Minimally invasive reconstruction of extensive mid-lower ureteral strictures using a bilateral Boari flap

doi:10.1016/j.ajur.2024.02.009

Asian Journal of Urology, 2024, 11 (3): 377-383 doi: 10.1016/j.ajur.2024.02.009

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Minimally invasive reconstruction of extensive mid-lower ureteral strictures using a bilateral Boari flap

Shuaishuai Chai^a,1,Hao Zhang^b,1,Gong Cheng^b,Jiawei Chen^b,Xincheng Gao^b,Yuancheng Zhou^b,Xingyuan Xiao^a,*(

),Bing Li^a,*(

)

^aDepartment of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
^bDepartment of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China

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Abstract

Objective: To describe and evaluate the technique using bilateral Boari flap ureteroneocystostomy (BBFUNC) for bilateral mid-lower ureteral strictures.

Methods: We retrospectively reviewed five patients who underwent minimally invasive BBFUNC in our institution (Union Hospital, Wuhan, China) between July 2019 and December 2021. The bilateral ureters were mobilized and transected above the stenotic segments. The bladder was isolated and incised longitudinally from the middle of the anterior wall. Then, an inverted U-shaped bladder flap was created on both sides, fixed onto the psoas tendon, and anastomosed to the ipsilateral distal normal ureter. Following double-J stenting, the Boari flaps were tubularized, and the bladder was closed with continuous sutures. The patients' perioperative data and follow-up outcomes were collected, and a descriptive statistical analysis was performed.

Results: No case converted to open surgery, and no intraoperative complication occurred. The median surgical time was 230 (range 203-294) min. The median length of the bladder flaps was 6.2 (range 4.3-10.0) cm on the left and 5.5 (range 4.7-10.5) cm on the right side. All patients had not developed recurrent ureteral stenosis during the median follow-up time of 17 (range 16-45) months and had a normal maximum flow rate after surgery. The median post-void residual was 7 (range 0-19) mL. The maximal bladder capacity was decreased in one (20%) patient.

Conclusion: The present study demonstrates that minimally invasive BBFUNC is feasible and safe in treating bilateral mid-lower ureteral strictures, and the impact on lower urinary tract function is limited.

Key words： Reconstructive surgery Boari flap Ureteral stricture Ureteroneocystostomy Minimally invasive

Received: 19 August 2023 Available online: 20 July 2024

Corresponding Authors: *E-mail address: 114714259@qq.com (X. Xiao),bingli2023@whu.edu.cn (B. Li).

About author:: ¹Both authors contributed equally to this work.

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Cite this article:

Shuaishuai Chai,Hao Zhang,Gong Cheng, et al. Minimally invasive reconstruction of extensive mid-lower ureteral strictures using a bilateral Boari flap[J]. Asian Journal of Urology, 2024, 11(3): 377-383.

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http://www.ajurology.com/EN/10.1016/j.ajur.2024.02.009 OR http://www.ajurology.com/EN/Y2024/V11/I3/377

Preoperative patient characteristics.

Port placement. (A) Robot-assisted BBFUNC; (B) Laparoscopic BBFUNC. BBFUNC, bilateral Boari flap ureteroneocystostomy.

Main steps of robot-assisted bilateral Boari flap ureteroneocystostomy. (A) After the bladder was fully dissociated, an inverted U-shape Boari flap was fashioned on both sides according to the length of ureteral defects with a broad base; (B) The Boari flaps were fixed to the ipsilateral psoas muscle; (C) A 10 Fr catheter was used to detect the patency of the proximal ureteral stump before anastomosis; (D) The Boari flap was anastomosed to the ipsilateral ureter after double-J stenting; (E) The Boari flaps were tubularized, and the bladder incision was closed; (F) A leakage test was performed. The ureterovesical anastomosis sites were marked by white arrows. The yellow and blue dash line represented the left and right bladder muscle flaps, respectively. LF, left flap; RF, right flap.

Perioperative and follow-up data.

AU and CT urography of Case 4. (A) Right AU before surgery; (B) Left AU before surgery; (C) Bilateral AU 6 weeks after surgery; (D) Hydronephrosis before surgery; (E) Hydronephrosis significantly relieved 6 months after surgery. AU, antegrade urography.

Voiding cystourethrogram of Case 1. (A) Six weeks after surgery—the bladder was approximately V-shaped, and the bilateral VUR was evident; (B) Eighteen months after surgery (storage period)—the bladder morphology was closer to normal, and the capacity had increased, but bilateral VUR still existed (the arrows indicated the VUR on the right side); (C) Eighteen months after surgery (urination period)—the contrast agent was fully discharged; (D) Thirty-two months after surgery (oblique right lateral view)—the VUR on the right side disappeared. VUR, vesicoureteral reflux.

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