Turk J Urol 2017; 43(3): 313-8 • DOI: 10.5152/tud.2017.

44520
313
LAPAROSCOPY
Original Article

Laparoscopic ureteral reimplantation with Boari flap for the

management of long- segment ureteral defect: A case series with
review of the literature
Ankur Bansal, Rahul Janak Sinha, Ankur Jhanwar, Gaurav Prakash, Bimalesh Purkait, Vishwajeet Singh

Cite this article as: Bansal A, Sinha RJ, Jhanwar A, Prakash G, Purkait B, Singh V. Laparoscopic ureteral reimplantation with Boari flap for
the management of long- segment ureteral defect: A case series with review of the literature. Turk J Urol 2017; 43: 313-8

ABSTRACT
Objective: The incidence of ureteral stricture is showing a rising trend due to increased use of laparoscopic
and upper urinary tract endoscopic procedures. Boari flap is the preferred method of repairing long- segment
ureteral defects of 8-12 cm. The procedure has undergone change from classical open (transperitoneal and
retroperitoneal) method to laparoscopic surgery and recently robotic surgery. Laparoscopic approach is cos-
metically appealing, less morbid and with shorter hospital stay. In this case series, we report our experience of
performing laparoscopic ureteral reimplantation with Boari flap in 3 patients.
Material and methods: This prospective study was conducted between January 2011 December 2014.
The patients with a long- segment ureteral defect who had undergone laparoscopic Boari flap reconstruc-
tion were included in the study. Outcome of laparoscopic ureteral reimplantation with Boari flap for the
manangement of long segment ureteral defect was evaluated.
Results: The procedure was performed on 3 patients, and male to female ratio was 1:2. One patient had bilat-
eral and other two patient had left ureteral stricture. The mean length of ureteral stricture was 8.6 cm (range
8.2 -9.2 cm). The mean operative time was 206 min (190 to 220 min). The average estimated blood loss was
100 mL (range 90-110 mL) and mean hospital stay was 6 days (range 5 to 7 days). The mean follow up was 19
months (range 17-22 months). None of the patients experienced any complication related to the procedure in
perioperative period.
Conclusion: Laparoscopic ureteral reimplantation with Boari flap is safe, feasible and has excellent long term re-
sults. However, the procedure is technically challenging, requires extensive experience of intracorporeal suturing.
Keywords: Boari flap; laparoscopic; ureter.

King George Medical Indroduction challenging and needs considerable expertise

University, Lucknow, Uttar
Pradesh, India of intracorporeal suturing. This procedure is
The incidence of ureteral stricture is rising indicated for management of long -segment
Submitted:
23.06.2016 due to increased use of laparoscopic and ureteral defect (>8 cm). This approach is cos-
upper urinary tract endoscopic procedures. metically appealing, less morbid with shorter
Accepted:
20.09.2016
[1,2]
Ureteral reimplantation with Boari flap hospital stay.
has undergone change from classical open
Material and methods
Available Online Date:
31.07.2017 (transperitoneal and retroperitoneal) method
Correspondence: to laparoscopic surgery and recently there are
Ankur Bansal reports of robot-assisted laparoscopic repairs. This prospective study was conducted
E-mail:
[email protected]
[3,4]
With increasing skills and availability of between 1st January 2011 to 31st December
laparoscopic instruments, there are studies on 2014, in the department of Urology, King
©Copyright 2017 by Turkish
Association of Urology
managing long- segment ureteral stricture by George’s Medical University situated in
laparoscopic reimplantation with Boari flap. North India. Informed consent was obtained
Available online at
www.turkishjournalofurology.com However, the reconstruction is technically from all patients. A total of 3 patients with a
 Turk J Urol 2017; 43(3): 313-8
314 DOI:10.5152/tud.2017.44520

