Ureteral reimplant

Ureter reimplant

Ureteroneocystotomy technique

Boari Flap technique

  1. Position patient supine, arms out, flex bed to open abdomen, cap PCN (if present) to distend upper tract, place foley on field
  2. Perform midline laparotomy, enter peritoneal cavity, place bookwalter retractor
  3. Identify ureter medial to gonadal vessels, anterior to psoas muscle, and superior to iliac branch point
  4. Free up ureter while maintaining blood supply and cut proximal to stricture
  5. Identify urachus, free from abdominal wall, then trace inferiorly to free bladder from abdominal wall, avoid injury vas deferens
  6. Distend bladder with 150mL and measure distance from ureteral stump to bladder dome
  7. Demarcate flap that is same length and width, then incise in U-shape (sharp dissection on mucosa)
  8. Hitch flap to psoas tendon using 2-0 PDS simple interrupteds x3-4, place stitches longitudinally to avoid injuring genitofemoral nerve
  9. Tunnel ureter through flap (if desired), spatulate, and anastomose to mucosa with 4-0 vicryl running
  10. Place appropriately sized stent over a wire, removing PCN prior to deploying stent
  11. Close bladder mucosa with 3-0 vicryl, close outer detrusor/peritoneum with 2-0 vicryl
  12. Leak test bladder with 150mL
  13. Place penrose drain near surgical site via separate stab incision, suture to skin with nylon
  14. Close fascia with #1 PDS x2, then close subcutaneous tissue and close skin with staples

Cohen Crosstrigonal technique

  1. Position supine, arms tucked, prep abdomen and genitals
  2. Pfannenstiel incision along Langer lines, incise down to fascia
  3. Separate fascia off underlying muscle
  4. Separate rectus muscles at linea alba almost to pubis, retract laterally with Denis Browne ring
  5. Place stitch on either side of midline incision, then make vertical cystotomy
  6. Pack bladder dome with moist raytec x3, retract edges superiorly and laterally
  7. Identify ureters at trigone, beware of ureteral duplication
  8. Place holding stitch past distal portion of ureteral orifice
  9. Incise mucosa with cautery (cut), ensure enough room around orifice for suturing
  10. Dissect away underlying tissue from ureter, obtain enough length that the ureter can reach the skin without tension
  11. Create the cross-trigonal tunnel with a right-angle retractor, grasp the ureteral retraction stitch and pull through the neohiatus
  12. Stitch the ureteral apex with 4-0 vicryl x1, then stitch in the rest of the ureter with 6-0 vicryl
  13. Close the mucosa over the dissection site with ***
  14. Remove the raytecs, close the bladder in two layers, start towards bladder neck, close one layer, then continue the same stitch on the outer layer
  15. Close the fascia with ***, scarpas with vicryl interrupted x3, and skin with subcuticular stitch, then apply dermabond