INDICATIONS
FOR COMBINED
HITCH PROCEDURE STEPHEN
VASILEV
PSOAS-BLADDER
WITH BOAR1 VESICAL FLAP
KISHEV,
M.D.
From the Section of Urologic Surgery, Surgical Service, Veterans Administration Hospital, Asheville, North Carolina
ABSTRACT - The combination of two operative methods ordinarily usedfor correction of injury to the pelvic portion of the ureter, the psoas-bladder hitch procedure and the Boari uesicalflap, allows repair of injuries of the middle third of the ureter. The proximal third of the ureter becomes easily accessible for reimplantation in the tunneled Boari flap, provided the mobilized and extraperitonealized bladder is fashioned into a sausage-like extension toward the psoas muscle. Possibilities fx- a longer Boari flap exist provided the bladder is of normal capacity and one adheres strictly to the recommended technique for fashioning a bladder flap, using a long oblique segment of the anterior bladder wall.
We recently described our experience with repair of the injured pelvic portion of the ureter by using the psoas-bladder hitch procedure with tunneling of the hitched bladder portion. 1 We were able to replace ureteral defects up to 5 cm. in length in 8 patients, in most of whom the neoureterocystostomy did not show evidence ofureteral reflux. We have subsequently combined the psoas-bladder hitch procedure with a Boari flap to replace a longer segment of ureter. Historical Notes Kelami and associates2-4 were the first to conceive a combined approach for repair of injuries to the ureter located at a greater distance from the bladder. After experiments on dogs, in a few of which signs of impairment of the blood supply in the Boari flap developed, they succeeded in repairing the stenotic distal two thirds of one ureter in a patient with stricture due to tuberculosis.2-4 Golimbu, Block, and Morales5 suggested the use of a modified Boari procedure in an experimental study before Kelami and his associates in which they succeeded in replacing the injured lower two thirds of the ureter in 8 mongrel dogs. However, they did not combine the Boari flap with the psoas-bladder hitch procedure. Presented at meeting of Southeastern lanta, Georgia, April, 1975.
UROLOGY
/
OCTOBER 1975 /
Section
of AUA, At-
VOLUME VI, NUMBER 4
We were not aware of Kelami’s experimental work and the technique used on his patient when we did our cases. Because of the complexity of the technique described by Kelami for creating a Boari flap, we are reporting a simpler technique used in 3 patients. Indications for Operation There are two groups of patients for whom this combined operation is indicated: patients with injury to the pelvic portion of the ureter with a defect which cannot be handled by using either procedure alone; and patients with injury or stenotic lesions involving the middle third of the ureter. Lesions of peluic portion of ureter An example is postoperative stenosis following end to end anastomosis of a ureter injured during radical retropubic prostatectomy with subsequent progressive hydronephrosis and hydroureter. A new neoureterocystostomy with antireflux procedure is obviously needed. However, since the visceral layer of the endopelvic fascia has been previously incised for removal of the specimen, and now replaced by dense scar tissue in both paravesical spaces, and since the bladder has been brought down retropubically toward the membranous urethra for anastomosis, the only
447
we call ureteritis plastica to distinguish it from periureteritis plastica. Vest and Barelare6 coined the term “periureteritis plastica” for a subdivision of retroperitoneal fibrosis. In this condition, the surgeon encounters a circular mass, similar to a diminutive garden hose, approximately 3 cm. in diameter which envelops mostly the middle third of the ureter and which, due to its fibrotic nature, causes ureteral stenosis. The hard periureteral tissue is grossly distinct from the uninvolved wall of the ureter. The authors borrow the name “periureteritis plastica” from linitis plastica of the stomach. This “garden hose” fibrosis, similar to the retroperitoneal fibrosis described by Ormend,“’ is readily incised, allowing the ureter to be shelled out. Once the ureter is out of its envelope, its lumen expands. Vest explains the pathogenesis of periureteritis plastica on an ascending periureteral lymphangitis. Other authors followed Vest and Barelare with descriptions of similar cases.g-12 FIGURE 1. Postoperative cystogram following combined approach to repair ureteral stenosis (Case 1); no ureteral rejlux.
