Laparoscopic Division of Crossing Vessels at the Ureteropelvic Junction

Endopyelotomy has become an accepted mode of treatment for primary and secondary ureteropelvic junction (UPJ) obstruction, but a 15% to 30% failure rate persists. The presence of crossing vessels at the UPJ has been implicated as a common cause of complications, failures, and recurrences. In the past, renal angiography was necessary to identify crossing vessels. We have utilized endoluminal ultrasonography to identify crossing vessels at the UPJ and to guide endoscopic incisional techniques. Previously, whenever crossing vessels were identified that could not be safely avoided during endopyelotomy, we had recommended dismembered pyeloplasty, an open surgical procedure with a long recovery time. We report our experience with laparoscopic division of crossing vessels in two patients, one with a symptomatic horseshoe kidney. Each patient had a large crossing vessel identified by endoluminal ultrasonography; consequently, endopyelotomy was abandoned. The location and distribution of the vessels were then delineated by angiography. The aberrant vessels were dissected free and divided laparoscopically. The patients returned to work within 1 week. Followup diuretic renal scans showed complete resolution of obstruction (T_1/2 < 10 minutes) in one patient; no change was noted in the patient with a horseshoe kidney. Both patients have remained free of symptoms and normotensive for more than 12 months. Laparoscopic division of crossing vessels may play a role in the treatment of patients with extrinsic ureteral obstruction from aberrant vessels.