Laparascopic Assisted Approach to a Right Pelvi-ureteric Junction Obstruction With Incomplete Duplex System. A Case Report”

Laparascopic Assisted Approach to a Right Pelvi-ureteric Junction Obstruction With Incomplete Duplex System. 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A Case Report” Tim Jumbi, Syovata Munyalo, David Shipapa, Brian Marete, Sarah Okebe This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5385261/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction The concurrence of PUJO and duplicated systems is rare and more so when associated with a crossing vessel. Management is dependent on the variant anatomy based on imaging and intra-operative findings. The use of laparoscopic assisted technique can be employed with extracorporeal suturing in limited resource settings where intracorporeal suturing would increase operative time and would require a higher level of skill and experience. Case Presentation. A 6-year-old female presented with a prolonged history of right flank pain. Imaging revealed right hydronephrosis with impaired drainage on diuretic renography. Intra-operatively, an incomplete right duplex system was found with a lower pole crossing vessel causing extrinsic obstruction to both upper and lower moieties. A laparoscopic assisted technique with extra-corporeal suturing was used to perform an upper pole ureter to lower pole pyeloplasty and lower moiety Anderson Hynes pyeloplasty. The patient was followed up with complete resolution of symptoms at 3 months and 6 months post operatively. Conclusion. Surgical decision-making on Duplex systems with PUJO is based on imaging detail and intra-op dissection of the anatomic variants. A laparoscopic assisted technique has the advantage of reducing operative time by extracorporeal suturing and the benefit of laparoscopic dissection which offers adequate exposure. Case report Incomplete Duplex system Laparascopic assisted approach. Figures Figure 1 Figure 2 Figure 3 Introduction The incidence of crossing vessels in the etiology of Pelvic-ureteric Junction Obstruction (PUJO) in children has been reported as ranging from 11–15% . However, the concurrence of PUJO and duplicated systems is much less common and more so when associated with a crossing vessel. Detection of such anomalies with imaging is key to the management approach and intraoperative decision-making is based on the anatomic variants. We herein report a case of PUJO associated with an incomplete duplex system in the upper urinary tract with a lower pole crossing vessel causing extrinsic obstruction to both upper and lower moieties. This report also describes a laparoscopic assisted technique which is useful in a resource limited setting where intracorporeal suturing would increase operative time and would require a higher level of skill and experience. Case Description A 6-year-old female presented to our outpatient clinic with complaints of right sided abdominal pain for over 2 years. Previously, she had been treated twice for urinary tract infections (UTIs). She had no history of hematuria. Her growth and developmental history did not reveal any relevant information related to the illness. She was stable on physical examination; her vital signs were normal. Her abdominal exam did not reveal any masses around the flanks. A urine analysis done was negative for UTI. A series of imaging were done which revealed the following. An ultrasound done detected a grade 2 hydronephrosis (Fig. 1A) with no hydro-ureter. There was an intervening cortical bar suggestive of a duplex system. The left kidney and bladder anatomy was normal. A diuretic DTPA scan was done albeit delayed for another 3 months due to high cost and limited access to the service. The DTPA scan revealed a hydronephrotic right kidney with impaired drainage. The differential right renal function was 58% against a GFR of 119ml/min. (Fig. 1B). Initially, as we awaited the DTPA scan, a conservative approach was employed with pain management and adequate hydration. However, the patient continued to have worsening right flank pain and an increasing level of hydronephrosis on subsequent ultrasound