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Hellström technique revisited: laparoscopic management of ureteropelvic junction obstruction

  • Maxwell V Meng
    Correspondence
    Reprint requests: Maxwell V. Meng, M.D., Department of Urology, A-631, University of California, San Francisco, School of Medicine, 400 Parnassus Avenue, San Francisco, CA 94143-0738, USA
    Affiliations
    Department of Urology, University of California, San Francisco, School of Medicine, San Francisco, California, USA
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  • Marshall L Stoller
    Affiliations
    Department of Urology, University of California, San Francisco, School of Medicine, San Francisco, California, USA
    Search for articles by this author

      Abstract

      Objectives

      To present our experience with the treatment of adult ureteropelvic junction (UPJ) obstruction using a laparoscopic Hellström vascular relocation technique.

      Methods

      Transperitoneal laparoscopy was performed in 35 patients for the management of UPJ obstruction. In 9 cases, we identified crossing lower pole vessels and performed the Hellström technique. We discuss our indications, intraoperative techniques, and outcomes when performing only vascular relocation in these patients.

      Results

      All 9 patients presented with long-standing flank pain and were identified as having UPJ obstruction (7 primary, 2 secondary) on radiographic imaging. The intraoperative decision to perform the Hellström technique was based on the presence of the crossing vessels, a grossly normal appearance of the ureter and UPJ, and a small renal pelvis. The crossing vessels were completely mobilized, displaced cephalad, and fixed using intracorporeal sutures. The mean operative time and blood loss was 164 minutes and 15 mL, respectively. At a mean follow-up of 19 months (range 14 to 31), the patients were asymptomatic with no evidence of obstruction on Lasix nuclear renography.

      Conclusions

      Traditional treatment of UPJ obstruction, with or without crossing vessels, has been accomplished by pyeloplasty. Dismembered pyeloplasty is a standard method in cases of associated crossing vessels; however, we propose that the Hellström technique be considered in cases in which the ureter appears normal and the pelvic anatomy is unfavorable for transection and anterior reanastomosis of the ureter and pelvis. These considerations are particularly relevant during the laparoscopic approach in which intracorporeal suturing and knot tying are technically challenging.
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