possibility for mobilization of the bladder is by extraperitonealization. The latter maneuver, however, is insufficient to allow formation of a long enough sausage-like extension of the bladder to reach the psoas muscle above the iliac vessels. However, it does allow a lateral displacement of the posterolateral aspect of the bladder in the direction of the psoas muscle, and creation of a short Boari flap from its anterior wall. The flap not only reaches the anterior surface of the muscle, but also allows tunneling for the neoureterocystostomy. A low-pressure cystogram taken four weeks after the procedures described shows no signs of ureteral reflux (Fig. 1 and 6B). A case of accidental injury to one of the ureters during excision of two large bladder diverticuli may serve as another example in this group. In this case the mobilized bladder did not reach the psoas muscle and required the addition of a Boari flap (Fig. 2). Lesions
of middle
third
ofureter
The second group of patients for whom this combined approach is indicated are those with injury or stenosis of the middle third of the ureter. One of our 3 cases, described herein, illustrates this and also indicates a new urologic entity which
448
FIGURE 2. (A) Bladder with two large diver-tic& is already extraperitonealized. Injury to left ureter. Technique for shaping Boarijlap. (B) Both diverticuli are excised; Boari fEap reflected toward psoas muscle and tunnelized. (C) Boari&p converted into tube and hitched to psoas muscle; stent is visible and peritoneal cavity closed.
UROLOGY
I OCTOBER1975 / VOLUMEVI, NUMBER4
Our patient, a fifty-one-yearCase abstract. old black man, had a left ureter that was enveloped by a fibrous mass 1.5 cm. in thickness along its middle third. Once the fibrous envelope was excised and the stenotic ureter became visible, a ureterotomy was carried out just distal to the stenotic portion. Although a 6 F ureteral catheter could not be passed through the stenotic segment, a flexible silver probe of the same caliber could be negotiated through the 8-cm. long stenotic lumen. Yellow thick fibrotic tissue replaced the muscular layer of the ureter, especially anteriorly and on both lateral walls. There were no dense adhesions to the peritoneum or lumbar muscle. Histologic examination of the stenotic middle third of the ureter showed that the muscle fibers were replaced to a high degree by fibrotic tissue and infiltrated with lymphocytes. The foldings of the lumen of the ureter in some of the levels were gone and replaced by a small round lumen (Fig. 3). Examination of the slides gave in addition to the periureteritis some levels showing a chronic ureteritis with direct involvement of the wall of the ureter. The patient’s medical history did not reveal cystitis or prostatitis which could be blamed for possible ascending periureteral lymphangitis nor abuse of phenacetin or methysergide (Sansert). However, in another hospital, six months earlier the patient had had exploration of the right side for retroperitoneal fibrosis. Apparently a ureteral transposition into the peritoneal cavity had been
FIGURE3. Histologic section through middle third of left ureter, multiple levels. In addition to periureteritis some levels also show a chronic ureteritis with direct involvement of wall of ureter. This is not typical&ding in Ormond’s disease. (Masson stain, original magn$cation x 7). Most of the muscle fibers are replaced by f&rous tissue. Lymphocytic infiltration - some levels show lack of foldings of narrow ureter-al lumen.
carried out, in addition to a Davis intubated ureterotomy, although the latter was not certain. On the excretory urogram there was prompt excretion of contrast material on the right side, and slight changes in the course of the ureter suggesting transposition of the middle segment into the peritoneal cavity. The retrograde ureteropyelogram on the left side showed hydronephrosis, with hydroureter of the proximal third of the ureter, and stenosis of the entire middle third
FIGURE 4. (A) Ureteritis plastica causing stenosis along middle third of left ureter. Retrograde ureterop yelogram shows hydronephrosis and hydroureter; proximal third of ureter tapers off into middle third. (B) Cystogram with 200 ml. x-ray contrast substance and 20 ml. additional amount injected under pressure in a patient brought into Trendelenburg position shows mild ureteral refEux and visualizes the Boari flap converted into a tube. Cystogram taken four weeks postoperatively. Bladder capacity 200 ml.
