Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada.
Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON, Canada.
BJU Int. 2022 Jun;129(6):679-687. doi: 10.1111/bju.15342. Epub 2021 Feb 7.
To compare the outcomes for laparoscopic vascular hitch (VH) and dismembered pyeloplasty in patients with pelvi-ureteric junction obstruction (PUJO) secondary to crossing vessels (CV).
Patients who underwent laparoscopic management of CV at our institution were identified between 2008 and 2020. Baseline characteristics and outcome measures were compared between those who underwent VH and those who underwent dismembered pyeloplasty. Those who underwent VH were selected intraoperatively by identifying CV in the absence of intrinsic obstruction by assessing resolution of hydronephrosis after cranially displacing the CV away from the PUJ, followed by intraoperative fluid bolus and diuretic test. In addition, a systematic search and meta-analysis were performed in June 2020 (International Prospective Register of Systematic Reviews [PROSPERO] ID CRD42020195833).
A total of 20 patients underwent VH and 74 dismembered pyeloplasty. On multivariate analysis, VH was associated with: shorter operative time (P = 0.001; odds ratio [OR] 0.455, 95% confidence interval [CI] 0.294-0.705) and length of stay (P = 0.012; OR 0.383, 95% CI 0.183-0.803), lower use of stents (P < 0.001; OR 0.024, 95% CI 0.004-0.141) and opioid administration (P = 0.005; OR 0.157, 95% CI 0.044-0.567). From our literature search, 194 records were identified and 18 records were included (three comparative and 16 non-comparative). Meta-analysis of the comparative studies and our institutional data showed similar success rates (relative risk [RR] 1.77, 95% CI 0.33-9.52) and complication rates (RR 0.75, 95% CI 0.20-2.82). VH was associated with shorter operative time (standardised mean difference [SMD] -1.65, 95% CI -2.58 to -0.72 h) and hospital stay (SMD -1.41, 95% CI -2.36 to -0.47 days). The VH success rates ranged from 87.5% to 100% in the identified studies. Failure of VH was associated with unrecognised concomitant intrinsic obstruction in addition to CV.
A VH, for well-selected patients with CV without concomitant intrinsic obstruction, offers a high success rate with shorter operative times.
比较腹腔镜血管钩（VH）和离断式肾盂成形术治疗交叉血管（CV）继发肾盂输尿管连接部梗阻（PUJO）患者的结局。
我们在 2008 年至 2020 年间确定了在我们机构接受 CV 腹腔镜治疗的患者。比较接受 VH 和接受离断式肾盂成形术的患者的基线特征和结局指标。术中通过评估 CV 离开 PUJ 后肾盂积水的缓解情况来识别 CV，如果没有内在梗阻，术中通过识别 CV 来选择 VH，随后进行术中液体冲击和利尿剂试验。此外，我们于 2020 年 6 月进行了系统搜索和荟萃分析（国际前瞻性注册系统评价 [PROSPERO] ID CRD42020195833）。
共 20 例患者接受 VH，74 例接受离断式肾盂成形术。多变量分析显示，VH 与：手术时间更短（P=0.001；比值比 [OR] 0.455，95%置信区间 [CI] 0.294-0.705）和住院时间更短（P=0.012；OR 0.383，95% CI 0.183-0.803）、支架使用率更低（P<0.001；OR 0.024，95% CI 0.004-0.141）和阿片类药物使用率更低（P=0.005；OR 0.157，95% CI 0.044-0.567）有关。从我们的文献搜索中，确定了 194 条记录，纳入了 18 条记录（3 项比较性研究和 16 项非比较性研究）。对比较性研究和我们机构数据的荟萃分析显示，相似的成功率（相对风险 [RR] 1.77，95% CI 0.33-9.52）和并发症发生率（RR 0.75，95% CI 0.20-2.82）。VH 与手术时间更短（标准化均数差 [SMD] -1.65，95% CI -2.58 至 -0.72 小时）和住院时间更短（SMD -1.41，95% CI -2.36 至 -0.47 天）有关。在确定的研究中，VH 的成功率范围为 87.5%至 100%。VH 失败与除 CV 之外未识别的伴发内在梗阻有关。
对于 CV 且无伴发内在梗阻的精选患者，VH 可提供高成功率并缩短手术时间。
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