A crossing vessel accompanying pelvi-ureteric junction obstruction (PUJO) occurs in 25-50% of cases. The Hellstrom vascular hitch procedure was first described in 1951 and has regained popularity since 2003 in the era of laparoscopic surgery as it negates the need for laparoscopic dismembering and suturing. Early reports have shown a higher recurrence rate with this procedure than dismembering pyeloplasty and vessel transposition. This paper retrospectively analyses 19 patients (eight vascular hitch vs. eleven dismembered pyeloplasty), ten boys, nine girls with mean age of 9.5 years (range 2-17.3) for postoperative outcomes (mean follow-up 12 months, range 6-50.7). Obstruction preoperatively was defined as hydronephrosis on ultrasound scan (USS) after hyper-hydration and / or poor drainage on MAG-3 renogram. On the basis of video analysis, three types of crossing vessels were identified: a) vessels just above the PUJ in front of the pelvis and not responsible for the PUJO, b) vessels at the PUJO but there is also an obvious intrinsic narrowing of the ureter, c) vessels below the PUJ with the ureter above kinked or ‘swan-necked’ and the vessels are not related to the obstruction. Operative time was shorter but not statistically significantly different in the hitch operations. None of the hitch operations had complications and all were asymptomatic clinically or had better MAG-3 drainage at 12 months. The authors conclude that the vascular hitch procedure should be part of the armamentarium of a urologist but that one can never be certain whether or not there is intrinsic constriction in addition to the vessel. In their view only type c) above could be deemed appropriate for the hitch. Careful selection is mandatory and this factor is corroborated by other studies.
Lower pole vessels in children with PUJO: laparoscopic vascular hitch or dismembered pyeloplasty?
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