USE OF BOARI FLAP IN LOWER URETERAL INJURIES HARVEY
KONIGSBERG,
KENNETH
J, BLUNT,
EDWARD
C. MUECKE,
M.D. M.D. M.D.
From the James Buchanan Brady Foundation, Department of Urology, The New York Hospital, Cornell Medical Center, New York, New York
- We review our experience with the Boari flap to correct distal ureteral injuries. Satisfactory results were obtained in 15 of 21 patients. We believe this procedure should be considered as an alternative to transureteroureterostomy, autotransplantation, and ileal interposition fur short or long distal ureteral defects.
ABSTRACT
In 1894 Boari’ reported the creation of a full thickness bladder flap which was turned up two inches across the pelvic brim and anastomosed to a shortened distal ureter in a dog. Four years later the dog was reported to be healthy. Additional isolated experiments using Boari’s technique were reported,2y3 but the first description in the American literature was that of Ockerblad in 19474 when he presented a case with a ten-year follow-up. By 1969, a total of 138 cases were reported,4-17 mostly in Europe where the Boari flap had an earlier acceptance than in this country. There have been many variations on the original technique. 18-21In the post-Paquinz2 era many surgeons used an antireflux tunnel and cuff
TABLE 1.
implantation of the ureter into the flap, whereas the end to end anastomosis was preferred by others since it gives greater length. Splinting the ureter is preferred by some whereas others23 rely on slash ureterostomy above the anastomosis. The tunnel technique reduces the incidence of reflux, but the ultimate success of the flap is related to type of anastomosis as wel1 as other factors. Bladder trabeculation, complete emptying of bladder, vesical and ureteral blood supply, and ureteral dilatation al1 contribute to the success or failure of the flap. With large bladders, a flap can be raised to replace the lower one half or even two thirds of the ureter. Ivancevic, Hohenfellner, and Wulff4 have recently reported that total replacement of
Postoperativeresults in 23 patients with Boari jlups
Result
Number of Cases
Excellent
9
Greatly reduced or
Fair
6
remained normal Reduced in 5
At high pressure 4*
Poor
8
Increased
2
Hydroureteronephrosis
in 6
Number of Patients Fistula Infection
Reflux
Symptoms
None
None
None
None
2
None in 5
Frequent or constant in al1
Al1 8
in 1
31
*End to end anastomosis in one patient. ) Previously irradiated for gynecologic cancer.
UROLOGY
/
JUNE 1975 /
VOLUME V, NUMBER 6
751
FIGURE 1. Surgical technique: (A) Boari bladderflap (bold lines) extends posteriorly to anteriorly over dome of bludder. (9) Ure ter implanted submucosally with “French cuff’ method of Paquin. 22 (C) Ureter left intubated and bladder temporarily drained via cystostomy tube. Note attachment of BoarifEap to psoas fascia to prevent postoperative coktractu~e of flap. _
a dog’s ureters by making a double flap in a two-stage procedure. We have used the Boari flap technique 23 times in 21 patients (Fig. 1). One patient had bilateral flaps, and another had a second flap on the same side after stricture developed in the first. He subsequently underwent a ureteral meatotomy and ultimately was classified as a “fair” result. There were 15 females and 6 males ranging in age from nine months to sixty-two years. Causes of their ureteral injuries and subsequent shortening were bladder or ureteral tumor (2), ureterolithiasis (3), hysterectomy and/or radiation (7), ureterocelectomy (l), and post-reimplant surgery (10). Ureterovesical anastomosis was made by a Paquin-type techniquez2 in al1 cases except two in which an end to end technique was used. Patients were followed for between one month and eleven years with an average follow-up of twenty-seven months. Twelve patients were followed for at least one year (Table 1). Case Abstracts Case 1 A stricture developed after left ureterolithotomy in a forty-year-old female. After a lei? nephrostomy, a nephroureterogram showed complete distal ureteral obstruction. A Boari tube was constructed. The patient has been followed postoperatively for one and one-half years and has an excellent clinical result (Fig. 2).
