Boari Flap Research Articles

Laparoscopic Ureteric Reconstruction After Partial Ureterectomy for Locally Advanced and Recurrent Pelvic Malignancies (with Video).

The urinary tract is one of the most frequently involved organs in advanced non-urologic pelvic malignances. Extensive resection of ureteric organs is mandatory during a curative surgery. Urinary reconstruction after partial ureterectomy, the most challenging situation, is associated with a higher incidence of complication than cystectomy, especially when performed with laparoscopy. Furthermore, to date, no generally accepted strategy for urinary reconstruction after extensive tumor resection with partial ureterectomy has been established. The study identified and scrutinized intraoperative videos and clinical records of patients with locally advanced or recurrent pelvic malignancies who underwent segmental ureterectomy during en bloc resection of advanced tumors between February 2020 and February 2024. The study enrolled nine patients, including four cases managed by ureteroureteral anastomosis, two cases managed by ureteroneocystomy, two cases managed by Boari flap reconstruction, and one case managed by ileal interposition. In all nine cases, R0 margins were obtained, and no case needed conversion to laparotomy. No clinical evidence of postoperative urinary leakage was identified. The median follow-up period was 14months (range, 5-19months). In three of the nine cases, recurrence was identified, at the 3rd, 18th, and 19th month follow-up evaluations, respectively. One patient died of systemic metastasis. Laparoscopic ureteric reconstruction is feasible for patients who undergo segmental ureterectomy during extensive surgery for locally advanced or recurrent pelvic malignancies. A low anastomotic leakage rate and favorable postoperative renal function could be achieved in this study when anastomosis was performed laparoscopically.

Long-term Renal Preservation and Complication Profile With Ileal Ureter Creation

ObjectivesTo examine long-term ileal ureter replacement results at over 32 years at our institution. Long segment or proximal ureteral strictures pose a challenging reconstructive problem. Ureteroureterostomy, psoas hitch, boari flap, buccal ureteroplasty and autotransplantation are common reconstructive techniques. We show that ileal ureter remains a lasting option. MethodsWe performed a retrospective review of patients undergoing open ileal ureter creation from 1989-2021. Patient demographics, operative history, and complications were examined. All patients were followed for change in renal function. Demographic data was analyzed and cox proportional hazard models performed. Results158 patients were identified with median follow-up time of 40 months. 81% had a unilateral ileal ureter creation. 50% were female, median age was 53.3. 27% of patients had radiation-induced strictures. Pre-operatively, 56.3% of patients were CKD stage 1-2 and 43.7% were stage 3-5. Post-operatively, 54% were stage 1-2 and 46% were stage 3-5. Cox proportional hazard models demonstrated no significant correlation between worsening renal function and stricture cause, bilateral repair, complications, or sex. 77% had no 30-day complications. Clavien complications included grade 1(18), grade 2(4), grade 3(9), grade 4(5). Long-term complications included worsening renal function(3%), incisional hernia(8.2%), and small bowel obstruction(6.9%). 5(3.1%) patients ultimately required dialysis and 5(3.1%) patients developed metabolic acidosis. ConclusionIleal ureteral reconstruction is often a last resort for patients with complex ureteral injuries. Clinicians can be reassured by our long-term data that ileal ureteral creation is a safe treatment with good preservation of renal function and low risk of hemodialysis and metabolic acidosis.

Ureteroplasty with buccal mucosa graft without omental wrap: an effective method to treat ureteral strictures

PurposeSuccessful treatment options for ureteral strictures are limited. Surgical options such as ileal interposition and kidney autotransplantation are difficult and associated with morbidity and complications. Techniques such as Boari flap and psoas hitch are limited to distal strictures. Only limited case studies on the success of open buccal mucosa graft (BMG) ureteroplasty exist to this date. The purpose of this study was to evaluate the success of open BMG ureteroplasty without omental wrap.MethodsIn this single-center retrospective study between July 2020 and January 2023, we included 14 consecutive patients with ureteric strictures who were treated with open BMG ureteroplasty without omental wrap. The primary outcome was the success of open BMG ureteroplasty. Further endpoints were complications and hospital readmission. Outcome variables were assessed by clinical examination, kidney sonography, and patient anamnesis.ResultsOut of 14 patients, 13 were stricture and ectasia-free without a double-J stent at a median follow-up of 15 months (success rate 93%). No complications were observed at the donor site, and the complication rate overall was low with 3 out of 14 patients (21%) having mild-to-medium complications.ConclusionsOpen BMG ureteroplasty without omental wrap is a successful and feasible technique for ureteric stricture repair.

