ENDOUROLOGY & LAPAROSCOPY

Hellstrom technique revisited: laparoscopic management of ureteropelvic junction obstruction
Meng MV, Stoller ML
From the Department of Urology, University of California, San Francisco, School of Medicine, San Francisco, California, USA
Urology. 2003; 62: 404-9

• Objectives: To present our experience with the treatment of adult ureteropelvic junction (UPJ) obstruction using a laparoscopic Hellstrom 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 Hellstrom 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 Hellstrom 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 Hellstrom 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.
  
  
• Editorial Comment
  This article describes the laparoscopic version of an infrequently used option for repair of ureteropelvic junction obstruction. In the Hellstrom approach to ureteropelvic junction obstruction, pyeloplasty is not performed and instead the anterior crossing vessels are relocated cephalad (a mean of 2.3 cm in this series). Proponents of this technique argue that if there is no intrinsic ureteral obstruction, and the problem is simply anterior crossing vessels that allow the renal pelvis to herniate forward and kink off the ureteropelvic junction, then this “vasculopexy” will solve the problem with less surgical intervention. In an editorial following the article, Dr. Stephen Nakada expressed concern that cases of intrinsic ureteral abnormality might easily be missed with the subjective assessment of the intra-operative appearance of the ureter, and that performing vasculopexy rather than formal dismembered pyeloplasty with anterior relocation of the ureter might risk failure of the procedure. Indeed, the (open surgical) Hellstrom procedure fell out of favor years ago probably because of exactly this problem – it was applied in situations where there was in fact an intrinsic ureteral abnormality. That the authors’ intra-operative assessment was accurate enough that their procedure was successful in all nine patients is impressive. Even with my own fairly large experience with laparoscopic pyeloplasty, I would be concerned that I would be unable to make this assessment with a high degree of accuracy in the operating room. The authors cover themselves well in this regard, stating “If one is not completely convinced that the UPJ itself is normal, dismembered pyeloplasty should be performed.” A laparoscopic Hellstrom procedure appears to provide a good outcome in properly selected patients – I would just caution the reader that this selection might be very difficult and that the price of incorrect selection (a failed procedure) must be considered very carefully.

Dr. J. Stuart Wolf Jr.
Associate Professor of Urology
University of Michigan
Ann Arbor, Michigan, USA