scan. Informed and written consent was obtained for right pyeloplasty indicated by worsening symptoms of pain. The patient was prepared for a right laparoscopic approach, patient positioning and port placement was done as shown in the diagram below (Fig. 2). Upon exposing the right kidney, we noted an incomplete duplex system. There were two ureters, an upper and lower ureter which joined to form a common ureter below the renal pelvis of the lower moiety. There was a crossing vessel causing obstruction in both upper and lower proximal ureters. (Fig. 3A) Dissection was done laparascopically to expose all structures, and a stay suture was placed on the lower pelvis which was used to exteriorize the site through a small flank incision for extracorporeal surgery. The lower ureter was dismembered from the pelvis allowing the vessel to pass posterior to the ureter. Thereafter, pyeloplasty was performed with the standard Anderson Hynes technique between the lower pole pelvis and the common ureter. Subsequently, the upper ureter was also dismembered from its union to the common ureter and an upper pole ureter to lower pole pyeloplasty was performed. This way the upper ureter drained on to the lower pelvis while the lower pelvis drained onto the common ureter (Fig. 3B). The crossing vessel would now sit posteriorly to both upper and lower systems therefore not causing any obstruction. A DJ stent was left in situ with the tip sitting at the lower pelvis. The total operative time was 150 minutes The DJ stent was removed in 6 weeks. There was resolution of symptoms after the surgery and an ultrasound scan done 3 months later showed a hydronephrosis of grade 1 which resolved at the 6-month follow-up scan. Discussion Duplication of the collecting system can occur in complete or incomplete variants with a reported incidence of 0.8% in literature. PUJO is a rare concurrence and when it occurs, it often affects the lower moiety in incomplete duplex systems. 2 The diagnosis of this rare entity is challenging given its rarity in occurrence and the nonspecific symptomatology, in our present case the initial diagnosis of right hydronephrosis was made via ultrasound after the patient complained of right sided flank pain for over 2 years. The duplex system on imaging may appear as two central echo complexes with hydronephrosis in one or both moieties and an intervening renal parenchyma. These findings were partialy appreciated in our reported case. Diuretic renography and functional magnetic resonance urography (fMRU) is usually performed to detect split renal function and to assess renal clearance. In particular, the utility of fMRU is considered superior due to its ability of detecting concurrent urologic pathology and vascular anatomy in addition to providing separate detail of each moiety which are all important in surgical planning. The feasibility of minimally invasive techniques including both laparascopic and robotic options is gaining popularity in the paediatric population. In addition to the other described benefits of shorter hospital stay, reduced pain and excellent cosmetic outcome, minimally invasive surgery provides excellent anatomic visualization of the duplicated system which enhances surgical decision making. These approaches can be compounded by availability of equipment and a steep learning curve especially on intra-corporeal suturing and knotting. In our case the laparascopic assisted approach provided a very clear description of the incomplete duplex and crossing vessel causing obstruction in both upper and lower ureters while performing faster extracorporeal suturing. Ueki et al describes a detailed 3-pronged approach approaches based on intraoperative findings of the intact ureteral length and the presence of crossing vessels. In the absence of crossing vessels an end to side pyelo-ureterostomy or and Anderson Hynes pyeloplasty of the affected lower pole is considered, however the presence of crossing vessels usually obstructs both ureters and the recommended procedure is an upper pole ureter to lower pole pelvis uretero-pyeloplasty with the Anderson–Hynes procedure for the lower