Minimally invasive reconstruction of extensive mid-lower ureteral strictures using a bilateral Boari flap

ObjectiveTo describe and evaluate the technique using bilateral Boari flap ureteroneocystostomy (BBFUNC) for bilateral mid-lower ureteral strictures. MethodsWe retrospectively reviewed five patients who underwent minimally invasive BBFUNC in our institution (Union Hospital, Wuhan, China) between July 2019 and December 2021. The bilateral ureters were mobilized and transected above the stenotic segments. The bladder was isolated and incised longitudinally from the middle of the anterior wall. Then, an inverted U-shaped bladder flap was created on both sides, fixed onto the psoas tendon, and anastomosed to the ipsilateral distal normal ureter. Following double-J stenting, the Boari flaps were tubularized, and the bladder was closed with continuous sutures. The patients' perioperative data and follow-up outcomes were collected, and a descriptive statistical analysis was performed. ResultsNo case converted to open surgery, and no intraoperative complication occurred. The median surgical time was 230 (range 203–294) min. The median length of the bladder flaps was 6.2 (range 4.3–10.0) cm on the left and 5.5 (range 4.7–10.5) cm on the right side. All patients had not developed recurrent ureteral stenosis during the median follow-up time of 17 (range 16–45) months and had a normal maximum flow rate after surgery. The median post-void residual was 7 (range 0–19) mL. The maximal bladder capacity was decreased in one (20%) patient. ConclusionThe present study demonstrates that minimally invasive BBFUNC is feasible and safe in treating bilateral mid-lower ureteral strictures, and the impact on lower urinary tract function is limited.

Newly modified 'pseudo flap' without compromising vascularity to enhance repair of long distal ureteral loss: A retrospective analysis of a prospective database.

To present an alternative technique called pseudo-flap for reconstructing long ureteral defects as an alternative to Boari flap. Despite being used for more than 70 years by urologists for tension-free reconstruction of distal and mid-ureteral defects, the Boari flap exhibits high complication rates, with an average of 27% (range 5.5%-30.4%). These complications arise from compromised blood supply, attributed to incisions made on all three sides of the flap and dependence on the flap base as the sole source of blood supply. We retrospectively reviewed patients who underwent our modified technique by a single surgeon between 2008 and 2021. We used a semi-oblique cystotomy on the lowest part of the anterior and contralateral aspects of the bladder after complete release from adhesions and sacrificing the superior vesical pedicle, if necessary. The innovative part of the technique involved making short relaxing incisions at different levels on both sides of a pseudo-flap while pushing the bladder dome upward to reach the healthy ureter in a tension-free manner, followed by anastomosis with a non-refluxing or refluxing technique. Fifteen patients underwent the pseudo-flap technique with a mean follow-up of 16.9months. Four had prior radiation, three had hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis, and one had a ureteral stricture in a transplanted kidney. Eight procedures were performed during intraoperative consultations.Only one patient (7%) developed a major complication (Clavien-Dindo grade ≥2). This patient developed postoperative leak, and none developed obstructive hydronephrosis, suggesting stricture or flap ischemia. The mean length of the flap was 9.3cm. Our pseudo-flap technique has lower complication rates than the traditional Boari flap. It is not technically challenging, minimally compromises blood supply and is thus especially suitable for complex, highly morbid patients with decreased tissue vascularity, such as those with prior radiation and peritoneal carcinomatosis.

Robot-assisted ureteric reconstructive surgeries for benign diseases: Initial single-center experience with point of technique.