UROLOGY
I
OCTOBER
1975 / VOLUME
VI, NUMBER 4
449
FIGURE 5. (A) Technique for extraperitonealization of bladder. Surgeon can incise peritoneum more easily if he injects saline solution. Zncision is extended toward lateral fossa on each side, namely up to proximal boundary of paravesical space; triangular patch of peritoneum remains adherent to bladder dome. (B) Extraperitonealization and mobilization in both paravesical spaces of bladder is completed without transecting right vascular pedicle of bladder. Triangular patch of peritoneum stays adherent to bladder dome (a). Any attempt to “shell out the patch” leads to injury of muscle layers of bladder wall. Posterior aspect of dome and patch above it is brought into approximation to psoas muscle; detached left rectus muscle is visible (b). (C) D e 1ineation of Boari flap on bladder using hooked knifefollowing distention of bladder with saline. Tagged sutures mark tip offlap situated close to lateral aspect of bladder neck. Oblique flap which is longer than 10 cm. has a base twice as wide as the 2.5cm. tip (arrow); detached rectus muscle is visible (a).
(Fig. 4A). The hydroureter of the proximal third tapered off in a cone-like fashion into the stenotic middle third. The renal scan gave evidence of a functioning left kidney. Postoperative cystogram showed an elongated Boari flap with mild reflux (Fig. 4B). The following is a description of the operative repair for defects involving the middle third of the ureter, but also applies for defects in the pelvic portion.
450
Surgical Technique Zncision A sandbag is placed under the thorax on the involved side to elevate the upper half of the patient’s body about 30 degrees from the table top. A large S-shaped incision is made. Its upper convex part runs along the twelfth rib whereas the distal convex part is extended suprapubically, as a Pfannensteil incision. The left rectus muscle
UROLOGY
/ OCTOBER1975 I VOLUMEVI, NUMBER4
FIGURE 6. (A) Stent in ureter is visible; note how it runs down into bladder and emergesfiom it through a stab incision. Neoureterocystostomy is completed; BoarifEap is also hitched to psoas muscle and is ready to be converted into tube (Case 3). (B) Tube hitched to psoas muscle; ureter-al stent brought out of bladder through stab incision in dome; peritoneal cavity closed. Triangular patch of peritoneum visible (Case 1, Fig. 1).
is detached from the pubic bone. The peritoneum is reflected medially through the proximal half of the “S” incision, the lower pole of the kidney is identified, and the tortuous, dilated proximal third of the ureter is dissected to the point where it tapers off into the middle ureteral third. The middle third of the ureter, with part of the pelvic segment, is then excised and the distal stump ligated. Mobilization
of the bladder,
Boari flap design
The bladder is extraperitonealized by injecting saline solution along a line running transversally about 4 cm. above the bottom of the rectovesical pouch and by cutting through the peritoneum adherent to the posterior wall of the bladder (Fig. 5A). This incision is extended into the so-called “peritoneal fossae” which represent the superior boundaries of the paravesical spaces. A triangular patch of the peritoneum is left adherent to the dome of the bladder, the posterior portion of which has already been mobilized. The connective tissue is transected in each paravesical space, and the vascular pedicles are exposed. By cutting through the visceral leaf of the endopelvic fascia further down along the lateral walls of the blad-
UROLOGY
/ OCTOBER1975
/ VOLUMEVI,
NUMBER4
der, one may easily achieve additional mobility of the organ (Fig. 5B). Then the bladder, distended with 200 ml. saline, having been mobilized and undermined toward the rectum and freed from its lateral attachments to the pelvic walls, is fixed to the psoas muscle with O-chromic catgut sutures. The triangular patch of peritoneum adherent to the bladder dome serves as a landmark to ascertain that the hitched portion of the organ is actually the posterior part of the bladder adjacent to the dome. By this maneuver, one bridges a distance of at least 5 cm. in a proximal direction along the course of the left ureter.l An oblique bladder flap is designed by partially cutting through the anterior bladder wall with a hooked knife (Fig. SC). The tip of the flap close to the bladder neck is made approximately 2.5 cm. wide, whereas the base of the flap is fashioned to be twice as wide. The latter occupies the area of attachment of the bladder to the psoas muscle, and incorporated proximal to it is the triangular adherent patch of peritoneum (not illustrated in the sketch). The total length of the flap is usually slightly longer than 10 cm. The flap is reflected toward the stump of the ureter and the lower pole of the kidney. The mild retraction of the flap when the bladder is no longer distended can be