pole. In our case, we elected to perform the latter based on the presence of crossing vessels which was causing upstream dilatation in both upper and lower moieties. In our institution, we routinely perform a double J(DJ) stented pyeloplasty as protocol in PUJO. Notably, a network meta-analysis which focused on the role of stents in paediatric pyeloplasty concluded that there were no significant differences in operative time, operative success, hospital stay, improvement of renal functions and overall complications for the external stented, DJ stented and stent-less procedures. Our follow up protocol after pyeloplasty is a clinic visit in 2 weeks, the DJ stent is removed after 4–6 weeks. We then perform an ultrasound 6 weeks after DJ stent removal and every 3 months thereafter. We only offer a diuretic study if there is persistent and/or increasing hydronephrosis. The follow up protocol in literature varies between institutions, however the goal remains the same which is to evaluate adequacy of drainage and detect complications that may need intervention. Conclusion The concurrence of PUJO and duplicated systems is a rare occurrence and more so when associated with a crossing vessel. Surgical decision-making is based on imaging detail and intra-op dissection of the anatomic variants. When both upper and lower moieties are retained, the goal of surgery is to relieve the obstruction and ensure dependent urine flow on both moieties. The use of minimal invasive techniques is based on availability of equipment and skill, a laparoscopic assisted technique can be useful for beginners this technique has the advantage of reducing operative time by extracorporeal suturing and the benefit of laparoscopic dissection which offers adequate exposure. Declarations Funding: There was no funding for this case report Author Contribution T.J conceptualized and prepared the manuscript. S.O, S.M, B.M and D.S assisted in data collection and review of manuscript. All authors read and approved the final manuscript Acknowledgement The Paediatric Surgical fraternity of the Kenyatta National Hospital and University of Nairobi Availability of data and materials: Not applicable References Schneider, A., Ferreira, C. G., Delay, C., Lacreuse, I., Moog, R., & Becmeur, F. (2013). Lower pole vessels in children with pelviureteric junction obstruction: Laparoscopic vascular hitch or dismembered pyeloplasty? Journal of Pediatric Urology, 9(4), 419–423. doi:10.1016/j.jpurol.2012.07.005 Karmungikar S, Yadav S, Goel A. Upper moiety vascular ureteropelvic junction obstruction in an incomplete duplex kidney: A variant of the Fraley ’ s syndrome? Indian J Urol 2023;29:245-8. doi: 10.4103/iju.iju_30_23 Avlan D, Gündoğdu G, Delibaş A, Nayci A. Pyeloureterostomy in the management of the lower pole pelvi-ureteric junction obstruction in incomplete duplicated systems. Urology. 2010 Dec;76(6):1468-71. doi: 10.1016/j.urology.2010.05.031. Epub 2010 Aug 24. PMID: 20739047 Calle, J. S., Maya, C. L., Emad-Eldin, S., Adeb, M. D., Back, S. J., Darge, K., & Otero, H. J. (2019). Morphologic and functional evaluation of duplicated renal collecting systems with MR urography: A descriptive analysis. Clinical Imaging. doi:10.1016/j.clinimag.2019.05.004 Metzelder ML, Petersen C, Ure BM. Laparoscopic pyeloplasty is feasible for lower pole pelvi-ureteric obstruction in duplex systems. Pediatr Surg Int. 2007 Sep;23(9):907-9. doi: 10.1007/s00383-007-1898-6. PMID: 17347838 Esposito C, Cerulo M, Lepore B, Coppola V, D'Auria D, Esposito G, Carulli R, Del Conte F, Escolino M. Robotic-assisted pyeloplasty in children: a systematic review of the literature. J Robot Surg. 2023 Aug;17(4):1239-1246. doi: 10.1007/s11701-023-01559-1. Epub 2023 Mar 13. PMID: 36913057; PMCID: PMC10374693 Ueki H, Terakawa T, Okamura Y, Bando Y, Hara T, Furukawa J, Nakano Y, Fujisawa M. Robot-assisted laparoscopic pyeloplasty in the management of lower pole ureteropelvic junction obstruction in a patient with an incomplete duplicated collecting system. IJU Case Rep. 2023 Aug 17;6(6):357-361. doi: 10.1002/iju5.12622. PMID: 37928291; PMCID: PMC10622220. Liu X, Huang C, Guo Y, Yue Y, Hong J. Comparison of DJ stented, external stented and stent-less procedures for pediatric pyeloplasty: A network meta-analysis. Int J Surg. 2019 Aug;68:126-133. doi: 10.1016/j.ijsu.2019.07.001. Epub 2019 Jul 4. PMID: 31279854. Gopal M, Peycelon M, Caldamone A, Chrzan R, El-Ghoneimi A, Olsen H, Leclair MD, Stillebroer A, MacDonald C, Tonnhofer U, Strasser C, Adam A, Spinoit AF, Haid B. Management of ureteropelvic junction obstruction in children-a roundtable discussion. J Pediatr Urol. 2019 Aug;15(4):322-329. doi: 10.1016/j.jpurol.2019.05.010. Epub 2019 May 16. PMID: 31227314. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5385261","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":380007849,"identity":"90f87373-a523-4ef6-a0cf-7bc133c148bc","order_by":0,"name":"Tim Jumbi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtUlEQVRIiWNgGAWjYFCCAwzMDAY2BgwSYF4CYQ08EC1pJGlhAGphOEyCFnvGM6abCwrOG5tLNzA+rmBIkyPCljNmt2cY3DaznHOA2fAMQ44xcVp4DG7bGNxIYJNsYKhIbCBSyzm4lnpitRwwg2rJSSDssAPHyoB+STY2uJHYbNhgkGZI0Bb2GYe33S74Y2e44UbywYcNFcnyBG1hkDgAYzECzTcgrIGBgZ+gQ0bBKBgFo2DEAwAzqzomvbOGGQAAAABJRU5ErkJggg==","orcid":"","institution":"Kenyatta National Hospital","correspondingAuthor":true,"prefix":"","firstName":"Tim","middleName":"","lastName":"Jumbi","suffix":""},{"id":380007850,"identity":"41fb5ad1-29da-49f0-bf93-fa0ef47a674f","order_by":1,"name":"Syovata Munyalo","email":"","orcid":"","institution":"Kenyatta National Hospital","correspondingAuthor":false,"prefix":"","firstName":"Syovata","middleName":"","lastName":"Munyalo","suffix":""},{"id":380007851,"identity":"2119835a-be5e-4924-a1cd-a0042fc7367c","order_by":2,"name":"David Shipapa","email":"","orcid":"","institution":"University of Nairobi","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Shipapa","suffix":""},{"id":380007852,"identity":"65c36931-4d4a-4b6d-929c-e63a201ef2a7","order_by":3,"name":"Brian Marete","email":"","orcid":"","institution":"University of Nairobi","correspondingAuthor":false,"prefix":"","firstName":"Brian","middleName":"","lastName":"Marete","suffix":""},{"id":380007853,"identity":"a1efcaf5-18eb-4579-8769-fab038c447f8","order_by":4,"name":"Sarah Okebe","email":"","orcid":"","institution":"University of Nairobi","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Okebe","suffix":""}],"badges":[],"createdAt":"2024-11-04 06:23:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5385261/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5385261/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71881797,"identity":"b34a3b23-af0a-470b-b5e0-1eb253546631","added_by":"auto","created_at":"2024-12-19 11:40:17","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":352497,"visible":true,"origin":"","legend":"\u003cp\u003eULTRASOUND AND DIURETIC RENOGRAPHY SCANS\u003c/p\u003e\n\u003cp\u003eA. An ultrasound showing grade 2 hydronephrosis with no hydroureter. A cortical bar (*) can be appreciated supporting a duplex system. The left kidney and bladder were normal(not shown).\u003c/p\u003e\n\u003cp\u003eB. B. The pelvicalyceal activity of the right kidney is delayed with progressive accumulation of activity in the dilated collecting system with no response on Lasix administration at t 20 min\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5385261/v1/06525789b1894a3c0c1af148.jpg"},{"id":71881796,"identity":"c3054021-037f-4f9f-b6bd-076f118e74f2","added_by":"auto","created_at":"2024-12-19 11:40:17","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":54836,"visible":true,"origin":"","legend":"\u003cp\u003eLaparascopic port placement and patient positioning\u003c/p\u003e\n\u003cp\u003eThe patient is put on the right lateral position and the ports are placed according to the figure shown.