752
Case
2
A right hydronephrosis developed after hysterectomy and right oophorectomy in a forty-one-year-old female. She had a right nephrostomy and ureteral reimplantation. After several episodes of pyelonephritis, the distal ureter was found to be strictured. A Boari procedure was performed. The patient has had reflux in the right upper collecting system, but over three and one-half years’ follow-up, she has had infrequent urinary tract infections only and no symptoms. The result is considered to be “fair” (Fig. 3). Case 3 A thirty-six-year-old female was evaluated elsewhere for recurrent cystitis and bilateral megaloureter. She underwent bilateral ureteral reimplants. Postoperatively massive bilateral reflux and hydronephrosis developed. Exploration of the right side revealed inadequate length of healthy ureter, and a Boari flap was made. Six months later a Boari flap was made on the left side. Eight months after the second she is free of infection operative procedure, with greatly improved upper tracts. An excellent result was obtained (Fig. 4). Comment Of the 8 patients with poor results, 3 previously had undergone irradiation to the pelvis. Another patient had carcinoma of the
UROLOGY
/ JUNE1975 / VOLUMEV,
NUMBERG
Case 1. (A) Preoperative excretorft urograms . FIGIJI E 2. litho,tc my. (B) Boari flap (arrows) raised to bridge uretero opera ive showing promptly functioning, unohvtructed upp
:r~g stricture in distal left ureter after uretero,I! discontinuity; one and one-half yec rs post-irlttr-y tracts.
FIGURE 3. Case 2. (A) Preoperative excr-etory urograms showing distal right ureter replaced with Boarijlap. (B) Three and one-half years postoperative .showing marketl iljlprovement in right upper urinary tract; intermittent infections and rejlur classify this as “fair” result.
UROLOC,Y
/
JUNE 1975
/
\‘OLUME
V, NUMRER
6
753
bladder which recurred in the flap. In 2 patients the flap was not pexed to the psoas muscle, a technique which, we believe, tends to prevent tension on the anastomosis. Two of our failures resulted from complete early stricturing of the flap itself and probably were caused by too vigorous mobilization of tissues or too narrow flaps. Reflux commonly occurred in patients with fair and poor results but rarely in those with good results. Over-all, acceptable results were obtained in two thirds of the surgical procedures.
Boari’s ureterocystoplasty was the first attempt to bridge inadequate distal ureteral length. We believe it stil1 deserves consideration as an alternative to more recent and complicated procedures, such as transureteroureterostomy, autotransplant, or ureteral replacement by Teflon or an isolated loop of bowel. The “psoas hitch” and the “tunnel and CUE” ureterovesical anastomosis are techniques which enhance surgical results. Factors associated with poor results are prior irradiation to the pelvis,
FIGURE 4. Case 3. and (B) Pre- and 19ostoperative excretory urograms and cystogl *ams showing bilateral reflux after reimplantation. (C) Postoperative jìlms show no rejlux.
754
UROLOGY
/ JUNE 1975 / VOLUME
V, NUMBER 6
thick-walled bladders, dilated ureters, and multiple previous ureterovesical procedures. 525 East 68th Street New York, New York 10021 (DR. MUECKE) References 1. BOARI,A.:
Chirurgia del1 uretere, con prefazience de Dott: 1. Albarran, 1,900 Contribute sperementale alla plastics delle uretere, Atti. Accad. Med. Ferrara, 14:
444 (1894). 2. DEMEL, R.: Ersatz des Ureters durch eine Plastik aus der Hanblase, Zentralbl. Chir. 51: 2008(1924). 3. SPIES,J. W., JOHNSON, C. E., and WELSON, C. S.:
Reconstruction of ureter by means of bladder Proc. Sec. Exp. Biol. Med. 30: 425 (1933).
flaps,
4. OCKERBLAD, N.: 5.
6. 7.
8.
9.
10.
Reimplantation of the ureter into the bladder by a flap method, J. Urol. 57: 845 (1947). BAIDIN, A. : Die Demel’sche Harnleiterautoplastik mit Hilfe der Harnblase beim Menschen, Zentralbl. Gynaekol. 54: 3237 (1930). Ureterersatz aus der Harnblase, RHODE, C.: Zentralbl. Chir. 64: 409 (1937). FLOCKS, R.: Ureterovesical anastomosis when the proximal portion of the ureter is short. Can. Med. Assoc. J. 55: 574 (1946). HENDERSON, D., and ST. CLAIR, L.: Boari’s operation: reimplantation of the ureter in the bladder utilizing a bladder flap, Urol. Cutan. Rev. 55: 80 (1951). KUSS, R.: Plastic ureterale par Lambeau vesical tubule (operation de Boari), a propos de 10 cas., Mem. Acad. Chir. Paris 79: 159 (1953). of lower ureters by a tube BURNS, R. : Reconstruction made from bladder flaps, J. Urol. 74: 348 (1955).