corrected easily by grasping the end of the Boari flap with two Allis clamps and stretching it. Tunneling offlap and ureterocystostomy (Fig. 6) The mucosa of the flap is tunneled by the usual technique, securing a tunnel at least 2.5 cm. in length. The most terminal 2 cm. of the flap is not incorporated into the tunnel to facilitate the creation of a waterproof tube and to make possible hitching of the tube to the psoas muscle. The end of the ureteral stump is tagged with a suture; and while the assistant keeps the end of the flap elevated, the tip of a tonsil clamp is passed through the muscular wall of the flap to grasp the suture. Once the ureter is brought through the tunnel, its end is spatulated and sutured with 3-O chromic catgut sutures to the slit previously made in the mucosa for initiating the submucosal tunnel. An exact coaptation with interrupted sutures is mandatory. A Silastic, 6 F tube or an 8 F Robinson catheter is inserted to drain the pelvis of the kidney through the reimplanted ureter, and its free end is brought out from the bladder in its right lateral aspect. The bladder wall is sutured in two layers. Distention through the Foley urethral catheter with saline will demonstrate if closure of the bladder and the Boari flap are watertight. A few interrupted chromic catgut sutures are applied to reinforce the hitching of the Boari flap to the psoas muscle. Comments There are two groups of patients with ureteral defects who can benefit from a combined psoasbladder hitch and Boari flap operation. The first group includes cases in which as a consequence of scarring and diminished bladder capacity the ureteral gap cannot be bridged by one of the operations alone; the second group includes stenosis or injury to the middle third of the ureter. The fixation of the bladder and flap appears extremely important for two reasons: (1) the flap with the reimplanted ureter can be immobilized and thus mimic physiologically the trigone of the bladder; and (2) kinking of the extravesical part of the reimplanted ureter can be avoided when the bladder becomes distended with urine.
452
Addendum Since submission of this article we have operated on a fourth patient using the combined technique described herein. A length of 15 cm. of the right ureter was resected for a pedunculated, 3-cm. long, grade 1 papilloma-type tumor located in the ureterovesical junction of the ureter. The pathologist reported only a small pedicle, without invasion of the ureteral wall. Department of Urology Veterans Administration Hospital Asheville, North Carolina 28805 ACKNOWLEDGMENT. To Ariadna I. Kivirand, M.D., Clinical Laboratory Service, V. A. Hospital, Asheville, for assistance in interpretation of surgical pathology; Charles Davis, M.D., Department of Genitourinary Pathology, Armed Forces Institute of Pathology, Washington; and Lee J. Burkhard, Medical Illustration Service, V. A. Hospital, Asheville, for prints and photographs.
References Psoas-bladder hitch procedure: our experience with injury to the ureter in adult males, J. Urol. 3: 772 (1975). 2. KELAMI, A., etal. : Autoplastische Ureterersatz, Verh. Dtsch. Ges. Ural. 24: 209 (1973). 3. KELAMI, A., et al. : Replacement of the ureter using the urinary bladder, Urol. Res. 1: 161 (1973). 1. KISHEV, S :
of the ureter using the uri4. KELAMI, A. : Replacement nary bladder. Motion picture presented at the Annual
Meeting of AUA, Saint Louis, May, 1974. 5. GOLIMBU, M., BLOCK, N., and MORALES, P.: Ureterovesical flap operation for middle and upper ureteral repair, Invest. Ural. 10: 313 (1973). plastica: a 6. VEST, S., and BARELARE, B. : Peri-ureteritis report of four cases, J. Ural. 70: 38 (1953). 7. ORMOND, J. K.: Bilateral ureteral obstruction due to envelopment and compression by inflammatory retroperitoneal process, ibid. 59: 1072 (1948). 8. IDEM: Idiopathic retroperitoneal fibrosis, J.A.M.A. 174: 1561 (1960). 9. HEJTMANCIK, J., and MAGID, M.: Bilateral periureteritis plastica, J, Ural. 76: 57 (1965). plastica, Br. J. Ural. 29: 10. HOUSTON, W. : Peri-ureteritis 38 (1957). Idiopathic retroperitoneal fibrosis involv11. RAPER, F.: ing the ureters, ibid. 28: 436 (1956). 12. MCDONALD, S., and DEDOMINICO, I.: Periureteral fibrosis, Canad. J. Surg. 1: 162 (1958).