We present our initial experience with robot-assisted reconstructive surgeries with the Da Vinci Xi robotic system for benign ureteric pathologies. This is a retrospective review of prospectively collected data of patients who underwent robot-assisted reconstructive procedures for benign diseases of the ureter at our department from April 2018 to November 2022. Demographic and perioperative details were recorded. Patients were followed up and surgical success was evaluated on the basis of symptomatic, functional, and radiological improvement. A total of 34 patients underwent robot-assisted reconstructions for benign ureteric pathologies by various techniques. Mean age, body mass index (BMI), hospital stay and follow-up duration were 36 years, 24.1 kg/m2, 5.29 days, and 7.08 months respectively. Procedures included pyeloplasty in eight, primary ureteroneocystostomy (UNC) in seven, Psoas hitch UNC in five, Boari flap UNC in six, Ureteroureterostomy in four, ureterocalicostomy in two and ileal ureteral transposition in two patients. Mean docking time, total operative time, and estimated blood loss were 31.5 min, 178 min, and 64.3 ml, respectively. All patients had radiologic or functional improvement on follow-up after 6 months. Robot-assisted reconstructive surgery for benign ureteric and bladder pathologies imparted excellent short-term outcomes without major complications with all the advantages of a minimally invasive approach.

Female Bladder Dysfunction Following Boari Bladder Flap Ureteral Reconstruction

ObjectivesTo describe our institution’s experience with Boari flap ureteral reconstruction, specifically focusing on the development of postoperative lower urinary tract symptoms (LUTS). MethodsA retrospective review of all Boari flaps performed at our institution between 2013 and 2023 was performed, excluding patients with urothelial carcinoma and males, given the frequency of LUTS from benign prostatic hyperplasia. Primary outcome was the development of new onset LUTS and subsequent treatment. Secondary outcomes included postoperative infections and ureteral stricture. Results29 total patients were identified. Mean age was 52.2 years (Standard deviation (SD) 13.1). Mean follow-up was 22.3 months (SD 25.3). Primary reasons for ureteral reconstruction were radiation damage (37.9%) and iatrogenic surgical injury (37.9%). A concurrent psoas hitch was performed in 18/29 (62%) cases, nephropexy was utilized in 1/29 (3.4%) cases, and contralateral bladder pedicles were ligated in 10/29 (34.5%) for increased bladder mobilization. Postoperatively, 8 patients (27.6%) developed new-onset LUTS, effectively managed with oral anticholinergics. Recurrent UTIs occurred in 5 patients (17.2%) and pyelonephritis in one (3.4%) patient. Two patients (6.9%) developed ureteral strictures, one treated with ileal ureter replacement and the other with ureteral balloon dilation. ConclusionsBoari bladder flap ureteral reconstruction leads to moderate rates of new onset LUTS postoperatively, which is important information when counseling women on reconstructive options. Boari flap ureteral reconstruction has a high success rate and serious complications are rare. In the setting of ureteral injury, reconstruction using Boari flaps with or without psoas hitch should be considered for definitive management.

The Whitaker test: a predictive tool for evaluating the surgical efficacy of upper urinary tract reconstruction in patients carrying a nephrostomy tube after surgery.

To explore the role of the Whitaker test in evaluating the postoperative outcome of upper urinary tract reconstruction surgery in patients carrying a nephrostomy tube after surgery. This was a prospective observational study performed in 42 patients with nephrostomy tube undergoing the Whitaker test after upper urinary tract reconstruction surgery between January 2020 and December 2021. Data on clinical information, the Whitaker test and surgical procedure were collected prospectively, and the long-term follow-up results were analysed retrospectively. The 46 ureters of 42 patients (right 16, left 22, bilateral 4) underwent six common upper urinary tract surgical reconstruction procedures and one combined procedure, including pyeloplasty, ureteroureterostomy, lingual mucosal onlay graft, appendiceal onlay flap, ureteral reimplantation, Boari flap, and ipsilateral lingual mucosal onlay graft combined ureteral reimplantation. All patients underwent the Whitaker test successfully without any discomfort after examination. The postoperative Whitaker test showed 43 kidneys without obstruction and 3 kidneys with obstruction. At a median follow-up of 18 months (range 13-31), the follow-up results showed that the overall success rate of the surgery was 100% (46/46). Concerning the concordance Whitaker test and follow-up results, the observed proportion of agreement was 93.5% (43/46). The Whitaker test can achieve similar consistency with the long-term follow-up results after upper urinary tract reconstruction surgery and can be used as a tool to evaluate the surgical efficacy of upper urinary tract reconstruction surgery, which can provide a prognostic efficacy evaluation for patients carrying a nephrostomy tube after surgery.