long- segment ureteral defect (median, 8.6 cm; range 8.2-9.2 resected. Ureteral cut end was then spatulated posteriorly at 6
cm) who had undergone laparoscopic Boari flap reconstruc- O’ clock position for 2.5 cms. Bladder then distended with 300
tion were included in the study. A detailed history and clinical mL of normal saline (0.9%) and all adhesions were cleared. On
examination was performed in all cases. Ultrasonographic anterolateral bladder wall, a flap was raised with the base and tip
examination of kidney, ureter and bladder (KUB) was done being 4 and 3 cm in width respectively. The tip of the flap was
in all cases. Other imaging studies like intravenous urography localized just proximal to the bladder neck and its base at dome.
(IVU) (n=3), and computed tomography urography (CTU) Tension-free anastomosis of spatulated ureter and bladder flap
(n=2) were performed to delineate the site and length of ure- was performed with 4-0 polyglactin sutures over a 6Fr/26 cm
teral stricture. In one patient with bilateral ureteral stricture double J stent. Anastomosis was performed over double J stent
had history of radical hysterectomy for cervical cancer. DTPA in continous watertight fashion. Bladder was closed in a single
(diethylenetriaminepentaacetic acid) scan was done in all layer with continuous sutures (Figure 1-6). A soft silastic tube
cases to assess the split renal function. Initially all patients had drain was inserted into pelvis at the end of the procedure. Drain
undergone percutaneous nephrostomy (PCN) and a nephrosto- was removed after 48 hrs and double J stent after six weeks.
gram was performed. Cystoscopy and retrograde ureterogram
were performed before proceeding for reconstruction. At three Results
months of follow up, a renal and bladder ultrasound, intra-
venous urography and DTPA scan were done. Resolution of A total of 3 patients underwent ureteral reconstruction.
hydronephrosis and unobstructed drainage were considered as Demographic characteristics of the patients are shown in Table
successful outcome. 1. The median age of the patients was 43.3 years (range 36 to
54 years) with male to female ratio of 1:2. The left side involve-
Surgical technique ment was predominant (R:L, 1:2). The cause for ureteral defect
All procedures were performed under general anaesthesia. was hysterectomy in 2 patients (66.6%), and colorectal surgery
Patient was placed in supine position with 45 degree tilt on in one patient (33.33%). The median interval between injury
the affected side. A 14 Fr Foley urethral catheter was inserted and repair was 3 months (2-4 months). One patient had history
before the procedure. Transperitoneal approach was employed of radical hysterectomy for carcinoma of cervix. She developed
in all cases and all repair was done by a single urologist using bilateral ureteral stricture following the procedure. She under-
three ports only. After creation of pneumoperitoneum, incision went right sided laparoscopic ureteroneocystostomy followed by
was made at white line of Toldt and colon was reflected medi- laparoscopic ureteral reimplatation Boari flap on the contralateral
ally. Ureter was identified and dissected caudally till the level side 3 months later. The median length of ureteral defect was 8.6
of stricture. Ureter was handled meticulously with preservation cm (range 8.2-9.2 cm). The median operative time was 206 min
of periureteral adventitia, and stenosed segment of ureter was (range 190 to 220 min). The average estimated blood loss was

Table 1. Baseline demographic and clinical data of the

patients
Parameters Case 1 Case 2 Case 3
Age (years) 40 54 36
BMI (kg/m ) 2
25.2 26.5 3.2
Sex (Male: female) Female Female Male
Laterality Left Bilateral Left
Ureteral defect (cm) 9.2 8.4 8.2
Interval between injury
and operative 2 3 4
intervention (months)
Serum creatinine (mg/dL) 1.5 1 1.1
Cause Post- Post-radical Post-colorectal
hysterectomy Hysterectomy surgery

Pre op PCN PCN Bilateral PCN PCN

BMI: body mass index; PCN: percutaneous nephrestomy Figure 1. Preparing for Boari flap
Bansal et al. Laparoscopic ureteral reimplantation with Boari flap for the management of long- segment ureteral defect: A case series with review of the
literature 315

Figure 2. Elevating Boari flap Figure 4. Antegrade placement of Double J stent

Figure 3. Spatulation of ureter Figure 5. Spatulated ureter anastomosed end- to- end with the
apex of flap and flap being tubularised over double J stent

100 mL (range 90-110 mL) and the median hospital stay was 6 [5]
Open Boari flap procedures have good long-term results.
days (range 5 to 7 days). There were no intraoperative complica- However, open procedure is associated with excessive pain, lon-
tions. Procedure was completed successfully in all three patients. ger hospital stay, and surgical scar. As the skill of the urologist is
None of the patients developed any postoperative complications. increasing in performing laparoscopic surgeries, there is a rapid
The median follow up was 19 months (17-22 months). Following transition from open to laparoscopic Boari flap reconstruction
stent removal, renal ultrasound showed resolution of hydrone- technique.
phrosis in all cases with unobstructed drainage pattern on DTPA
scan. Periperative data is summarised in Table 2. Fugita et al.[6] in 2001, first successfully performed laparoscopic
reconstruction with Boari flap in three patients with long- seg-
Discussion ment ureteral stricture and concluded that the procedure is effec-
tive and feasible (Table 3).[3,6-17] Rassweiler et al.[7] observed
Boari described this method of ureteral reconstruction in 1894 longer operative time (253 minutes vs. 220 minutes), shorter
in a canine model[4] and in human it was first described in 1947. hospital stay (8 days vs.17 day) with 100% successs rate in the
 Turk J Urol 2017; 43(3): 313-8
316 DOI:10.5152/tud.2017.44520