UROLOGY
/
OCTOBER 1975 /
VOLUME VI, NUMBER 4
FOR COMBINED
HITCH PROCEDURE STEPHEN
VASILEV
PSOAS-BLADDER
WITH BOAR1 VESICAL FLAP
KISHEV,
M.D.
From the Section of Urologic Surgery, Surgical Service, Veterans Administration Hospital, Asheville, North Carolina
ABSTRACT - The combination of two operative methods ordinarily usedfor correction of injury to the pelvic portion of the ureter, the psoas-bladder hitch procedure and the Boari uesicalflap, allows repair of injuries of the middle third of the ureter. The proximal third of the ureter becomes easily accessible for reimplantation in the tunneled Boari flap, provided the mobilized and extraperitonealized bladder is fashioned into a sausage-like extension toward the psoas muscle. Possibilities fx- a longer Boari flap exist provided the bladder is of normal capacity and one adheres strictly to the recommended technique for fashioning a bladder flap, using a long oblique segment of the anterior bladder wall.
We recently described our experience with repair of the injured pelvic portion of the ureter by using the psoas-bladder hitch procedure with tunneling of the hitched bladder portion. 1 We were able to replace ureteral defects up to 5 cm. in length in 8 patients, in most of whom the neoureterocystostomy did not show evidence ofureteral reflux. We have subsequently combined the psoas-bladder hitch procedure with a Boari flap to replace a longer segment of ureter. Historical Notes Kelami and associates2-4 were the first to conceive a combined approach for repair of injuries to the ureter located at a greater distance from the bladder. After experiments on dogs, in a few of which signs of impairment of the blood supply in the Boari flap developed, they succeeded in repairing the stenotic distal two thirds of one ureter in a patient with stricture due to tuberculosis.2-4 Golimbu, Block, and Morales5 suggested the use of a modified Boari procedure in an experimental study before Kelami and his associates in which they succeeded in replacing the injured lower two thirds of the ureter in 8 mongrel dogs. However, they did not combine the Boari flap with the psoas-bladder hitch procedure. Presented at meeting of Southeastern lanta, Georgia, April, 1975.
UROLOGY
/
OCTOBER 1975 /
Section
of AUA, At-
VOLUME VI, NUMBER 4
We were not aware of Kelami’s experimental work and the technique used on his patient when we did our cases. Because of the complexity of the technique described by Kelami for creating a Boari flap, we are reporting a simpler technique used in 3 patients. Indications for Operation There are two groups of patients for whom this combined operation is indicated: patients with injury to the pelvic portion of the ureter with a defect which cannot be handled by using either procedure alone; and patients with injury or stenotic lesions involving the middle third of the ureter. Lesions of peluic portion of ureter An example is postoperative stenosis following end to end anastomosis of a ureter injured during radical retropubic prostatectomy with subsequent progressive hydronephrosis and hydroureter. A new neoureterocystostomy with antireflux procedure is obviously needed. However, since the visceral layer of the endopelvic fascia has been previously incised for removal of the specimen, and now replaced by dense scar tissue in both paravesical spaces, and since the bladder has been brought down retropubically toward the membranous urethra for anastomosis, the only
447
we call ureteritis plastica to distinguish it from periureteritis plastica. Vest and Barelare6 coined the term “periureteritis plastica” for a subdivision of retroperitoneal fibrosis. In this condition, the surgeon encounters a circular mass, similar to a diminutive garden hose, approximately 3 cm. in diameter which envelops mostly the middle third of the ureter and which, due to its fibrotic nature, causes ureteral stenosis. The hard periureteral tissue is grossly distinct from the uninvolved wall of the ureter. The authors borrow the name “periureteritis plastica” from linitis plastica of the stomach. This “garden hose” fibrosis, similar to the retroperitoneal fibrosis described by Ormend,“’ is readily incised, allowing the ureter to be shelled out. Once the ureter is out of its envelope, its lumen expands. Vest explains the pathogenesis of periureteritis plastica on an ascending periureteral lymphangitis. Other authors followed Vest and Barelare with descriptions of similar cases.g-12 FIGURE 1. Postoperative cystogram following combined approach to repair ureteral stenosis (Case 1); no ureteral rejlux.