Management of a long segment of bilateral ureteric injury: A combination of Boari flap and ureteroneocystostomy with psoas hitch

Iatrogenic ureteric injuries are a relatively common complication of pelvic and gynecological surgeries which, if left untreated, could lead to medical and legal issues. Therefore, reconstruction of the ureter is still regarded as requiring a sophisticated approach which demands a specialist urologist. This case involves a post-hysterectomy and bilateral salpingo-oophorectomy 46-year-old woman who presented with a bilateral ureteric injury. A left Boari flap and right Lich-Gregoir ureteroneocystostomy with psoas hitch was performed for the correction of the bilateral long segment defect.

Role of 3-dimensional Imaging in the Management of Ureteric Fistula

A patient in her late 20s presented with a month-long history of continuous dribbling of urine associated with right flank following suction-evacuation for an incomplete abortion. Contrast-Enhanced Computed Tomography (CECT) abdomen and Computerised Tomography (CT) urogram demonstrated a 1cm focal defect in the right lateral wall of the uterus communicating with a collection in the right hemipelvis and right paracolic region. Fluid was demonstrated in the uterus and cervix. The right ureter narrowed abruptly at the level of the S1 vertebra, with prominence of the proximal ureter. An opacified tract was seen between the right ureter and the uterus [Figures 1, 2 and 3] diagnosed as a fistula. The patient had a total laparoscopic hysterectomy with ureteric reimplantation into a Boari flap surgery and psoas hitch of the urinary bladder, with the clinical application of pre-operative 3D CT imaging allowing for surgical improved planning to optimise the outcome [Supplemental Figure 1].

Management of Iatrogenic Ureteral Trauma Post Caesarean Section

Trauma in the ureter occurs in 1-2.5% of all urogenital trauma, and the most common causes of iatrogenic ureteral trauma come from the Obstetrics Gynecology field (59%). One of the causes of delayed diagnosis of ureteral trauma is the lack of operator awareness. This case report described a 29-year-old woman suspected of ureteral trauma after urine-like fluid was found during a cesarean section operation. After 12 days, a clear-yellowish fluid was obtained from the abdominal drain, so the patient was referred to urologists. The abdominal drain produced fluid approximately 250-300cc/24 hours, clear yellow color. IVP and left RPG inferred left distal ureter laceration AAST grade III. Re-exploration, ureteroneocystostomy using Boari Flap technique, and DJ-Stent insertion were done. On the second day postoperative, the abdominal drain production was < 25cc/24 hours in red color. Ureteral trauma is rare, often unnoticed, and often diagnosed late due to a lack of operator alertness.

A Multi-Institutional Experience Utilizing Boari Flap in Robotic Urinary Reconstruction.

Objectives: There is presently scarce literature describing the outcomes of patients undergoing robotic ureteral reconstruction (RUR) using the Boari flap (BF) technique. Herein, we report our prospective, multi-institutional experience using BF in patients undergoing robotic urinary reconstruction. Patients and Methods: We reviewed our prospective, multicenter database for all patients undergoing RUR between September 2013 and September 2021 in which a BF was utilized. Preoperative, perioperative, and follow-up data were collected and analyzed. Major complications were defined as a Clavien-Dindo classification grade >2. Surgical failure was defined as recurrent symptoms, obstruction on imaging, or the need for additional surgical interventions. Results: We identified 50 patients who underwent RUR using a BF. Four (8%) underwent the Single Port approach. Twenty-four patients (48%) were active or former tobacco users. Thirty-four patients (68%) had previously undergone abdominal surgery, 17 (34%) had prior ureteral stricture interventions, and 9 (18%) had prior abdominopelvic radiation. The most common stricture etiology was malignancy (34.4%). The median follow-up was 15.0 months with a 90% (45/50) success rate. The five documented cases of failure occurred at a median of 1.8 months following the procedure. Conclusion: In the largest prospective, multi-institutional study of patients undergoing RUR with BF in the literature to date, we demonstrate a low rate of complications and a high rate of surgical success in three tertiary academic medical centers. All observed failures occurred within 2 months of surgical intervention.

