Subpelvine Stenose & kreuzende Gefäße – Pro „vascular hitch“

Zusammenfassung

Die Möglichkeit, eine durch aberrierende Unterpolgefäße bedingte subpelvine Stenose durch eine gefäßverlagernde Pyeloplastik (‚vascular hitch‘) zu behandeln, wird kontrovers diskutiert. Seit diese Technik bei Patienten mit aberrierenden Unterpolgefäßen minimal invasiv durchgeführt wird, mehren sich Publikationen mit kurz-, mittel- und langzeitiger Nachbeobachtung. Die Erfolgsraten werden hierbei analog zur Anderson-Hynes-Plastik mit > 90 % angegeben. Insgesamt scheint eine assoziierte intrinsische Stenose selten zu sein. Eine histologisch nachweisbare muskuläre Hypertrophie kann auch nur Hinweis auf eine Gegenregulation und zumindest bis zu einem gewissen Grad reversibel sein. Für die sicherere Differenzierung der Patienten, bei denen eine Gefäßverlagerung ausreichend ist, von den Patienten, die besser initial eine Anderson-Hynes-Pyeloplastik erhalten sollten, empfiehlt sich ein intraoperativer Diuresetest (Volumenbolus plus intravenöse Furosemidgabe). Eine assoziierte intrinsische Stenose erscheint bei trichterförmigem und ansonsten unauffällig aussehendem pyeloureteralen Übergang, abnehmender Hydronephrose nach Mobilisierung des Nierenbeckens und der aberrierenden Unterpolgefäße und einer effizienten Peristaltik über den pyeloureteralen Übergang während des intraoperativen Diuresetests unwahrscheinlich. Die Vascular-hitch-Technik ist weniger anspruchsvoll als die laparoskopische Anderson-Hynes-Plastik und geht daher mit kürzeren Operations- und Narkosezeiten einher. Weitere Vorteile sind: kein Risiko der Leckage oder späteren Anastomosenstenose und keine Notwendigkeit intraluminaler Stents. Die vascular hitch Operation stellt somit bei einem selektionierten Patientengut mit rein extrinsischer subpelviner Stenose eine scheinbar auch langfristig wirksame Alternative zur klassischen Anderson-Hynes-Plastik dar.

Abstract

The vascular hitch procedure for pelviureteric junction obstruction caused by crossing lower-pole vessels is a controversial treatment option. Since this minimally-invasive technique has been introduced in patients with aberrant lower-pole vessels, multiple publications have reported successful short, intermediate and long-term outcomes. Success rates of > 90 % are similar to those of Anderson-Hynes pyeloplasty. In general, an associated intrinsic stenosis seems to be rare. Histological evidence of muscular hypertrophy may simply indicate a compensatory mechanism and may be reversible to a certain degree. To differentiate between those patients who are eligible for a vascular hitch procedure and those who should receive an initial Anderson-Hynes pyeloplasty, an intraoperative diuretic test should be performed (volume bolus plus intravenous administration of furosemide). An associated intrinsic stenosis seems to be unlikely in a funnel-like and otherwise normal-looking pelviureteric junction, decreasing hydronephrosis after mobilisation of renal pelvis and crossing vessels and effective peristalsis of the renal pelvis after intraoperative diuretic testing. The vascular hitch technique is less demanding than laparoscopic Anderson-Hynes pyeloplasty and less time-consuming with regard to the duration of the surgical procedure and anaesthesia. Further advantages are: no risk of urinary leakage or anastomotic stricture and no need for intra-luminal stenting. Therefore, in a selected group of patients with solely extrinsic pelviureteric junction obstruction, the vascular hitch procedure is a valuable alternative to classic Anderson-Hynes pyeloplasty with seemingly long-term efficiency.

Schlüsselwörter

aberrierende Unterpolgefäße - subpelvine Stenose - vascular hitch Operation - gefäßverlagernde Pyeloplastik - extrinsische Stenose

Keywords

crossing aberrant vessels - pelviureteric junction obstruction - vascular hitch procedure - extrinsic stenosis

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