possibility for mobilization of the bladder is by extraperitonealization. The latter maneuver, however, is insufficient to allow formation of a long enough sausage-like extension of the bladder to reach the psoas muscle above the iliac vessels. However, it does allow a lateral displacement of the posterolateral aspect of the bladder in the direction of the psoas muscle, and creation of a short Boari flap from its anterior wall. The flap not only reaches the anterior surface of the muscle, but also allows tunneling for the neoureterocystostomy. A low-pressure cystogram taken four weeks after the procedures described shows no signs of ureteral reflux (Fig. 1 and 6B). A case of accidental injury to one of the ureters during excision of two large bladder diverticuli may serve as another example in this group. In this case the mobilized bladder did not reach the psoas muscle and required the addition of a Boari flap (Fig. 2). Lesions
of middle
third
ofureter
The second group of patients for whom this combined approach is indicated are those with injury or stenosis of the middle third of the ureter. One of our 3 cases, described herein, illustrates this and also indicates a new urologic entity which
448
FIGURE 2. (A) Bladder with two large diver-tic& is already extraperitonealized. Injury to left ureter. Technique for shaping Boarijlap. (B) Both diverticuli are excised; Boari fEap reflected toward psoas muscle and tunnelized. (C) Boari&p converted into tube and hitched to psoas muscle; stent is visible and peritoneal cavity closed.
UROLOGY
I OCTOBER1975 / VOLUMEVI, NUMBER4
Our patient, a fifty-one-yearCase abstract. old black man, had a left ureter that was enveloped by a fibrous mass 1.5 cm. in thickness along its middle third. Once the fibrous envelope was excised and the stenotic ureter became visible, a ureterotomy was carried out just distal to the stenotic portion. Although a 6 F ureteral catheter could not be passed through the stenotic segment, a flexible silver probe of the same caliber could be negotiated through the 8-cm. long stenotic lumen. Yellow thick fibrotic tissue replaced the muscular layer of the ureter, especially anteriorly and on both lateral walls. There were no dense adhesions to the peritoneum or lumbar muscle. Histologic examination of the stenotic middle third of the ureter showed that the muscle fibers were replaced to a high degree by fibrotic tissue and infiltrated with lymphocytes. The foldings of the lumen of the ureter in some of the levels were gone and replaced by a small round lumen (Fig. 3). Examination of the slides gave in addition to the periureteritis some levels showing a chronic ureteritis with direct involvement of the wall of the ureter. The patient’s medical history did not reveal cystitis or prostatitis which could be blamed for possible ascending periureteral lymphangitis nor abuse of phenacetin or methysergide (Sansert). However, in another hospital, six months earlier the patient had had exploration of the right side for retroperitoneal fibrosis. Apparently a ureteral transposition into the peritoneal cavity had been
FIGURE3. Histologic section through middle third of left ureter, multiple levels. In addition to periureteritis some levels also show a chronic ureteritis with direct involvement of wall of ureter. This is not typical&ding in Ormond’s disease. (Masson stain, original magn$cation x 7). Most of the muscle fibers are replaced by f&rous tissue. Lymphocytic infiltration - some levels show lack of foldings of narrow ureter-al lumen.
carried out, in addition to a Davis intubated ureterotomy, although the latter was not certain. On the excretory urogram there was prompt excretion of contrast material on the right side, and slight changes in the course of the ureter suggesting transposition of the middle segment into the peritoneal cavity. The retrograde ureteropyelogram on the left side showed hydronephrosis, with hydroureter of the proximal third of the ureter, and stenosis of the entire middle third
FIGURE 4. (A) Ureteritis plastica causing stenosis along middle third of left ureter. Retrograde ureterop yelogram shows hydronephrosis and hydroureter; proximal third of ureter tapers off into middle third. (B) Cystogram with 200 ml. x-ray contrast substance and 20 ml. additional amount injected under pressure in a patient brought into Trendelenburg position shows mild ureteral refEux and visualizes the Boari flap converted into a tube. Cystogram taken four weeks postoperatively. Bladder capacity 200 ml.
