Robotic Assisted Boari Flap in a Patient After Pelvic Radiation

Objectives: There are various techniques for robotic ureteral reimplantation using Boari flap (BF) have been described in the literature. BF uteroneocystotomy can be performed with refluxing or non-refluxing extravesical implant approach. This video details surgical steps of robotic assisted BF (RABF) with refluxing extravesical implant while maintaining basic principles of ureteral reconstruction including posterior ureteric spatulation, careful ureter handling, tension free and bladder water tight anastomosis.

Methods: We present a clinical case of a 76 years old with stage III B squamous cell carcinoma of the cervix status post chemoradiation two years ago. The patient had bilateral hydronephrosis and distal ureteral stricture which was unsuccessfully managed with ureteral balloon dilation. Antegrade pyelogram showed bilateral ureteral obstruction at the ureterovesical junction. She subsequently failed the ureteral stent placement and percutaneous nephrostomy. After extensive counseling, the patient opted for robotic assisted bilateral ureteroneocystotomy, ureteral stent placement and cystoscopy. However, due to the left ureter injury 1 cm below the bifurcation of left common iliac artery during ureterolysis, the decision was made to perform RABF with refluxing extravesical implant technique and bilateral ureteral stent placement. The surgery had 50 mL blood loss. The end-to-end ureteral flap anastomosis was performed without anti-refluxing system (or submucosal tunneling) using 4-0 absorbable polyglactin-910 suture in the continuous non-locking fashion. The patient was discharged home two days postoperatively. Foley catheter was kept for 14 days. Fluoroscopy cystogram at 2 weeks postoperatively showed contrast extravasation at the anastomosis site. Ureteral stents remained for 6 weeks. Antegrade nephrostogram at 6 weeks after the surgery showed no leakage.

Clinical Relevance: Ureteral injury (UI) is an uncommon surgical complication, and 90% of UI cases occur at the distal third of the ureter. The ureter is at potential risk during surgeries in the lower abdomen and pelvis including gynecological, colorectal, urologic, vascular or even spinal procedures. In this video, the ureteral injury occurred due to poor appearing tissue after pelvic radiation despite care was taken for dissection. However, we demonstrate that RABF ureteroneocystotomy with refluxing extravesical reimplant technique is feasible, less technically challenging and stricture formation. This minimal invasive approach is an excellent alternative to open surgery while maintaining basic principles of ureteral reimplantation.