\u003c/p\u003e\n\u003cp\u003eC. Camera port 5mm\u003c/p\u003e\n\u003cp\u003eW. Working ports 5mm\u003c/p\u003e\n\u003cp\u003eR. Retracting port 5mm (For liver retraction)\u003c/p\u003e\n\u003cp\u003eS. Suction port/Assistant 5mm\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5385261/v1/a0b0520c346f5ea49c17dde2.jpg"},{"id":71881863,"identity":"7c809d6e-b4e7-4a9d-a5b9-8acca001baab","added_by":"auto","created_at":"2024-12-19 11:40:23","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":63074,"visible":true,"origin":"","legend":"\u003cp\u003eINTRAOPERATIVE FINDINGS AND APPROACH\u003c/p\u003e\n\u003cp\u003eA. Laparoscopic depiction of intraoperative findings. an incomplete duplex system with two proximal ureters, an upper and lower ureter which joined to a common ureter below the renal pelvis of the lower moiety. There was a crossing vessel causing obstruction in both upper and lower proximal ureters.\u003c/p\u003e\n\u003cp\u003eB. A pyeloplasty was performed with the standard Anderson Hynes technique between the lower pelvis and the common ureter. An end-to-side uretero-pyeloplasty was performedbetween the lower pelvis and the upper ureter. This way the upper ureter drained on to the lower pelvis while the lower pelvis drained onto the common ureter. The previously crossing vesselbecomes posterior and non-obstructive to the urinary flow.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5385261/v1/f47548b1c5f9041be40d609e.jpg"},{"id":72130855,"identity":"915bc4d7-5d3d-46d9-870a-cf037ee9645f","added_by":"auto","created_at":"2024-12-23 04:09:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":692941,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5385261/v1/a10a5fc2-21d4-4924-9c09-d9419cec409d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eLaparascopic Assisted Approach to a Right Pelvi-ureteric Junction Obstruction With Incomplete Duplex System. A Case Report”\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe incidence of crossing vessels in the etiology of Pelvic-ureteric Junction Obstruction (PUJO) in children has been reported as ranging from 11\u0026ndash;15%\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e. However, the concurrence of PUJO and duplicated systems is much less common and more so when associated with a crossing vessel. Detection of such anomalies with imaging is key to the management approach and intraoperative decision-making is based on the anatomic variants.\u003ca class=\"FNLink\" href=\"#Fn2\" id=\"#FNLinkFn2\"\u003e\u003c/a\u003e We herein report a case of PUJO associated with an incomplete duplex system in the upper urinary tract with a lower pole crossing vessel causing extrinsic obstruction to both upper and lower moieties. This report also describes a laparoscopic assisted technique which is useful in a resource limited setting where intracorporeal suturing would increase operative time and would require a higher level of skill and experience.\u003c/p\u003e"},{"header":"Case Description","content":"\u003cp\u003eA 6-year-old female presented to our outpatient clinic with complaints of right sided abdominal pain for over 2 years. Previously, she had been treated twice for urinary tract infections (UTIs). She had no history of hematuria. Her growth and developmental history did not reveal any relevant information related to the illness. She was stable on physical examination; her vital signs were normal. Her abdominal exam did not reveal any masses around the flanks. A urine analysis done was negative for UTI. A series of imaging were done which revealed the following. An ultrasound done detected a grade 2 hydronephrosis (Fig.\u0026nbsp;1A) with no hydro-ureter. There was an intervening cortical bar suggestive of a duplex system. The left kidney and bladder anatomy was normal. A diuretic DTPA scan was done albeit delayed for another 3 months due to high cost and limited access to the service. The DTPA scan revealed a hydronephrotic right kidney with impaired drainage. The differential right renal function was 58% against a GFR of 119ml/min. (Fig.\u0026nbsp;1B).\u003c/p\u003e \u003cp\u003eInitially, as we awaited the DTPA scan, a conservative approach was employed with pain management and adequate hydration. However, the patient continued to have worsening right flank pain and an increasing level of hydronephrosis on subsequent ultrasound scan. Informed and written consent was obtained for right pyeloplasty indicated by worsening symptoms of pain.\u003c/p\u003e \u003cp\u003eThe patient was prepared for a right laparoscopic approach, patient positioning and port placement was done as shown in the diagram below (Fig.