UROLOGY
I
OCTOBER
1975 / VOLUME
VI, NUMBER 4
449
FIGURE 5. (A) Technique for extraperitonealization of bladder. Surgeon can incise peritoneum more easily if he injects saline solution. Zncision is extended toward lateral fossa on each side, namely up to proximal boundary of paravesical space; triangular patch of peritoneum remains adherent to bladder dome. (B) Extraperitonealization and mobilization in both paravesical spaces of bladder is completed without transecting right vascular pedicle of bladder. Triangular patch of peritoneum stays adherent to bladder dome (a). Any attempt to “shell out the patch” leads to injury of muscle layers of bladder wall. Posterior aspect of dome and patch above it is brought into approximation to psoas muscle; detached left rectus muscle is visible (b). (C) D e 1ineation of Boari flap on bladder using hooked knifefollowing distention of bladder with saline. Tagged sutures mark tip offlap situated close to lateral aspect of bladder neck. Oblique flap which is longer than 10 cm. has a base twice as wide as the 2.5cm. tip (arrow); detached rectus muscle is visible (a).
(Fig. 4A). The hydroureter of the proximal third tapered off in a cone-like fashion into the stenotic middle third. The renal scan gave evidence of a functioning left kidney. Postoperative cystogram showed an elongated Boari flap with mild reflux (Fig. 4B). The following is a description of the operative repair for defects involving the middle third of the ureter, but also applies for defects in the pelvic portion.
450
Surgical Technique Zncision A sandbag is placed under the thorax on the involved side to elevate the upper half of the patient’s body about 30 degrees from the table top. A large S-shaped incision is made. Its upper convex part runs along the twelfth rib whereas the distal convex part is extended suprapubically, as a Pfannensteil incision. The left rectus muscle
UROLOGY
/ OCTOBER1975 I VOLUMEVI, NUMBER4
FIGURE 6. (A) Stent in ureter is visible; note how it runs down into bladder and emergesfiom it through a stab incision. Neoureterocystostomy is completed; BoarifEap is also hitched to psoas muscle and is ready to be converted into tube (Case 3). (B) Tube hitched to psoas muscle; ureter-al stent brought out of bladder through stab incision in dome; peritoneal cavity closed. Triangular patch of peritoneum visible (Case 1, Fig. 1).
is detached from the pubic bone. The peritoneum is reflected medially through the proximal half of the “S” incision, the lower pole of the kidney is identified, and the tortuous, dilated proximal third of the ureter is dissected to the point where it tapers off into the middle ureteral third. The middle third of the ureter, with part of the pelvic segment, is then excised and the distal stump ligated. Mobilization
of the bladder,
Boari flap design
The bladder is extraperitonealized by injecting saline solution along a line running transversally about 4 cm. above the bottom of the rectovesical pouch and by cutting through the peritoneum adherent to the posterior wall of the bladder (Fig. 5A). This incision is extended into the so-called “peritoneal fossae” which represent the superior boundaries of the paravesical spaces. A triangular patch of the peritoneum is left adherent to the dome of the bladder, the posterior portion of which has already been mobilized. The connective tissue is transected in each paravesical space, and the vascular pedicles are exposed. By cutting through the visceral leaf of the endopelvic fascia further down along the lateral walls of the blad-
UROLOGY
/ OCTOBER1975
/ VOLUMEVI,
NUMBER4
der, one may easily achieve additional mobility of the organ (Fig. 5B). Then the bladder, distended with 200 ml. saline, having been mobilized and undermined toward the rectum and freed from its lateral attachments to the pelvic walls, is fixed to the psoas muscle with O-chromic catgut sutures. The triangular patch of peritoneum adherent to the bladder dome serves as a landmark to ascertain that the hitched portion of the organ is actually the posterior part of the bladder adjacent to the dome. By this maneuver, one bridges a distance of at least 5 cm. in a proximal direction along the course of the left ureter.l An oblique bladder flap is designed by partially cutting through the anterior bladder wall with a hooked knife (Fig. SC). The tip of the flap close to the bladder neck is made approximately 2.5 cm. wide, whereas the base of the flap is fashioned to be twice as wide. The latter occupies the area of attachment of the bladder to the psoas muscle, and incorporated proximal to it is the triangular adherent patch of peritoneum (not illustrated in the sketch). The total length of the flap is usually slightly longer than 10 cm. The flap is reflected toward the stump of the ureter and the lower pole of the kidney. The mild retraction of the flap when the bladder is no longer distended can be
