Wednesday, June 23, 2010

Boari Flap reconstruction for upper ureteric stricture

21 year old patient came to us with history of having been operated outside for ? twisted ovarian cyst. The laparoscopy was abandoned because contrary to their expectations they found retroperitoneal mass on the right side of the retroperitoneum.She came to us with a post-operative contrast enhanced CT Scan which revealed urinoma near middle of the right ureter


The urinoma was encapsulated in thick capsule (? Chronic process).On clinical examination she was looking ill and frail. She had loose motions(? Pelvic collection induced).Her vitals though were maintained except for tachycardia.She had normal hematological and biochemical parameters. Her abdomen was mildly distended with urinary leakage through one of the ports.She was taken up for Retrograde Pyelography which showed mid-ureteric disruption and dye leaking into a diffuse cavity.The patient was made prone for percutaneous nephrostomy drainage.Right Percutaneous Drainage was performed through a midcalyceal approach for possible antegrade stenting sometimes in future.She started draining around 100 ml of urine per hour through the nephrostomy and her leakage of urine through the port and the abdominal distension subsided.Her loose motions also subsided The very next day she started looking fresh and was back to her normal routine.She was called after a period of 6 weeks thinking that this time is enough for urinoma would subside and the inflammatory reaction would also subside.

She was taken up for laparotomy.A midline infra-umbilical incisiwas given .The bladder was capacious.
The ureter could be traced only till mid part.After that there was a massive fibrosis.The ureter was disconnected there and Boaris flap was raised from the bladder was anastomosed to the upper ureter after adequate spatulation.

The surgery was concluded with putting a stent in neo-ureter and supra-pubic tube in bladder.

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