Ureter reimplant
Ureteroneocystotomy technique
Boari Flap technique
- Position patient supine, arms out, flex bed to open abdomen, cap PCN (if present) to distend upper tract, place foley on field
- Perform midline laparotomy, enter peritoneal cavity, place bookwalter retractor
- Identify ureter medial to gonadal vessels, anterior to psoas muscle, and superior to iliac branch point
- Free up ureter while maintaining blood supply and cut proximal to stricture
- Identify urachus, free from abdominal wall, then trace inferiorly to free bladder from abdominal wall, avoid injury vas deferens
- Distend bladder with 150mL and measure distance from ureteral stump to bladder dome
- Demarcate flap that is same length and width, then incise in U-shape (sharp dissection on mucosa)
- Hitch flap to psoas tendon using 2-0 PDS simple interrupteds x3-4, place stitches longitudinally to avoid injuring genitofemoral nerve
- Tunnel ureter through flap (if desired), spatulate, and anastomose to mucosa with 4-0 vicryl running
- Place appropriately sized stent over a wire, removing PCN prior to deploying stent
- Close bladder mucosa with 3-0 vicryl, close outer detrusor/peritoneum with 2-0 vicryl
- Leak test bladder with 150mL
- Place penrose drain near surgical site via separate stab incision, suture to skin with nylon
- Close fascia with #1 PDS x2, then close subcutaneous tissue and close skin with staples
Cohen Crosstrigonal technique
- Position supine, arms tucked, prep abdomen and genitals
- Pfannenstiel incision along Langer lines, incise down to fascia
- Separate fascia off underlying muscle
- Separate rectus muscles at linea alba almost to pubis, retract laterally with Denis Browne ring
- Place stitch on either side of midline incision, then make vertical cystotomy
- Pack bladder dome with moist raytec x3, retract edges superiorly and laterally
- Identify ureters at trigone, beware of ureteral duplication
- Place holding stitch past distal portion of ureteral orifice
- Incise mucosa with cautery (cut), ensure enough room around orifice for suturing
- Dissect away underlying tissue from ureter, obtain enough length that the ureter can reach the skin without tension
- Create the cross-trigonal tunnel with a right-angle retractor, grasp the ureteral retraction stitch and pull through the neohiatus
- Stitch the ureteral apex with 4-0 vicryl x1, then stitch in the rest of the ureter with 6-0 vicryl
- Close the mucosa over the dissection site with ***
- 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
- Close the fascia with ***, scarpas with vicryl interrupted x3, and skin with subcuticular stitch, then apply dermabond