V01-04 SINGLE-PORT ROBOTIC EXTRAPERITONEAL RIGHT URETERAL REIMPLANTATION WITH BOARI FLAP

You have accessJournal of UrologyCME1 Apr 2023V01-04 SINGLE-PORT ROBOTIC EXTRAPERITONEAL RIGHT URETERAL REIMPLANTATION WITH BOARI FLAP Melissa Moran, Alain Kaldany, Krishna Doppalapudi, Arnav Srivastava, and Sammy Elsamra Melissa MoranMelissa Moran More articles by this author , Alain KaldanyAlain Kaldany More articles by this author , Krishna DoppalapudiKrishna Doppalapudi More articles by this author , Arnav SrivastavaArnav Srivastava More articles by this author , and Sammy ElsamraSammy Elsamra More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003221.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with multiple abdominal surgeries often harbor hostile abdomens with significant bowel adhesions. It is thus difficult to obtain safe transperitoneal access when placing robotic trocars. An extraperitoneal approach, in contrast, allows for safe entry into the abdomen. In the case of a mid to distal ureteral stricture requiring extraperitoneal Boari flap ureteral reimplantation, the conventional multiport approach would be suboptimal as arm spacing would be insufficient. Here we demonstrate our surgical technique and the feasibility of a single port (SP) extraperitoneal Boari flap ureteral reimplantation. METHODS: A 70-year-old female with a history of rectal cancer treated with multiple abdominal surgeries and chemoradiation was diagnosed with a distal right ureteral stricture. She was offered SP robotic ureteral reimplantation for definitive management. The patient was positioned in steep Trendelenburg with a left-sided tilt. A 4 centimeter (cm) incision was created over the right lateral aspect of the abdomen 8 cm above the anterior superior iliac spine, and the retroperitoneal space was entered. The SP access port was placed and the robot was docked. The ureter was identified crossing the iliac vessels and was dissected proximally and distally. Once scar tissue was encountered, the ureter was transected. The bladder was mobilized and the medial umbilical ligament was cut. The distance from the ureter to the bladder was measured, and a Boari flap of this length was created. The posterior ureter was then spatulated and a Boari flap anastomosis was performed. The bladder was closed in a Heineke-Mikulicz fashion and a double-J ureteral stent was placed in the right ureter. The bladder was distended to ensure a watertight closure. A drain was placed and the Foley catheter was exchanged. RESULTS: The operative time was roughly three hours, with 50 milliliters of estimated blood loss. On post-operative day one, the drain was removed and patient was discharged home. Imaging two weeks later showed improved hydronephrosis with no urine extravasation, and the Foley catheter was removed. The ureteral stent was removed at four weeks post-operatively. Ultrasound and renal scan three months later demonstrated improved hydronephrosis with preserved renal function and no evidence of obstruction. CONCLUSIONS: To our knowledge, this is the first video demonstrating an SP extraperitoneal Boari flap ureteral reimplantation. This approach is feasible and allows a surgeon to safely and effectively perform a primarily retroperitoneal procedure without entering a hostile abdomen. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e80 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Melissa Moran More articles by this author Alain Kaldany More articles by this author Krishna Doppalapudi More articles by this author Arnav Srivastava More articles by this author Sammy Elsamra More articles by this author Expand All Advertisement PDF downloadLoading ...

V03-01 SINGLE-PORT KIDNEY AUTO-TRANSPLANTATION (SP-KAT) WITH BOARI FLAP URETERAL REIMPLANT: DESCRIPTION OF OUR NOVEL APPROACH

