Minimally Invasive Management of Ureteral Distal Strictures: Robotic Ureteroneocystostomy With a Bilateral Boari Flap.

OBJECTIVE: To describe robotic ureteroneocystostomy performed by bilateral Boari flap.

METHODS: An 82-year-old female with bilateral mid ureteral strictures secondary to uterine cancer treated with radiation was managed with ureteral stenting and bilateral nephrostomy tubes. Nevertheless, patient had severe colic and recurrent urinary tract infections and thus agreed to undergo bilateral robotic ureteral reconstructive surgery. Patient positioning and ports placement were similar to those of robotic prostatectomy. Ureters were divided at the level of the common iliac bifurcation and mobilized proximally. Strictures were excised and ureters were spatulated. After the bladder was dropped from the abdominal wall, a bladder flap was created with a broad base to ensure adequate blood supply. The ureteral anastomosis to the bladder flap was started using 3-0 Vicryl interrupted sutures to secure the posterior ureter to the bladder flap. The flap was then bisected in the midline to create a tension-free anastomosis. The ureteral anastomosis was completed over a double J ureteral stent. The wings of the bisected bladder flap were reapproximated with a 3-0 barbed suture to form a "Y" bladder configuration. Procedures were done bilaterally. The remainder of the cystotomy was closed with barbed suture. The bladder was tested for leakages and a drain was placed.

RESULTS: Blood loss was 50 mL. The patient recovered uneventfully and was discharged on postoperative day 4 with nephrostomy tubes and Jackson-Pratt drain removed prior to discharge. Follow-up cystogram revealed no leakage and bilateral reflux in the reconstructed bladder. Ureteral stents were removed 4 weeks postoperatively. Follow-up for these patients is recommended with either a renal scan or CT scan with delayed imaging. For this patient with severe chronic kidney disease, she unfortunately could not receive intravenous contrast and renal scan proved unreliable. Therefore, our follow-up was performed on the basis of her renal function (creatinine) which remained stable without nephrostomies or ureteral stents. Postoperatively, the patient did not complain of de novo lower urinary tract symptoms nor did she require anticholinergics.

CONCLUSION: Robotic bilateral Boari flap is feasible for patients with bilateral distal ureteral strictures. Further studies are needed to assess long-term outcomes. Given the significant degree of bladder reconstruction required for this procedure, we recommend an assessment of bladder capacity preoperatively in the form of a gravity cystogram or video urodynamics.