A successful case of vascular hitch procedure in adulthood: A simpler alternative for the vascular obstruction of the pyelo-ureteral junction

Abstract

Congenital obstruction of the upper urinary tract is often caused by the pyeloureteral junction syndrome, the lower polar vessel being the most common extrinsic etiology.

We report on a case that was successfully treated using the Vascular HITCH, an alternative method with lower morbidity than Anderson and Hynes pyeloplasty considered the gold standard procedure.

Our objective is to outline the aforementioned method and illustrate its ease of use and possible efficacy in carefully chosen adult patients.

A very specific set of patients who meet pre- and post-operative criteria are required for vascular HITCH. The outcomes of this method are encouraging.

1 Introduction

The pyelo-ureteral junction syndrome is the most common cause of congenital obstruction of the upper urinary tract. A syndrome that has several intrinsic or extrinsic etiologies, which may also be concurrent.

The lower polar vessel represents the most common extrinsic cause (20% of renal pedicule variants) causing a compression that hinders the flow of urine from the renal pelvis to the ureter. Although the dismembered pyeloplasty, as described by Anderson and Hynes (1949), is considered the gold standard, it is associated to some few risks, which justifies the search for alternatives. Therefore a proposal for an alternative surgical procedure has been put forth such as the Vascular Hitch, described initially in the 1950s by HellSTROM, modified by Chapman and performed laparoscopically in 2003 by MENG.

It is essentially a transposition of the lower polar vessel thus lifting the sub pelvis obstacle. The main goals remain: reducing the duration of the surgery and the surgical morbidity while maintaining an equivalent efficacy to the classical approach.

2 Case report and technique

We present the case of a 20 years young man presenting moderate chronic low back pain with a medical history of upper urinary infection, and the implementation of left JJ stent to treat an obstructive pyelonephritis episode.

The contrast enhanced ct-scan showed: a left pyelocaliceal dilatation with preserved renal parenchyma caused by a pyelo-ureteral junction syndrome ( Fig. 1 ). The DMSA Scintigraphy revealed a left kidney function estimated at 47 %.

The stent was then removed shortly before the procedure to allow the kidney pelvis to enlarge, which would have aided Anderson pyeloplasty if we had decided on this option.

Indeed, the choice of technique is made perioperatively following a thorough examination of the pyeloureteral junction.

After a routine anesthesia check-up, the patient was admited in the operating room. Under general anesthesia and after the placement of a foley catheter the patient then was shifted to a right lateral decubitus position. The camera port was superior and lateral to the umbilicus and two 5 mm manipulation trocars were placed according to the triangulation principle.

By laparoscopic means, the procedure follows the standard steps for accessing the pyelo-ureteral junction (video 1):

The following is/are the supplementary data related to this article:

Video S1

Creating a pneumoperitoin then the Colonic mobilization: The descending colon was mobilized, thus accessing the renal lodge. At the lower pole, the ureter and gonadal vein were located, and they were dissected superiorly to the renal pelvis. Then came the identification of the vascular obstruction of the renal pelvis by an inferior polar vessel.

A thorough inspection of the pyeloureteral junction was conducted, ensuring a normal appearance that would not suggest an intramural anomaly.

Technique Vascular HITCH: meticulous dissection of the pyeloureteral junction.

Identification and dissection of the lower polar pedicle ( Fig. 2 ).

Assessing and ensuring a good pelvic drainage and ureteral peristalsis after the injection of 0.5 mg/kg of Furosemide. The vessel was therefore moved in a more cephalic position, approximately 1.5 cm above the junction. Then sutured within the anterior wall of the pelvispyelic tunnel with 3 separate non-transfixing points according to the technique Hellstrom-Chapman ( Fig. 3 ).