UROLOGY
/
JUNE 1975 !
VOLUME V, NUMBER 6
11. CONGER, K., and
ROUSE, P.: Ureteroplasty by bladder flap technique: report of two cases, ibid. 74: 485 (1955). 12. DILLON, J.: IJse of bladder pedicles as substitute for lower ureter, ibid. 83: 583 (1960). 13. KIMCHI, D., and WIESENFELD, A.: Injuries to the lower third of the ureter treated by bladder flapplasty, ibid. 89: 800 (1963). 14. FIRSTATER, M.: Boari’s operation for the treatment of megaureter, ibid. 93: 569 (1965). 15. CUKIER, J.: Description of 63 bladder flap operations, Acts. Urol. Belg. 34: 15 (1966). 16. WILLIAMS, J., and PORTER, R.: The Boari bladder flap in lower ureteric injuries, Br. J. Urol. 38: 528 (1966). 17. GOW, J.:
The results of the reimplantation of the ureter by the Boari technique, Proc. R. Sec. Med.
61: 128 (1968). 18. VICK, N. F., UHLMON, R. C.: Open bladder flap ureterovesicocystostomy, J. Urol. 105: 209 (1971). 19. PEARSON, B. S.: Experiences with the Boari flap, Br. J. Urol. 42: 740 (1970). 20. GOLIMBU, M., BLOCK, N., and MORALES, P.: Ureterovesical flap operation for middle and upper ureteral repair, Invest. Urol. 10: 313 (1973). 21. JONES,A. E., TAYLOR,R. R., and WOODHEAD, D. M.: Bladder flap incorporating the intact ureterovesical junction, J. Urol. 109: 55 (1973). 22. PAQUIN, A. J.: Ureterovesical anastomosis: the ibid. 82: description and evaluation of a technique, 573 (1959). 23. FIRSTATER, M.: Unintubated Boari’s ureterocystoplasty, ibid. 93: 567 (1965). 24. IVANCEVIC, L. D., HOHENFELLNER, R., and WULFF, H. D.: Total replacement of the ureter using a bladder flap and cinematographic studies on the newly constructed ureter, ibid. 107: 576 (1972).
755
KONIGSBERG,
KENNETH
J, BLUNT,
EDWARD
C. MUECKE,
M.D. M.D. M.D.
From the James Buchanan Brady Foundation, Department of Urology, The New York Hospital, Cornell Medical Center, New York, New York
- We review our experience with the Boari flap to correct distal ureteral injuries. Satisfactory results were obtained in 15 of 21 patients. We believe this procedure should be considered as an alternative to transureteroureterostomy, autotransplantation, and ileal interposition fur short or long distal ureteral defects.
ABSTRACT
In 1894 Boari’ reported the creation of a full thickness bladder flap which was turned up two inches across the pelvic brim and anastomosed to a shortened distal ureter in a dog. Four years later the dog was reported to be healthy. Additional isolated experiments using Boari’s technique were reported,2y3 but the first description in the American literature was that of Ockerblad in 19474 when he presented a case with a ten-year follow-up. By 1969, a total of 138 cases were reported,4-17 mostly in Europe where the Boari flap had an earlier acceptance than in this country. There have been many variations on the original technique. 18-21In the post-Paquinz2 era many surgeons used an antireflux tunnel and cuff
TABLE 1.
implantation of the ureter into the flap, whereas the end to end anastomosis was preferred by others since it gives greater length. Splinting the ureter is preferred by some whereas others23 rely on slash ureterostomy above the anastomosis. The tunnel technique reduces the incidence of reflux, but the ultimate success of the flap is related to type of anastomosis as wel1 as other factors. Bladder trabeculation, complete emptying of bladder, vesical and ureteral blood supply, and ureteral dilatation al1 contribute to the success or failure of the flap. With large bladders, a flap can be raised to replace the lower one half or even two thirds of the ureter. Ivancevic, Hohenfellner, and Wulff4 have recently reported that total replacement of
Postoperativeresults in 23 patients with Boari jlups
Result
Number of Cases
Excellent
9
Greatly reduced or
Fair
6
remained normal Reduced in 5
At high pressure 4*
Poor
8
Increased
2
Hydroureteronephrosis
in 6
Number of Patients Fistula Infection
Reflux
Symptoms
None
None
None
None
2
None in 5
Frequent or constant in al1
Al1 8
in 1
31
*End to end anastomosis in one patient. ) Previously irradiated for gynecologic cancer.