\u0026nbsp;2). Upon exposing the right kidney, we noted an incomplete duplex system. There were two ureters, an upper and lower ureter which joined to form a common ureter below the renal pelvis of the lower moiety. There was a crossing vessel causing obstruction in both upper and lower proximal ureters. (Fig.\u0026nbsp;3A) Dissection was done laparascopically to expose all structures, and a stay suture was placed on the lower pelvis which was used to exteriorize the site through a small flank incision for extracorporeal surgery. The lower ureter was dismembered from the pelvis allowing the vessel to pass posterior to the ureter. Thereafter, pyeloplasty was performed with the standard Anderson Hynes technique between the lower pole pelvis and the common ureter. Subsequently, the upper ureter was also dismembered from its union to the common ureter and an upper pole ureter to lower pole pyeloplasty was performed. This way the upper ureter drained on to the lower pelvis while the lower pelvis drained onto the common ureter (Fig.\u0026nbsp;3B). The crossing vessel would now sit posteriorly to both upper and lower systems therefore not causing any obstruction. A DJ stent was left in situ with the tip sitting at the lower pelvis. The total operative time was 150 minutes\u003c/p\u003e \u003cp\u003eThe DJ stent was removed in 6 weeks. There was resolution of symptoms after the surgery and an ultrasound scan done 3 months later showed a hydronephrosis of grade 1 which resolved at the 6-month follow-up scan.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDuplication of the collecting system can occur in complete or incomplete variants with a reported incidence of 0.8% in literature.\u003ca class=\"FNLink\" href=\"#Fn3\" id=\"#FNLinkFn3\"\u003e\u003c/a\u003e PUJO is a rare concurrence and when it occurs, it often affects the lower moiety in incomplete duplex systems. \u003csup\u003e2\u003c/sup\u003e The diagnosis of this rare entity is challenging given its rarity in occurrence and the nonspecific symptomatology, in our present case the initial diagnosis of right hydronephrosis was made via ultrasound after the patient complained of right sided flank pain for over 2 years. The duplex system on imaging may appear as two central echo complexes with hydronephrosis in one or both moieties and an intervening renal parenchyma. These findings were partialy appreciated in our reported case. Diuretic renography and functional magnetic resonance urography (fMRU) is usually performed to detect split renal function and to assess renal clearance. In particular, the utility of fMRU is considered superior due to its ability of detecting concurrent urologic pathology and vascular anatomy in addition to providing separate detail of each moiety which are all important in surgical planning.\u003ca class=\"FNLink\" href=\"#Fn4\" id=\"#FNLinkFn4\"\u003e\u003c/a\u003e\u003c/p\u003e \u003cp\u003eThe feasibility of minimally invasive techniques including both laparascopic and robotic options is gaining popularity in the paediatric population. In addition to the other described benefits of shorter hospital stay, reduced pain and excellent cosmetic outcome, minimally invasive surgery provides excellent anatomic visualization of the duplicated system which enhances surgical decision making.\u003ca class=\"FNLink\" href=\"#Fn5\" id=\"#FNLinkFn5\"\u003e\u003c/a\u003e These approaches can be compounded by availability of equipment and a steep learning curve especially on intra-corporeal suturing and knotting.\u003ca class=\"FNLink\" href=\"#Fn6\" id=\"#FNLinkFn6\"\u003e\u003c/a\u003e In our case the laparascopic assisted approach provided a very clear description of the incomplete duplex and crossing vessel causing obstruction in both upper and lower ureters while performing faster extracorporeal suturing.