Table 2. Perioperative data of patients

Parameters Case 1 Case 2 Case 3

Operative time (min) 190 220 210
Blood loss (mL) 90 110 100
Time to drain removal (hours) 48 48 48
Hospital stay (days) 6 7 5
Pain score (VAS) at POD 1 3 3 3
Analgesic requirement
(Tramadol in mg) 200 400 300
Follow up (months) 18 17 22
Conversion to open No No No
Post- Op US KUB HDN HDN HDN
resolved resolved resolved
DTPA Renal Scan Non- Non- Non-
Obstructive obstructive obstructive
VAS: visual analogue scale; USG KUB: ultrasound kidney, ureter, bladder; DTPA:
Figure 6. Closure of bladder defect with continous vicryl suture diethylenetriaminepentaacetic acid

Table 3. Literature review: reported series of laparoscopic ureteral reimplantation with Boari flap
Stricture OT Time Hospital Blood F-up Analgeic
Authors Cases (n) length (cms) Etiology M/F Side (min) stay (d) loss(ml) (mo) requirement
Fergany et al.[10] 6 pigs 140
Fugita et al.[6] 3 6.6 1M 1R
2 F 2 L 220 6.3 470 11 45 g morphine
Castillo et al.[9] 9 4-7 8US 156 3 124 17.6 32 mg morphine
1 UT
Modi et al.[11] 1 210 3 90 50 mg morphine
Rasweiler et al. 4
[7]
2M 3 R 254 8.2 270 4.9 mg piritramide
2 F 1L
Basiri et al.[12] 1 UT M L 406 5 300
Nerli et al.
[13]
1 5 H F L 160
Ramalingam et al. 3 8 [8]
POM 1M 3 R 320 100 6m-3yrs
US 2 F
Symons et al.[14] 3 5.6 US 3 M 1R 307 7.3 0.8 g/dl 5 175 mg diclofenac
2 L Hb drop 150 mg tramadol
Schimpf and Wegner[3] 2 RALBF US 1 F R 172 2 0 12
UT 1 M 224 5 200 4
Allarpathi et al.[15] 2 RALBF UT 1 M 2R 245 2 30 6 22 mg morphine
1F
Soares et al.[16] 2 H 2F 1R
US 1L 120 2 140 6
Gozen et al. [17]
9 US 247.4 8 283 35
M: male; F: female; R: right; L: left; RALBF: robot-assisted laparoscopic reimplantation withBoari flap; US: ureteral stricture; UT: ureteral tumor; H: hysterectomy; min: minute; d:
days; mo: months; F-up: follow up; yrs: years
Bansal et al. Laparoscopic ureteral reimplantation with Boari flap for the management of long- segment ureteral defect: A case series with review of the
literature 317

laparoscopic group as compared with open ureteral reimplanta- Author Contributions: Concept – A.J, R.J.S., A.B.; Design – A.J.,
tion with Boari flap. R.J.S., A.B.; Supervision – A.B., G.P., B.P., V.S.; Resources – A.J.,
R.J.S., A.B., V.S.; Materials – A.B., G.P., B.P., V.S.; Data Collection
and/or Processing – A.J., R.J.S., A.B., G.P., B.P., V.S.; Analysis
Ramalingam et al.[8] performed laparoscopic ureteral reimplan- and/or Interpretation – A.J., R.J.S., A.B., G.P., B.P., V.S.; Literature
tation with Boari flap in 3 patients successfully with median Search – A.J., R.J.S., A.B., G.P., B.P., V.S.; Writing Manuscript –
A.J., R.J.S., A.B., G.P., B.P., V.S.; Critical Review – A.J., R.J.S.,
operative time of 320 mins (range 300-320 min). Castillo et A.B., G.P., B.P., V.S .
al.[9] reported 9 cases of laparoscopic reimplantation procedure
with Boari flap. In their study, median operative time was 156 Conflict of Interest: No conflict of interest was declared by the
mins, median hospital stay was 3 days and median length of authors.
follow- up was 17.6 months. Abraham et al.[18] reported compa- Financial Disclosure: The authors declared that this study has
rable results between early and delayed repair with Boari flap, received no financial support.
however early repair is challenging. Schimpf and Wagner[3]
performed first robotic Boari flap procedure. The operative References
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