UROLOGY
/
JUNE 1975 /
VOLUME V, NUMBER 6
751
FIGURE 1. Surgical technique: (A) Boari bladderflap (bold lines) extends posteriorly to anteriorly over dome of bludder. (9) Ure ter implanted submucosally with “French cuff’ method of Paquin. 22 (C) Ureter left intubated and bladder temporarily drained via cystostomy tube. Note attachment of BoarifEap to psoas fascia to prevent postoperative coktractu~e of flap. _
a dog’s ureters by making a double flap in a two-stage procedure. We have used the Boari flap technique 23 times in 21 patients (Fig. 1). One patient had bilateral flaps, and another had a second flap on the same side after stricture developed in the first. He subsequently underwent a ureteral meatotomy and ultimately was classified as a “fair” result. There were 15 females and 6 males ranging in age from nine months to sixty-two years. Causes of their ureteral injuries and subsequent shortening were bladder or ureteral tumor (2), ureterolithiasis (3), hysterectomy and/or radiation (7), ureterocelectomy (l), and post-reimplant surgery (10). Ureterovesical anastomosis was made by a Paquin-type techniquez2 in al1 cases except two in which an end to end technique was used. Patients were followed for between one month and eleven years with an average follow-up of twenty-seven months. Twelve patients were followed for at least one year (Table 1). Case Abstracts Case 1 A stricture developed after left ureterolithotomy in a forty-year-old female. After a lei? nephrostomy, a nephroureterogram showed complete distal ureteral obstruction. A Boari tube was constructed. The patient has been followed postoperatively for one and one-half years and has an excellent clinical result (Fig. 2).
752
Case
2
A right hydronephrosis developed after hysterectomy and right oophorectomy in a forty-one-year-old female. She had a right nephrostomy and ureteral reimplantation. After several episodes of pyelonephritis, the distal ureter was found to be strictured. A Boari procedure was performed. The patient has had reflux in the right upper collecting system, but over three and one-half years’ follow-up, she has had infrequent urinary tract infections only and no symptoms. The result is considered to be “fair” (Fig. 3). Case 3 A thirty-six-year-old female was evaluated elsewhere for recurrent cystitis and bilateral megaloureter. She underwent bilateral ureteral reimplants. Postoperatively massive bilateral reflux and hydronephrosis developed. Exploration of the right side revealed inadequate length of healthy ureter, and a Boari flap was made. Six months later a Boari flap was made on the left side. Eight months after the second she is free of infection operative procedure, with greatly improved upper tracts. An excellent result was obtained (Fig. 4). Comment Of the 8 patients with poor results, 3 previously had undergone irradiation to the pelvis. Another patient had carcinoma of the
UROLOGY
/ JUNE1975 / VOLUMEV,
NUMBERG
Case 1. (A) Preoperative excretorft urograms . FIGIJI E 2. litho,tc my. (B) Boari flap (arrows) raised to bridge uretero opera ive showing promptly functioning, unohvtructed upp
:r~g stricture in distal left ureter after uretero,I! discontinuity; one and one-half yec rs post-irlttr-y tracts.
FIGURE 3. Case 2. (A) Preoperative excr-etory urograms showing distal right ureter replaced with Boarijlap. (B) Three and one-half years postoperative .showing marketl iljlprovement in right upper urinary tract; intermittent infections and rejlur classify this as “fair” result.
UROLOC,Y
/
JUNE 1975
/
\‘OLUME
V, NUMRER
6
753
bladder which recurred in the flap. In 2 patients the flap was not pexed to the psoas muscle, a technique which, we believe, tends to prevent tension on the anastomosis. Two of our failures resulted from complete early stricturing of the flap itself and probably were caused by too vigorous mobilization of tissues or too narrow flaps. Reflux commonly occurred in patients with fair and poor results but rarely in those with good results. Over-all, acceptable results were obtained in two thirds of the surgical procedures.
Boari’s ureterocystoplasty was the first attempt to bridge inadequate distal ureteral length. We believe it stil1 deserves consideration as an alternative to more recent and complicated procedures, such as transureteroureterostomy, autotransplant, or ureteral replacement by Teflon or an isolated loop of bowel. The “psoas hitch” and the “tunnel and CUE” ureterovesical anastomosis are techniques which enhance surgical results. Factors associated with poor results are prior irradiation to the pelvis,
FIGURE 4. Case 3. and (B) Pre- and 19ostoperative excretory urograms and cystogl *ams showing bilateral reflux after reimplantation. (C) Postoperative jìlms show no rejlux.