\u003c/p\u003e \u003cp\u003eUeki et al describes a detailed 3-pronged approach approaches based on intraoperative findings of the intact ureteral length and the presence of crossing vessels. In the absence of crossing vessels an end to side pyelo-ureterostomy or and Anderson Hynes pyeloplasty of the affected lower pole is considered, however the presence of crossing vessels usually obstructs both ureters and the recommended procedure is an upper pole ureter to lower pole pelvis uretero-pyeloplasty with the Anderson\u0026ndash;Hynes procedure for the lower pole. \u003ca class=\"FNLink\" href=\"#Fn7\" id=\"#FNLinkFn7\"\u003e\u003c/a\u003e In our case, we elected to perform the latter based on the presence of crossing vessels which was causing upstream dilatation in both upper and lower moieties.\u003c/p\u003e \u003cp\u003eIn our institution, we routinely perform a double J(DJ) stented pyeloplasty as protocol in PUJO. Notably, a network meta-analysis which focused on the role of stents in paediatric pyeloplasty concluded that there were no significant differences in operative time, operative success, hospital stay, improvement of renal functions and overall complications for the external stented, DJ stented and stent-less procedures.\u003ca class=\"FNLink\" href=\"#Fn8\" id=\"#FNLinkFn8\"\u003e\u003c/a\u003e\u003c/p\u003e \u003cp\u003eOur follow up protocol after pyeloplasty is a clinic visit in 2 weeks, the DJ stent is removed after 4\u0026ndash;6 weeks. We then perform an ultrasound 6 weeks after DJ stent removal and every 3 months thereafter. We only offer a diuretic study if there is persistent and/or increasing hydronephrosis. The follow up protocol in literature varies between institutions, however the goal remains the same which is to evaluate adequacy of drainage and detect complications that may need intervention.\u003ca class=\"FNLink\" href=\"#Fn9\" id=\"#FNLinkFn9\"\u003e\u003c/a\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe concurrence of PUJO and duplicated systems is a rare occurrence and more so when associated with a crossing vessel. Surgical decision-making is based on imaging detail and intra-op dissection of the anatomic variants. When both upper and lower moieties are retained, the goal of surgery is to relieve the obstruction and ensure dependent urine flow on both moieties. The use of minimal invasive techniques is based on availability of equipment and skill, a laparoscopic assisted technique can be useful for beginners this technique has the advantage of reducing operative time by extracorporeal suturing and the benefit of laparoscopic dissection which offers adequate exposure.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThere was no funding for this case report\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eT.J conceptualized and prepared the manuscript. S.O, S.M, B.M and D.S assisted in data collection and review of manuscript. All authors read and approved the final manuscript\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe Paediatric Surgical fraternity of the Kenyatta National Hospital and University of Nairobi\u003c/p\u003e\u003ch2\u003eAvailability of data and materials:\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSchneider, A., Ferreira, C. G., Delay, C., Lacreuse, I., Moog, R., \u0026amp; Becmeur, F. (2013). Lower pole vessels in children with pelviureteric junction obstruction: Laparoscopic vascular hitch or dismembered pyeloplasty? Journal of Pediatric Urology, 9(4), 419\u0026ndash;423. doi:10.1016/j.jpurol.2012.07.005\u003c/li\u003e\n\u003cli\u003eKarmungikar S, Yadav S, Goel A. Upper moiety vascular ureteropelvic junction obstruction in an incomplete duplex kidney: A variant of the Fraley\u003cstrong\u003e\u0026rsquo;\u003c/strong\u003es syndrome? Indian J Urol 2023;29:245-8. doi: 10.4103/iju.iju_30_23\u003c/li\u003e\n\u003cli\u003eAvlan D, G\u0026uuml;ndoğdu G, Delibaş A, Nayci A. Pyeloureterostomy in the management of the lower pole pelvi-ureteric junction obstruction in incomplete duplicated systems. Urology. 