V872: Robotic Boari Flap for Distal Ureteral Obstruction

Video

Introduction and Objectives
Creation of Boari flap remains an option for ureteral reimplantations in patients with mid or extensive distal ureteral strictures. The introduction of da Vinci robotic system has allowed many urologic reconstructive procedures to be performed intracorporeally. The minimally invasive approach may allow for shorter hospital stay, decreased blood loss, and less post-operative pain. In this video, we present a robot-assisted creation of a Boari flap ureteral reconstruction in a patient with a long distal ureteral stricture and obstruction.

Methods
The patient is a 62 year old male with right-sided ureteral obstruction secondary to extrinsic compression from lymphoma as well as prior ureteral instrumentation from stone disease ultimately requiring chronic ureteral stenting. Despite remission with chemotherapy, the patient continued to have persistent obstruction. Retrograde pyelogram demonstrated ureteral narrowing to the level the iliac vessels. Definitive repair using robotic techniques was arranged. Our port placement setup was similar to our setup for robotic-assisted radical cystectomy displacing ports slightly cephalad to gain adequate access proximal to the ureteral stricture. Once the obstruction was identified, the ureter is mobilized from the surrounding lymph node disease and divided proximal to the obstruction. The bladder was mobilized and a simple posas hitch was initially performed. Because more length was needed to perform a tension- free ureteral reconstruction, the Boari flap was constructed. A ureteral stent was placed through an assistant port prior to completion of anastomosis and bladder closure.

Results
The total robotic console time was 180 minutes and total operative time was 240 minutes. Intraoperative blood loss was minimal. Patient had an uneventful post-operative course and was discharged on post-operative day 2 with foley catheter and ureteral stent. Follow-up cystogram at one week demonstrated no leak and retrograde filling of contrast in the right upper tract. Six-month renal ultrasound was normal. Follow-up nuclear renal scan showed prompt perfusions and drainage of both kidneys.

Conclusions
Robotic-assisted ureteral reconstruction using a Boari flap is a feasible and safe option for long distal ureteral strictures that are not amenable to repair with a simple posas hitch ureteral reimplantation.

Funding: None