Rehman J, Landman J, Sundaram C, Clayman R V
Department of Surgery (Division of Urologic Surgery), Washington University School of Medicine, St. Louis, Missouri, USA.
J Urol. 2001 Aug;166(2):593-6.
Extrinsic ureteropelvic junction obstruction due to anterior crossing segmental renal vessels is present in more than 50% of patients in adulthood. In this situation the ureter must usually be dismembered and transposed anterior to the crossing vascular structures, where it is anastomosed to the renal pelvis. Via the open retroperitoneal approach there may be a limited view of the anterior surface of the ureteropelvic junction and, hence, anterior crossing vessels may possibly be missed. We describe 2 patients with ureteropelvic junction obstruction in whom anterior vessels were missed during open retroperitoneal repair. Laparoscopic transperitoneal secondary pyeloplasty with posterior displacement of the crossing renal vessel was performed in each case.
Two patients presented with symptomatic congenital ureteropelvic junction obstruction after failed endopyelotomy in 1 and failed open retroperitoneal procedures in both. Preoperatively spiral computerized tomography angiography with a ureteropelvic junction protocol revealed crossing vessels in the 2 cases. This finding was confirmed at transperitoneal laparoscopic pyeloplasty. The ureter and renal pelvis were transposed anterior to the crossing vessels and 2 rows of running sutures were placed to complete the anastomosis.
The 2 laparoscopic procedures were completed successfully. The anterior crossing vessels were preserved in each case. Currently the patients are asymptomatic and furosemide washout renal scan was normal.
Spiral CT angiography reliably delineates the renal vascular anatomy in patients with ureteropelvic junction obstruction. This study may be valuable before planned open retroperitoneal ureteropelvic junction obstruction repair. Laparoscopic pyeloplasty may successfully manage anterior crossing vessels associated with secondary ureteropelvic junction obstruction.
成年患者中超过50%存在因前方交叉的节段性肾血管导致的外在性肾盂输尿管连接处梗阻。在这种情况下，通常必须将输尿管离断并移位至交叉血管结构前方，在此处与肾盂进行吻合。通过开放腹膜后入路，肾盂输尿管连接处前表面的视野可能有限，因此，前方交叉血管可能会被遗漏。我们描述了2例肾盂输尿管连接处梗阻患者，在开放腹膜后修复过程中遗漏了前方血管。每例均进行了腹腔镜经腹二次肾盂成形术并将交叉肾血管向后移位。
2例患者均因症状性先天性肾盂输尿管连接处梗阻就诊，其中1例内镜肾盂切开术失败，2例开放腹膜后手术均失败。术前采用肾盂输尿管连接处扫描方案的螺旋计算机断层血管造影显示2例均有交叉血管。这一发现经经腹腹腔镜肾盂成形术得到证实。将输尿管和肾盂移位至交叉血管前方，放置2排连续缝线完成吻合。
2例腹腔镜手术均成功完成。每例均保留了前方交叉血管。目前患者无症状，速尿清除肾扫描正常。
螺旋CT血管造影能可靠地描绘肾盂输尿管连接处梗阻患者的肾血管解剖结构。这项研究对于计划进行的开放腹膜后肾盂输尿管连接处梗阻修复术前可能有价值。腹腔镜肾盂成形术可成功处理与继发性肾盂输尿管连接处梗阻相关的前方交叉血管。