2010 Dec;76(6):1468-71. doi: 10.1016/j.urology.2010.05.031. Epub 2010 Aug 24. PMID: 20739047\u003c/li\u003e\n\u003cli\u003eCalle, J. S., Maya, C. L., Emad-Eldin, S., Adeb, M. D., Back, S. J., Darge, K., \u0026amp; Otero, H. J. (2019). Morphologic and functional evaluation of duplicated renal collecting systems with MR urography: A descriptive analysis. Clinical Imaging. doi:10.1016/j.clinimag.2019.05.004 \u003c/li\u003e\n\u003cli\u003eMetzelder ML, Petersen C, Ure BM. Laparoscopic pyeloplasty is feasible for lower pole pelvi-ureteric obstruction in duplex systems. Pediatr Surg Int. 2007 Sep;23(9):907-9. doi: 10.1007/s00383-007-1898-6. PMID: 17347838\u003c/li\u003e\n\u003cli\u003eEsposito C, Cerulo M, Lepore B, Coppola V, D'Auria D, Esposito G, Carulli R, Del Conte F, Escolino M. Robotic-assisted pyeloplasty in children: a systematic review of the literature. J Robot Surg. 2023 Aug;17(4):1239-1246. doi: 10.1007/s11701-023-01559-1. Epub 2023 Mar 13. PMID: 36913057; PMCID: PMC10374693\u003c/li\u003e\n\u003cli\u003eUeki H, Terakawa T, Okamura Y, Bando Y, Hara T, Furukawa J, Nakano Y, Fujisawa M. Robot-assisted laparoscopic pyeloplasty in the management of lower pole ureteropelvic junction obstruction in a patient with an incomplete duplicated collecting system. IJU Case Rep. 2023 Aug 17;6(6):357-361. doi: 10.1002/iju5.12622. PMID: 37928291; PMCID: PMC10622220.\u003c/li\u003e\n\u003cli\u003eLiu X, Huang C, Guo Y, Yue Y, Hong J. Comparison of DJ stented, external stented and stent-less procedures for pediatric pyeloplasty: A network meta-analysis. Int J Surg. 2019 Aug;68:126-133. doi: 10.1016/j.ijsu.2019.07.001. Epub 2019 Jul 4. PMID: 31279854.\u003c/li\u003e\n\u003cli\u003eGopal M, Peycelon M, Caldamone A, Chrzan R, El-Ghoneimi A, Olsen H, Leclair MD, Stillebroer A, MacDonald C, Tonnhofer U, Strasser C, Adam A, Spinoit AF, Haid B. Management of ureteropelvic junction obstruction in children-a roundtable discussion. J Pediatr Urol. 2019 Aug;15(4):322-329. doi: 10.1016/j.jpurol.2019.05.010. Epub 2019 May 16. PMID: 31227314.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Case report, Incomplete Duplex system, Laparascopic assisted approach.","lastPublishedDoi":"10.21203/rs.3.rs-5385261/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5385261/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction\u003c/p\u003e \u003cp\u003eThe concurrence of PUJO and duplicated systems is rare and more so when associated with a crossing vessel. Management is dependent on the variant anatomy based on imaging and intra-operative findings. The use of laparoscopic assisted technique can be employed with extracorporeal suturing in limited resource settings where intracorporeal suturing would increase operative time and would require a higher level of skill and experience.\u003c/p\u003e \u003cp\u003eCase Presentation. A 6-year-old female presented with a prolonged history of right flank pain. Imaging revealed right hydronephrosis with impaired drainage on diuretic renography. Intra-operatively, an incomplete right duplex system was found with a lower pole crossing vessel causing extrinsic obstruction to both upper and lower moieties. A laparoscopic assisted technique with extra-corporeal suturing was used to perform an upper pole ureter to lower pole pyeloplasty and lower moiety Anderson Hynes pyeloplasty. The patient was followed up with complete resolution of symptoms at 3 months and 6 months post operatively.\u003c/p\u003e \u003cp\u003eConclusion. Surgical decision-making on Duplex systems with PUJO is based on imaging detail and intra-op dissection of the anatomic variants. A laparoscopic assisted technique has the advantage of reducing operative time by extracorporeal suturing and the benefit of laparoscopic dissection which offers adequate exposure.\u003c/p\u003e","manuscriptTitle":"Laparascopic Assisted Approach to a Right Pelvi-ureteric Junction Obstruction With Incomplete Duplex System. A Case Report”","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-19 11:39:13","doi":"10.21203/rs.3.rs-5385261/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f064d9fd-bc83-4d52-874a-d3a1994f07ba","owner":[],"postedDate":"December 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-23T04:08:30+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-19 11:39:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5385261","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5385261","identity":"rs-5385261","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}