Laparoscopic vascular relocation procedures in the treatment of hydronephrosis due to aberrant vessels compression in children

Introduction. Congenital hydronephrosis, can be caused by intrinsic and / or extrinsic uretero-pelvic obstruction. Regardless of the type of obstruction, pyeloplasty remains the traditional surgical procedure for hydronephrosis in children, though procedures that aim to relocate the vascular pedicle, commonly known as “vascular hitch”, were described for hydronephrosis associated with aberrant renal vessels. Because of the development of minimally invasive surgery, this surgical technique gained its maximum utility in laparoscopy. We describe our experience with laparoscopic technique of relocating the aberrant vessels, in children with PUJO. Materials and method. Between January 2007–February 2015, a total of 35 patients, were operated by a laparoscopic technique for hydronephrosis. In this group, we studied eight patients (five boys and three girls), with a mean age of 9.7 years (range 4e17), diagnosed with vascular compression of the pelviureteric junction, who underwent laparoscopic relocation of the aberrant vessels. Surgical indication was based on an intermittent lumbar pain associated with evidence of pelviureteric obstruction (ultrasound / urography / DTPA scintigraphy). Results. The laparoscopic surgical technique involved dissection and mobilization of the lower pole vessels, freeing the junction and suspension of the vascular pedicle on the anterior pelvic wall. None of the patients required ureteral stenting, but a lumbar drain was held in place for 48 hours. In a single case we practiced the suspension of the pelvis to the psoas muscle, in a girl who had a simultaneous pelvic bifidity, and developed a troublesome postoperative course, caused by inefficient drainage of the renal pelvis, so the final solution was a uretero-calycostomy and ureteral stenting. The main outcome variables measured were relief of pain, improvement of the value of the urinary tract distension on ultrasound and of the renal function on scintigraphy, performed 3 and 6 months after surgery. Average operating time was 110 minutes. All patients were discharged on the fourth postoperative day, except for one patient, who was hospitalized for 21 days. All of the patients remained free of symptoms after six months. They showed no obstruction signs on ultrasound, with improvement of the renal appearance. Conclusions. Vascular relocation procedures are simple, requiring less operative time than pyeloplasty. Their advantages are maintaining the integrity of the urinary tract, without anastomosis or ureteral stenting. Controversy remains regarding patency of the pelviureteric junction.