754
UROLOGY
/ JUNE 1975 / VOLUME
V, NUMBER 6
thick-walled bladders, dilated ureters, and multiple previous ureterovesical procedures. 525 East 68th Street New York, New York 10021 (DR. MUECKE) References 1. BOARI,A.:
Chirurgia del1 uretere, con prefazience de Dott: 1. Albarran, 1,900 Contribute sperementale alla plastics delle uretere, Atti. Accad. Med. Ferrara, 14:
444 (1894). 2. DEMEL, R.: Ersatz des Ureters durch eine Plastik aus der Hanblase, Zentralbl. Chir. 51: 2008(1924). 3. SPIES,J. W., JOHNSON, C. E., and WELSON, C. S.:
Reconstruction of ureter by means of bladder Proc. Sec. Exp. Biol. Med. 30: 425 (1933).
flaps,
4. OCKERBLAD, N.: 5.
6. 7.
8.
9.
10.
Reimplantation of the ureter into the bladder by a flap method, J. Urol. 57: 845 (1947). BAIDIN, A. : Die Demel’sche Harnleiterautoplastik mit Hilfe der Harnblase beim Menschen, Zentralbl. Gynaekol. 54: 3237 (1930). Ureterersatz aus der Harnblase, RHODE, C.: Zentralbl. Chir. 64: 409 (1937). FLOCKS, R.: Ureterovesical anastomosis when the proximal portion of the ureter is short. Can. Med. Assoc. J. 55: 574 (1946). HENDERSON, D., and ST. CLAIR, L.: Boari’s operation: reimplantation of the ureter in the bladder utilizing a bladder flap, Urol. Cutan. Rev. 55: 80 (1951). KUSS, R.: Plastic ureterale par Lambeau vesical tubule (operation de Boari), a propos de 10 cas., Mem. Acad. Chir. Paris 79: 159 (1953). of lower ureters by a tube BURNS, R. : Reconstruction made from bladder flaps, J. Urol. 74: 348 (1955).
UROLOGY
/
JUNE 1975 !
VOLUME V, NUMBER 6
11. CONGER, K., and
ROUSE, P.: Ureteroplasty by bladder flap technique: report of two cases, ibid. 74: 485 (1955). 12. DILLON, J.: IJse of bladder pedicles as substitute for lower ureter, ibid. 83: 583 (1960). 13. KIMCHI, D., and WIESENFELD, A.: Injuries to the lower third of the ureter treated by bladder flapplasty, ibid. 89: 800 (1963). 14. FIRSTATER, M.: Boari’s operation for the treatment of megaureter, ibid. 93: 569 (1965). 15. CUKIER, J.: Description of 63 bladder flap operations, Acts. Urol. Belg. 34: 15 (1966). 16. WILLIAMS, J., and PORTER, R.: The Boari bladder flap in lower ureteric injuries, Br. J. Urol. 38: 528 (1966). 17. GOW, J.:
The results of the reimplantation of the ureter by the Boari technique, Proc. R. Sec. Med.
61: 128 (1968). 18. VICK, N. F., UHLMON, R. C.: Open bladder flap ureterovesicocystostomy, J. Urol. 105: 209 (1971). 19. PEARSON, B. S.: Experiences with the Boari flap, Br. J. Urol. 42: 740 (1970). 20. GOLIMBU, M., BLOCK, N., and MORALES, P.: Ureterovesical flap operation for middle and upper ureteral repair, Invest. Urol. 10: 313 (1973). 21. JONES,A. E., TAYLOR,R. R., and WOODHEAD, D. M.: Bladder flap incorporating the intact ureterovesical junction, J. Urol. 109: 55 (1973). 22. PAQUIN, A. J.: Ureterovesical anastomosis: the ibid. 82: description and evaluation of a technique, 573 (1959). 23. FIRSTATER, M.: Unintubated Boari’s ureterocystoplasty, ibid. 93: 567 (1965). 24. IVANCEVIC, L. D., HOHENFELLNER, R., and WULFF, H. D.: Total replacement of the ureter using a bladder flap and cinematographic studies on the newly constructed ureter, ibid. 107: 576 (1972).
755
