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A Contemporary Analysis of UPJ Obstruction Repair Reveals the Incidence of Crossing Vessels Increases After Age 4
Madeline Cancian, MD, Liza Aguiar, MD, Anthony Caldamone, MD, Gyan Pareek, MD.
Brown University, Providence, RI, USA.
Background: Ureteropelvic junction obstruction (UPJO) presents in patients at all ages. UPJ obstruction may be associated with crossing vessels. The literature suggests that an intrinsic cause without lower pole vessel crossing is more likely to be present in those diagnosed with prenatal hydronephrosis. We hypothesize that younger patients are more likely to have an intraoperative finding of an intrinsic cause of UPJO without a crossing vessel compared to older patients.
Methods: Our database was queried for patients undergoing pyeloplasty (CPT 50400, 50405, 50544) between 6/1/2002 to 3/10/3016. We excluded all patients with anatomic abnormalities, including horseshoe kidneys and pelvic kidneys, as well as patients undergoing surgery for upper tract tumor. We reviewed hospital records to determine the anatomy of the UPJ obstruction and the nature of presentation; hydronephrosis on imaging or symptoms including pain or nausea. Data was analyzed in excel using t-tests and linear regressions.
Results: 178 pts underwent pyeloplasty between 6/18/2002 to 3/10/2016. Median age was 10.5 years, ranging from 2 mo to 79 years. 43% were right sided, 35% were female. Of the 178 patients, 57 (32%) patients had crossing vessels found at the time of repair. Incidence of crossing vessels increased at 5 years of age. 4/65 (6%) of patients < 5 years had evidence of a crossing vessel compared to 53/113 (47%) of patients >5 years of age (p<0.05). There was no trend in increasing incidence of crossing vessels by either date of surgery (R2=0.05) or age of patient at surgery (if age>5, R2=0.02). The incidence of crossing vessels was the same regardless of side of obstruction (p=0.46) or gender (p=0.20). Of the 65 patients <5 years of age, cause of presentation was identified in 55. 53 presented with prenatally diagnosed hydronephrosis of which 3 (6%) had crossing vessels identified at time of surgery. Additionally, one patient aged 3 presented with pain, no crossing vessels identified, and one patient aged one had an incidental finding on trauma work up with crossing vessels identified. Among patients > 5 the cause of presentation was identified in 101 patients. 88/101 (85%) presented with pain, of which 46 (53%) had crossing vessels present. 13 presented with an incidental finding on imaging of which 31% had crossing vessels present (p=0.17). Surgical approach was open in 99 cases, laparoscopic in 24 cases and robotic in 55 cases. The first robotic case was in 12/2007 and the last laparoscopic case was completed in 6/2013.
Conclusion: Patients less than 5 years old who underwent pyeloplasty were less likely to have an associated crossing vessel found at the time of UPJ repair. There was no trend to increasing incidence of crossing vessels if patient was older than 4 years. Patients who present with incidental finding of hydronephrosis are less likely to have a crossing vessel present, however this was not statistically significant in the older age group.
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