You have accessJournal of UrologyCME1 Apr 2023V03-01 SINGLE-PORT KIDNEY AUTO-TRANSPLANTATION (SP-KAT) WITH BOARI FLAP URETERAL REIMPLANT: DESCRIPTION OF OUR NOVEL APPROACH Jaya Sai Chavali, Jihad Kaouk, Ethan Ferguson, Roxana Ramos, Albert Geskin, Alvin Wee, and Mohamed Eltemamy Jaya Sai ChavaliJaya Sai Chavali More articles by this author , Jihad KaoukJihad Kaouk More articles by this author , Ethan FergusonEthan Ferguson More articles by this author , Roxana RamosRoxana Ramos More articles by this author , Albert GeskinAlbert Geskin More articles by this author , Alvin WeeAlvin Wee More articles by this author , and Mohamed EltemamyMohamed Eltemamy More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003241.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We aim to demonstrate the feasibility and safety of the novel minimally invasive technique for efficient, multiquadrant robotic kidney transplantation using da Vinci single-port robot platform (SP-KAT). The study patient had a good split renal function and complete ureter avulsion. METHODS: Eight consecutive patients underwent SP KAT using the DaVinci SP platform. Overall patient clinicopathologic variables were recorded in Table 1. We demonstrate our technique in 58 year old male that presented after complete avulsion of the ureter during ureteroscopy. He had good split renal function on imaging. Technical steps of the surgery included (1). Robotic nephrectomy; (2) Kidney benching; (3) Dissection of Iliac vessels and Kidney placement; (4) Vascular anastomosis; (5) Ureteral reimplant. Extra corporeal kidney benching performed at the same time while the iliac vessels are being exposed robotically for subsequent transplant. This patient in addition required Boari flap ureteroneocystostomy due to insufficient length of ureter. RESULTS: All SP KAT cases were successfully performed without repositioning or conversion to open. Total operative time was 701 minutes. Estimated blood loss was 500cc. The Foley and stent removed at 2 and 6 weeks postoperatively. Patient had complete preservation of renal function. No documented postoperative complications up to latest follow up at 1 year. CONCLUSIONS: We demonstrate our single-port efficient, multiquadrant robotic kidney transplantation technique performed though a single incision further reducing surgical morbidity. All the cases were completed successfully without conversion or loss of graft function. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e246 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jaya Sai Chavali More articles by this author Jihad Kaouk More articles by this author Ethan Ferguson More articles by this author Roxana Ramos More articles by this author Albert Geskin More articles by this author Alvin Wee More articles by this author Mohamed Eltemamy More articles by this author Expand All Advertisement PDF downloadLoading ...

MP42-16 BLADDER PRESERVATION OR COMPLETE CYSTECTOMY DURING PELVIC EXENTERATION OF PATIENTS WITH RECTAL CANCER. WHAT SHOULD WE DO?

You have accessJournal of UrologyCME1 Apr 2023MP42-16 BLADDER PRESERVATION OR COMPLETE CYSTECTOMY DURING PELVIC EXENTERATION OF PATIENTS WITH RECTAL CANCER. WHAT SHOULD WE DO? Catalina Palma, Charlotte Van Kessel, Michael Solomon, Scott Leslie, Nicola Jeffery, Peter Lee, and Kirk Austin Catalina PalmaCatalina Palma More articles by this author , Charlotte Van KesselCharlotte Van Kessel More articles by this author , Michael SolomonMichael Solomon More articles by this author , Scott LeslieScott Leslie More articles by this author , Nicola JefferyNicola Jeffery More articles by this author , Peter LeePeter Lee More articles by this author , and Kirk AustinKirk Austin More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In patients with locally advanced (LARC) or recurrent (LRRC) rectal cancer and bladder involvement, pelvic exenteration (PE) with partial (PC) or radical (RC) cystectomy can potentially be curative. Urinary tract reconstruction involves ileal/colonic conduit for RC, or either primary bladder repair or ureteric reimplantation with Boari flap and psoas hitch for PC. Where PC potentially provides less post-operative morbidity, a radical resection is the most important prognostic factor for survival. The purpose of this study was to compare PC and RC in PE patients in terms of oncological outcome and post-operative complications. METHODS: This was a retrospective cohort analysis of a prospectively maintained surgical database. Patients who underwent PE for LARC or LRRC with bladder involvement between 1998 and 2021 were included. Post-operative complications and overall survival were compared between patients with PC and RC. Statistical analysis was performed using SPSS. RESULTS: 329 patients were included; 60 patients with PC and 269 with RC. No significant difference in R0 resection was observed between PC and RC groups (81.8% versus 84.7%, p=0.621). 10 patients in PC group had a positive margin; in 3/10 patients this was at the bladder or ureter margin. Patients with LRRC and PC had poorest oncological outcome with 69% R0 resection; patients with LARC and PC demonstrated highest R0 rate of 96.3% (p=0.008). Overall survival (OS) was 88 months versus 58 months in the PC and RC group, respectively (p=0.265). 1-, 3- and 5-year OS were 90.8%, 68.1% and 58.6% in PC group, and 88.7%, 62.2% and 49.5% in the RC group. Factors that were significantly associated with poorer OS included age, positive resection margin and longer duration of surgery. RC patients demonstrated longer operating time, higher intra-operative blood loss, and longer hospital stay. RC patients also experienced significantly higher rates of wound related complications (25.0% vs. 39.8%, p=0.032). Rates of urinary sepsis or urological leaks did not differ between groups. CONCLUSIONS: This study demonstrates that PC as part of a PE can be performed safely without compromising oncological outcome in patients with LARC. In patients with LRRC, PC results in poor oncological outcome and a more aggressive surgical approach with RC seems justified. The main benefit of PC is a reduction in wound related complications compared to RC, although more urological re-interventions are observed in this group. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e574 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Catalina Palma More articles by this author Charlotte Van Kessel More articles by this author Michael Solomon More articles by this author Scott Leslie More articles by this author Nicola Jeffery More articles by this author Peter Lee More articles by this author Kirk Austin More articles by this author Expand All Advertisement PDF downloadLoading ...

