Abstract
Introduction:
Crossing lower-pole vessels are a frequent cause of extrinsic ureteropelvic junction obstruction (UPJO), yet intrinsic narrowing may coexist and mandates reconstruction. We evaluated a simple intraoperative diuretic drainage test to verify the mechanism of obstruction and guide real-time selection between laparoscopic vascular hitch (Hellström) and laparoscopic dismembered pyeloplasty.
Materials and Methods:
After complete mobilization of the renal pelvis, proximal ureter, and lower-pole crossing vessels, patients received a 10 mL/kg crystalloid bolus followed by intravenous furosemide. The crossing vessels were gently elevated for 5–20 min while the pelvis was observed for decompression. Brisk decompression was interpreted as purely extrinsic compression and treated with vascular hitch; persistent dilation suggested intrinsic UPJ narrowing and prompted dismembered pyeloplasty with anterior transposition of the anastomosis. Single-surgeon (MEC) pediatric series at a tertiary center using the diuretic drainage test in consecutive cases with preoperative imaging consistent with UPJO and crossing vessels. Two representative index cases (adolescents) demonstrated severe hydronephrosis with delayed drainage on MAG3 and are shown with pre-/postoperative cross-sectional and ultrasound comparisons. Primary outcomes were operative time, hospital length of stay (LOS), change in renal pelvis anteroposterior diameter (APD) on ultrasound, and complications. Group comparisons (pyeloplasty vs. hitch) used t-tests/Fisher’s exact tests.
Results:
Thirty-eight patients were included (Hitch n = 23; pyeloplasty n = 15). Age and laterality were similar between groups (mean age 10.8 ± 3.8 vs. 11.2 ± 3.9 years; p = 0.732). Vascular hitch significantly reduced operative time (148.2 ± 40.6 vs. 224.4 ± 47.3 min; mean difference −76.2 min, 95% Cl −105.4 to −47.1; p < 0.001) and LOS (10.2 ± 12.5 vs. 44.4 ± 42.2 h; mean difference −34.2 h, 95% CI −58.0 to −10.4; p = 0.008). Improvement in APD was comparable (absolute change 1.82 ± 1.32 vs. 2.49 ± 1.79 cm, p = 0.196; relative reduction 0.58 ± 0.20 vs. 0.61 ± 0.20, p = 0.626). Complication rates were low and not different (8.7% vs 13%; p = 0.418). The test identified intrinsic UPJ narrowing intraoperatively in the pyeloplasty cohort and confirmed purely extrinsic obstruction in hitch cases, with favorable postoperative imaging in both scenarios.
Conclusions:
A standardized intraoperative diuretic drainage test is a practical adjunct that verifies the mechanism of UPJO and safely tailors operative choice. When extrinsic compression is confirmed, vascular hitch achieves similar anatomical improvement to pyeloplasty while significantly shortening operative time and LOS. This approach may reduce unnecessary reconstruction and optimize recovery in appropriately selected patients.
Disclosure Statement:
The authors report no conflicts of interest. The authors declare that they have no commercial or financial relationships that could be construed as a potential conflict of interest within the past 2 years. Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure.
Funding Information:
No funding was received for this article.
Runtime of video:
7 mins 56 secs.