MISSED ANTERIOR CROSSING VESSELS DURING OPEN RETROPERITONEAL PYELOPLASTY: LAPAROSCOPIC TRANSPERITONEAL DISCOVERY AND REPAIR

PURPOSE: Extrinsic ureteropelvic junction obstruction due to anterior crossing segmental renal vessels is present in more than 50% of patients in adulthood. In this situation the ureter must usually be dismembered and transposed anterior to the crossing vascular structures, where it is anastomosed to the renal pelvis. Via the open retroperitoneal approach there may be a limited view of the anterior surface of the ureteropelvic junction and, hence, anterior crossing vessels may possibly be missed. We describe 2 patients with ureteropelvic junction obstruction in whom anterior vessels were missed during open retroperitoneal repair. Laparoscopic transperitoneal secondary pyeloplasty with posterior displacement of the crossing renal vessel was performed in each case. MATERIALS AND METHODS: Two patients presented with symptomatic congenital ureteropelvic junction obstruction after failed endopyelotomy in 1 and failed open retroperitoneal procedures in both. Preoperatively spiral computerized tomography angiography with a ureteropelvic junction protocol revealed crossing vessels in the 2 cases. This finding was confirmed at transperitoneal laparoscopic pyeloplasty. The ureter and renal pelvis were transposed anterior to the crossing vessels and 2 rows of running sutures were placed to complete the anastomosis. RESULTS: The 2 laparoscopic procedures were completed successfully. The anterior crossing vessels were preserved in each case. Currently the patients are asymptomatic and furosemide washout renal scan was normal. CONCLUSIONS: Spiral CT angiography reliably delineates the renal vascular anatomy in patients with ureteropelvic junction obstruction. This study may be valuable before planned open retroperitoneal ureteropelvic junction obstruction repair. Laparoscopic pyeloplasty may successfully manage anterior crossing vessels associated with secondary ureteropelvic junction obstruction.     

Electrocardiographic artefact with SSEP monitoring unit during scoliosis surgery

A case of somatosensory evoked potential (SSEP) induced electrocardiographic artefact simulating supraventricular tachycardia (SVT) is described in a three year old girl with Goldenhar syndrome, during anterior thoracoscopic discectomy with posterior spinal fusion for scoliosis. Adenosine was administered for this misinterpreted EKG with coincidental cessation of SVT like trace.     

Endometriosis and the Infertile Patient

Approximately one-third of all patients who suffer from endometriosis may not be able to conceive. More than 10% of infertile patients have endometriosis as the causative factor of their infertility. The stressful effect of infertility on the couple's life may be devastating. The infertility and endocrinology nurse may play a major role in alleviating the painful experience of such unfortunate patients. The pathogenesis, pathophysiology, diagnosis, and therapy of endometriosis are described. The important role of the nurse in the management of patients with endometriosis is emphasized.