MP65-18 LONG-TERM RENAL PRESERVATION WITH ILEAL URETER CREATION

You have accessJournal of UrologyCME1 Apr 2023MP65-18 LONG-TERM RENAL PRESERVATION WITH ILEAL URETER CREATION Mary E Soyster, Ramzy T Burns, Jason L Zappia, Peter Arnold, Joshua Roth, Maria Francesca Roth, and Matthew Mellon Mary E SoysterMary E Soyster More articles by this author , Ramzy T BurnsRamzy T Burns More articles by this author , Jason L ZappiaJason L Zappia More articles by this author , Peter ArnoldPeter Arnold More articles by this author , Joshua RothJoshua Roth More articles by this author , Maria Francesca RothMaria Francesca Roth More articles by this author , and Matthew MellonMatthew Mellon More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003323.18AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Long segment or proximal ureteral defects can often pose a challenging reconstructive problem. Ureteroureterostomy, psoas hitch, boari flap, buccal ureteroplasty and autotransplantation are common reconstructive techniques for ureteral injuries, however, in cases where these are not viable options, ileal replacement is considered. We present our long term results of ureteral replacement with ileum with over 32 years of experience. To the best of our knowledge, this is the longest follow up series on ileal ureter creation. METHODS: We performed a retrospective review of patients greater than 18 years old undergoing ileal ureter creation at Indiana University from 1989 to 2021. Patient demographics, etiology, renal function, and complications were examined. All patients were followed pre and post-operatively for change in renal function. . Deterioration was defined as an increase in the chronic kidney disease (CKD) stage. RESULTS: Of the 159 patients with ileal ureter creation, 80.5% had unilateral ileal ureter creation, 19.5% had bilateral reconstruction. 50.3% of these were female. Average age at operation was 52.8 (SD 14.9). Average follow up was 41 months, ranging from 6-179 months. 26.4% of patients had radiation induced strictures. Pre-operatively, 57.9% of patients were in CKD stage 1-2 by MDRD criteria, and 42.1% were in stage 3-5 CKD. Post-operative, 54.7% were in stage 1-2 and 45.3% were in stage 3-5. Logistic regression examining outcomes of worsening renal function demonstrated no significant correlation between worsening renal function and stricture cause (p=.09), bilateral repair (p=.103), post-operative complications (p=.130), or sex (p=.42). 76.7% had no short-term (within 30 day) complications. Identified Clavien complications included grade 1 (18[11.3%]), grade 2 (4[2.5%]), grade 3 (9[5.7%]0, grade 4 (5[3.1%]) and grade 5 (1[.6%]. Long term complications included worsening renal function (34.6%), incisional hernia (8.2%), small bowel obstruction (6.9%). 5 patients (3.1%) on long term follow up had renal failure requiring dialysis, and 5 (3.1%) patients suffered from metabolic acidosis. CONCLUSIONS: Ileal ureteral reconstruction is often a last resort for patients with ureteral injuries. However, our long-term follow up confirms that this is a safe approach with good preservation of renal function and low risk of hemodialysis and metabolic acidosis. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e898 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mary E Soyster More articles by this author Ramzy T Burns More articles by this author Jason L Zappia More articles by this author Peter Arnold More articles by this author Joshua Roth More articles by this author Maria Francesca Roth More articles by this author Matthew Mellon More articles by this author Expand All Advertisement PDF downloadLoading ...

