vessels was performed by cutting the vain and fixing the artery to the lipid layer around the kidney and renal pelvis. Results: The procedure was successful in all the cases without any perioperative complications. The operative time was 2.20 hours (1.45 - 2.50) including cystoscopy, DJ placement, and transposition. Mean hospital stay was 2.9 (2-5) days, and patients were followed up an average of 9.1 (3-22) months. Except one case of rehospitaliza- tion due to pain, no complication occurred. The rate of clinical and radiological improvement was 100% and IVP showed a decrease in the degree of hydronephrosis as well as the resolution of obstruction observed in renogram. Conclusion: With regard to our findings, it seems, at least in a proportion of patients with UPJ stenosis accompanied with crossing vessels, that mechanical com- pression is the mere cause of obstruction and primary stenosis does not coexist. As a result, treatment is achieved by transposition of the crossing vessels without enter- ing the renal unit. KEY WORDS: transposition, aberrant vessel, UPJ obstruction, laparoscopy, pyeloplasty Accepted for publication LAPAROSCOPIC URETEROPELVIC JUNCTION DECOMPRESSION FOR THE MANAGEMENT OF OBSTRUCTION dysfunctional propagation of peristaltic waves. (1) Von Rokitansky was the first one who lighted on the association of hydronephrosis with aber- rant vessels in 1842.(2) Open surgical transposi- tion of the vessels responsible for UPJO was per- formed and reported by H. Nixon(3), C. McCreadie(4), and T.L. Chapman.(5) However, according to some references, the role of cross- ing vessels in obstruction is trivial.(6, 7) We describe our experience in laparoscopic sur- gery of 10 cases with UPJO and lower pole aber- rant vessel. MATERIALS AND METHODS A total of 10 patients (4 males and 6 females, mean age 31.9, 14-59) underwent transperitoneal laparoscopic transposition of aberrant vessels. 4 had right sided and 6 had left sided involvement. One case was detected accidentally and others admitted with pain. Three trocars were inserted intraoperatively. Parietal peritoneum was dissect- ed on linea alba, umbilical area (10 mm), mid- line, 5 cm above umbilicus (5 mm), and midclav- icular line next to the umbilicus (10 mm). The colon was pushed aside and upper ureter and renal pelvis was set loose. The vain was cut and the artery was relocated and fixed to the pelvis. Afterwards, if normal peristalsis and complete emptying of renal pelvis was seen, the artery would be fixed to the lipid layer around renal pelvis by means of a vicryl suture. Classic pyelo- plasty was done in case of incomplete drainage of the pelvis. No drain was placed and patients were followed up by renogram and IVP after 3 months, and clinical examination, urine analysis, urine culture, CBC, and Cr. RESULTS The procedure was successfully done without any perioperative or postoperative complication. The vain was cut and the artery was fixed to the renal pelvis and the lipid layer around the kidney in all patients. Open conversion did not occurred at all. The operation time was 2.20 hours (1.45- 2.50) including cystoscopy, DJ placement, and transposition and mean hospital stay was 2.9 (2- 5) days. 3 patients received intra venous Pethedine HCL (25 mg) but other patients did not require analgesics during hospital stay. Perioperative or postoperative transfusion was not required in any case. Patients were followed up for an average 9.1 (3-22) months. One case of pain and UTI was observed during the follow-up in whom conservative therapy was efficient. Radiological evaluation of all patients showed a reduction in hydronephrosis degree and patients recovered from pain and other clin- ical problems existing before operation. It can be inferred that radiological and clinical improve- ment was 100%. Blood pressure and urine culture were normal in all cases. 7 patients underwent cystoscopy preceding the operation and DJ catheter was placed in the ureter. In 3 cases DJ catheter was not used. DISCUSSION Lower renal pole aberrant vessels accompany- ing UPJO are frequent and it is believed that the establishment of UPJ obstruction is due to abnormal propagation of peristaltic waves in this point and the extrinsic compression of crossing vessel does not play a primary role. Consequently, cutting or transposition of vessels is not sufficient and pyeloplasty is necessary (1). However, there are a few reports of improvement without complementary pyeloplasty. (3-5) Open surgery is the approach used in previous studies, but since laparoscopy is applicable and less invasive, we can use it to relocate these ves- sels without pyeloplasty. Smith and coworkers used Chapman's technique in open surgeries of 19 patients. They dispensed with pyeloplasty and performed transposition in cases in which nor- mal peristalsis and emptying of renal pelvis were observed. They were successful in 80% of patients. Durand(14) cut the vessels in 97 patients underwent open surgery and pyeloplasty was required in only 10%. Kelly cut the vessels using laparoscope in 2 cases, both with clinical improvement.(15) Johnston showed resolution of obstruction in 32 out of 36 transpositions by pelvic pressure studies.(13) Cutting renal arteries results in ischemia and hypertension as they are end arteries, so it is not recommended. Whereas, cutting aberrant veins, particularly right renal vein which is shorter is possible and brings out no complication. Thus, we decided to cut the vein and relocate the artery and fix it to the lipid layer of pelvis and kidney. 2 LAPAROSCOPIC URETEROPELVIC JUNCTION DECOMPRESSION FOR THE MANAGEMENT OF OBSTRUCTION Patients were selected to undergo pyeloplasty or transposition intraoperatively, according to observation of emptying and decompression of renal pelvis, and normal peristalsis. In this approach we do not enter the renal system avoid- ing the risk of leakage, fistula, secondary steno- sis, and UTI seen in the classic pyeloplasty. Also transposition of vessels is more feasible and faster than performing pyeloplasty and patients do not require DJ catheter and drain as we did not insert DJ catheter in the last 3 cases. Patients can be discharged home on the first postoperative day (last 3 cases). Symptoms were relieved or improved after the operation. IVP after the 3rd postoperative month demonstrated reduction in the degree of hydronephrosis, dilated urinary system, or patent UPJ in all of the cases, indicating a 100% success. These results are comparable to open and laparoscopic pyeloplasty outcomes.(9-12) It is note worthy to mention that preoperative- ly detection of the cases is not possible and we did not evaluate the existence of aberrant vessels in any patients either. It seems that in some patients with UPJO and aberrant vessel, extrinsic compression and angu- lation of the ureter plays a primary role in the obstruction in the absence of any primary disor- der. Accordingly, treatment can be obtained merely by transposition of the vessels. Further studies with larger sample size and longer follow- up are warranted in order to confirm our find- ings. CONCLUSION Based on the mentioned findings, it seems at least in a proportion of patients with UPJ steno- sis accompanied with crossing vessels, that mechanical compression is the mere cause of obstruction and primary stenosis does not coex- ist. Thus, the treatment is achieved by transposi- tion of the crossing vessels without entering the renal unit. REFERENCES 1. Jenny SB, Franke JJ, Smith JA. Management of upper urinary tract obstruction. In: Walsh, PC, Retik AB, Vaughan Jr. ED, editors. Campbell's Urology. 8th ed. Philadelphia: W. B. Saunders; 2002. p. 464. 2. Brosig W, Kollwitz AA. Transposition of lower polar vessels: an operative approach to hydronephrosis. J Urol 1961; 85: 453-458. 3. Nixon HH. 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