V01-12: Robotic Ureteroneocystostomy With Bilateral Boari Flap
Mid ureteral reconstruction often requires Boari flap to bridge the gap between ureter and bladder. Bilateral mid ureteral strictures can present as a surgical challenge. Robotic bilateral Boari flap has not yet been described in the literature. Here, we present a case where robotic ureteroneocystostomy was completed using a bilateral Boari flap.
An 82 year old female with a history of uterine cancer treated with external beam radiation presented with bilateral mid ureteral strictures. Strictures were managed with ureteral stents and bilateral nephrostomy tubes, however patient was having severe stent colic and frequent urinary tract infections. Operative repair using the da Vinci Si Robot was chosen for definite management. The patient was positioned in lithotomy and steep trendelenburg and port placement was similar to that of robotic prostatectomy. Ureters were divided at the level of the common iliac bifurcation and mobilized proximally. Strictures were excised and ureters was spatulated. After the bladder was dropped from the abdominal wall, a bladder flap was created with a broad base to ensure an excellent blood supply. The ureteral anastomosis to the bladder flap was started using 3-0 Vicryl interrupted sutures to secure the posterior ureter to the bladder flap. The flap was then bisected in the midline to create a tension free anastomosis for each ureter. The ureteral anastomosis was completed with a JJ stent in place bilaterally. The wings of the bisected bladder flap were re-approximated with a 3-0 V-Loc suture to form a &[Prime]Y&[Prime] bladder configuration. The remainder of the cystotomy was closed with V-Loc suture. The bladder was tested for any leaks and a drain was placed at the conclusion of the case.
Patient tolerated the procedure well with 50 mL blood loss. She recovered uneventfully and was discharged on postoperative day 4 with her nephrostomy tubes and JP drain removed prior to discharge. Follow-up cystogram demonstrated no leak and bilateral reflux in the reconstructed bladder. Ureteral stents were removed four weeks post operatively.
Robotic bilateral Boari flap is feasible for patients with bilateral mid to distal ureteral strictures. Further studies are needed to assess long-term outcomes in this population.