Boari flap ureteral reimplantation

Radical nephroureterectomy (RNU) with bladder cuff removal is currently considered as the standard of care for the management of upper tract urothelial carcinomas (UTUC)(1). However, RNU could induce unnecessary increased risk of non-cancer related death, by the potential cardiovascular morbidity associated with chronic renal failure (2).  Kidney-sparing surgery for low-risk UTUC allows sparing the morbidity associated with radical surgery, without compromising oncological outcomes and kidney function (3). In low-risk cancers this is the primary approach. In a recent meta-analysis Fang et al. noted that in selected cases of high risk UTUC a segmental ureterectomy can be considered as a valid option without comprising the oncological outcomes  (4). Distal ureterectomy with reïmplantation of the ureter in the bladder (ureteroneocystostomy) is performed as form of kidney-sparing surgery. Ureteroneocystostomy is also the procedure of choice to correct benign distal ureteral injuries or strictures in close proximity to the bladder that measure 3-5 cm (5). The ureteral defect can be bridged by a vesico-psoas hitch (tacking the posterior bladder wall to the psoas muscle) or Boari bladder flap (tubularization of a flap of bladder to extend from the bladder to the ureteral orifice). A minimally invasive robotic or laparoscopic approach offers advantages as less postoperative pain, less blood loss and quicker recovery. The robotic approach by itself offers the extra benefit of improved dexterity, EndoWrist instrumentation and 3-dimensional visualization with magnification in order to faciltate these technically challenging procedures.


Recommended reading:

  1.  Cummings KB. Nephroureterectomy: rationale in the management of transitional cell carcinoma of the upper urinary tract. Urol Clin North Am 1980;7(3):569–78.
  2.  Raman JD, Lin YK, Kaag M, et al. High rates of advanced disease, complications, and decline of renal function after radical nephroureter- ectomy. Urol Oncol 2014;32(1). 47 e9e14. 
  3. Yakoubi, R., et al. Radical nephroureterectomy versus endoscopic procedures for the treatment of localised upper tract urothelial carcinoma: a meta-analysis and a systematic review f current evidence from comparative studies. Eur J Surg Oncol, 2014. 40: 1629
  4. Fang D.  A systematic review and meta-analysis of oncological and renal function outcomes obtained after segmental ureterectomy versus radical nephroureterectomy for upper tract urothelial carcinoma. Eur J Surg Oncol.2016 Nov;42(11):1625-1635. doi: 10.1016/j.ejso.2016.08.008
  5. Elliott SP, McAninch JW. Ureteral injuries: external and iatrogenic. Urol Clin North Am. 2006 Feb. 33(1):55-66
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