BERKELEY, CA (UroToday Inc.) - The need for ureteral reconstruction may arise secondary to various clinical scenarios, including iatrogenic injury, trauma or malignancies. The Boari flap is a viable alternative for ureteral reconstruction when long defects of the mid to lower ureter must be bridged to the bladder. As with many reconstructive procedures traditionally done via open techniques, laparoscopic Boari flaps have been performed and a report on a series of eight patients undergoing laparoscopic Boari flap procedures at one institution has been recently published. The report, by O. A. Castillo and colleagues from Santiago, Chile and Boston can be found in the March, 2005 issue of the Journal of Urology.

In the series, eight patients were evaluated for flank pain or hematuria and were found to have distal ureteral strictures measuring 4 to 7 cm on excretory urogram (IVP) and retrograde pyelography. Two patients had a history of an abdominal hysterectomy and pelvic radiotherapy for cervical carcinoma, and 2 had myelomeningocele and were on clean intermittent catheterization. One had undergone a previous gastrocystoplasty. Other patients had undergone prior ureteroscopy or open ureterolithotomy, and one patient had undergone a prior failed open Boari flap reconstruction. All patients had pre-operative differential renal function of 25% or greater on the affected side along with a normal contralateral kidney on diuretic renal scans.

Intraoperative parameters analyzed were operative duration and intraoperative complications. The postoperative results assessed were hospital stay, renal function, symptomatic improvement and imaging studies. Postoperative follow-up was performed at 3, 6 and 12 months during year one and every 6 months thereafter. It consisted of serum creatinine measurement and IVP at every visit,, and a diuretic renal scan at 6 months. Mean follow-up was 17.6 months.

The operative technique is discussed in some detail with a five-port transperitoneal approach being utilized most commonly. The uretero-boari flap anastomosis was performed with 4-0 polyglactin sutures, and the bladder was closed with running 3-0 polyglactin sutures. A psoas hitch was utilized to achieve additional bladder stability. Foley catheters were left in place for 7 days at which time a cystogram was performed to document bladder healing. 7Fr JJ Ureteral stents were utilized and kept in place for 6 weeks.

Analysis showed a mean operative duration of 156.6 minutes, with a mean estimated blood loss of 124 cc. There were no intraoperative complications or conversions. All patients were discharged home within 4 days. All patients were symptom-free at follow-up and had an unobstructed ureterovesical anastomosis on follow-up excretory urography. They showed improved renal function (30% or greater on the affected side) on renal scintigraphy. Two post-operative complications did occur. One patient had a pulmonary embolism and subsequent gross hematuria upon anticoagulation. This forced prolonged catheter drainage. One patient who had undergone pelvic radiation for cervical carcinoma had uroperitoneum 24 hours after Foley catheter removal despite a negative cystogram prior to catheter removal. The patient underwent repeat laparoscopy with drainage of the extravasated urine and subsequent laparoscopic repair of the leak in the bladder. The Foley was removed 10 days after this second exploration with no sequelae.

In conclusion, the laparoscopic Boari flap is a feasible alternative to open reconstruction if the surgeon possess advanced laparoscopic skills, and it can lead to good post-operative results along with the expected rapid return to activity seen with other laparoscopic procedures.

J Urol. 2005 Mar;173(3):862-5