BOARI FLAP RECONSTRUCTION OF THE URETER FOR LONG SEGMENT LOWER URETERIC STRICTURE

A 45 year old patient came with the complaint of left flank pain on and off. He had a history of undergoing URS and ESWL on the same side twice before.

On evaluation we found that he had hydroureteronephrosis on left side with 1 cm long lower ureteric stone ( the stone was oblong in shape).

We performed CT urography which showed the stone just below the iliac bifurcation. We took the patient up for left URS.

During the surgery we found that the lower ureteric segment was too tight for instrument to be manipulated in the lower ureter. We passed a guide wire with difficulty in the pelvicalyceal system but could not thread  stent or the ureteric catheter over it.

We decided to go for antegrade stenting thinking that stent might go antegradely.We performed a dye study after PCN .The dye went till the stone but after that there was no passage at all. The segment of the  lower ureter was 7-8 cm.

We counseled the patient for open exploration and proceed. We thought the management would decide upon the length, bladder capacity and mobility of the ureter.

The ureteric stricture on exploration was long and extended just below the iliac bifurcation.

We removed the calculus and then performed the Boari Flap reconstruction with Psoas hitch.

Anatomy of the ureter:

 

 

 

The ureters are paired muscular ducts with narrow lumina that carry urine from the kidneys to the bladder. The ureter is roughly 25-30 cm long in adults and courses down the retroperitoneum in an S curve. At the proximal end of the ureter is the renal pelvis; at the distal end is the bladder. The ureter begins at the level of the renal artery and vein posterior to these structures. This ureteropelvic junction usually coincides with the second lumbar vertebra on the left, with the right being marginally lower. The image below depicts the anatomy of the ureters.

 

Boari Flap reconstruction of the ureter:

 

Boari flap is a useful adjunct when the diseased segment of ureter is too long or ureteral mobility is too limited to perform a primary ureteroureterostomy. Boari flaps can be created to bridge a 10- to 15-cm defect. If needed, spiral bladder flaps can be constructed to reach the renal pelvis in some circumstances