corrected easily by grasping the end of the Boari flap with two Allis clamps and stretching it. Tunneling offlap and ureterocystostomy (Fig. 6) The mucosa of the flap is tunneled by the usual technique, securing a tunnel at least 2.5 cm. in length. The most terminal 2 cm. of the flap is not incorporated into the tunnel to facilitate the creation of a waterproof tube and to make possible hitching of the tube to the psoas muscle. The end of the ureteral stump is tagged with a suture; and while the assistant keeps the end of the flap elevated, the tip of a tonsil clamp is passed through the muscular wall of the flap to grasp the suture. Once the ureter is brought through the tunnel, its end is spatulated and sutured with 3-O chromic catgut sutures to the slit previously made in the mucosa for initiating the submucosal tunnel. An exact coaptation with interrupted sutures is mandatory. A Silastic, 6 F tube or an 8 F Robinson catheter is inserted to drain the pelvis of the kidney through the reimplanted ureter, and its free end is brought out from the bladder in its right lateral aspect. The bladder wall is sutured in two layers. Distention through the Foley urethral catheter with saline will demonstrate if closure of the bladder and the Boari flap are watertight. A few interrupted chromic catgut sutures are applied to reinforce the hitching of the Boari flap to the psoas muscle. Comments There are two groups of patients with ureteral defects who can benefit from a combined psoasbladder hitch and Boari flap operation. The first group includes cases in which as a consequence of scarring and diminished bladder capacity the ureteral gap cannot be bridged by one of the operations alone; the second group includes stenosis or injury to the middle third of the ureter. The fixation of the bladder and flap appears extremely important for two reasons: (1) the flap with the reimplanted ureter can be immobilized and thus mimic physiologically the trigone of the bladder; and (2) kinking of the extravesical part of the reimplanted ureter can be avoided when the bladder becomes distended with urine.
452
Addendum Since submission of this article we have operated on a fourth patient using the combined technique described herein. A length of 15 cm. of the right ureter was resected for a pedunculated, 3-cm. long, grade 1 papilloma-type tumor located in the ureterovesical junction of the ureter. The pathologist reported only a small pedicle, without invasion of the ureteral wall. Department of Urology Veterans Administration Hospital Asheville, North Carolina 28805 ACKNOWLEDGMENT. To Ariadna I. Kivirand, M.D., Clinical Laboratory Service, V. A. Hospital, Asheville, for assistance in interpretation of surgical pathology; Charles Davis, M.D., Department of Genitourinary Pathology, Armed Forces Institute of Pathology, Washington; and Lee J. Burkhard, Medical Illustration Service, V. A. Hospital, Asheville, for prints and photographs.
References Psoas-bladder hitch procedure: our experience with injury to the ureter in adult males, J. Urol. 3: 772 (1975). 2. KELAMI, A., etal. : Autoplastische Ureterersatz, Verh. Dtsch. Ges. Ural. 24: 209 (1973). 3. KELAMI, A., et al. : Replacement of the ureter using the urinary bladder, Urol. Res. 1: 161 (1973). 1. KISHEV, S :
of the ureter using the uri4. KELAMI, A. : Replacement nary bladder. Motion picture presented at the Annual
Meeting of AUA, Saint Louis, May, 1974. 5. GOLIMBU, M., BLOCK, N., and MORALES, P.: Ureterovesical flap operation for middle and upper ureteral repair, Invest. Ural. 10: 313 (1973). plastica: a 6. VEST, S., and BARELARE, B. : Peri-ureteritis report of four cases, J. Ural. 70: 38 (1953). 7. ORMOND, J. K.: Bilateral ureteral obstruction due to envelopment and compression by inflammatory retroperitoneal process, ibid. 59: 1072 (1948). 8. IDEM: Idiopathic retroperitoneal fibrosis, J.A.M.A. 174: 1561 (1960). 9. HEJTMANCIK, J., and MAGID, M.: Bilateral periureteritis plastica, J, Ural. 76: 57 (1965). plastica, Br. J. Ural. 29: 10. HOUSTON, W. : Peri-ureteritis 38 (1957). Idiopathic retroperitoneal fibrosis involv11. RAPER, F.: ing the ureters, ibid. 28: 436 (1956). 12. MCDONALD, S., and DEDOMINICO, I.: Periureteral fibrosis, Canad. J. Surg. 1: 162 (1958).
UROLOGY
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OCTOBER 1975 /
VOLUME VI, NUMBER 4