Robot-assisted ureterectomy with Boari flap reconstruction for distal ureteral stenosis

Robot-assisted ureterectomy with Boari flap reconstruction for distal ureteral stenosis

The Ileal Ureter: Over a Century of Urologic Innovation

Objectives Surgical techniques to repair a ureteral stricture may depend on the stricture’s etiology, length, and location. Options may range from primary ureteral reimplantation for short, distal strictures, buccal mucosa onlay ureteroplasty for complex proximal or mid ureteral defects, to Boari flap or even autotransplantation for longer mid to distal ureteral defects. Replacement of the entire ureter with a segment of ileum is rare but may provide durable results when indicated. Our objective was to illustrate how the history and evolution of the ileal ureter entered the contemporary surgical armamentarium. Methods A comprehensive literature review was performed in conjunction with library resources in the History of Medicine section at the University of Rochester. We used PubMed to identify contemporary medical literature, ILLiad to access archived texts and historic surgical and urological textbooks to obtain additional historical information and references. Results We documented perhaps the first description of the ileal ureter in a canine model by Guido Tizzoni and Alfonso Foggi in 1888. Adaptations of ileal ureters over the next century, and beyond, have increased the safety, feasibility, and reproducibility of thre procedure for replacement of the ureter rendered unsalvageable by strictural disease, trauma, or malignancy. Conclusions Tizzoni and Foggi described the first ileal ureter in the canine model in 1888.

Robot-assisted ipsilateral partial nephrectomy with distal ureterectomy for synchronous renal and ureteric tumors—a case report

BackgroundIpsilateral synchronous renal and ureteric tumor is uncommon. Nephron sparing surgery is the standard for small renal masses. Ureteric tumors can be selectively managed with nephron sparing surgery, especially in renal dysfunction. This case report details the management of double malignancy by nephron sparing surgery with robot-assisted approach.Case reportA 63-year-old gentleman with diabetes presented with history of intermittent gross hematuria for 2 weeks. He was clinically normal. On evaluation, he had grade 4 renal dysfunction (Se. creatinine 4.5 mg%) with mild proteinuria. Magnetic resonance imaging revealed right renal upper polar Bosniak III lesion and right hydroureteronephrosis due to 2 cm ureteric tumor near the vessel crossing. Renogram showed overall GFR of 22 ml/min with 31% (6 ml/min) contribution from the right side. He underwent robot-assisted right partial nephrectomy with distal ureterectomy and Boari flap ureteric reimplantation. Histopathology revealed margins free T2 clear cell carcinoma (kidney) and high-grade T3 transitional cell carcinoma (ureter). His nadir creatinine at 1 year follow-up was 3.3 mg% and no recurrence on MRI, cystoscopy, and ureteroscopy at 1 year.ConclusionMinimally invasive nephron sparing surgery is feasible and reasonable option with satisfactory oncological control even in ipsilateral synchronous renal and ureteric tumors in selected patients with renal dysfunction.

Ureteral Tract Injuries: Management and Post-Operative Considerations

<h3>Study Objective</h3> Review surgical management of ureteral injury, review postoperative care considerations, discuss complications and long-term follow-up. <h3>Design</h3> Educational video. <h3>Setting</h3> Tertiary care, academic center. <h3>Patients or Participants</h3> N/A. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> In this video, we review the management of different types of ureteral injury repair depending on the mechanism and location of injury. In particular, we illustrate ureteroureterostomy (end to end anastomosis), Boari flap, and psoas hitch. We review key surgical principles and evidence-based post-operative considerations, including ureteral stenting, drain placement and bladder decompression. Long term complications and care are discussed. <h3>Conclusion</h3> The ability to identify the location and extent of ureteral injuries critical to choosing the appropriate type of surgical repair. Understanding key surgical principles and postoperative considerations will assist in the prevention of short and long-term complications.