Robotic Boari Bridging till proximal ureter

The minimally invasive management of ureteric strictures extending into the proximal ureter is technically demanding. There are mainly 2 options for obliterative strictures, either a Boari Flap or ileal ureter replacement, auto-transplantation being reserved for the most difficult cases. Boari flap is the obvious preference because of ease of surgery, lack of bowel related complications and absen

			The 5 “Ds” to help recall all stages of detrusor damage & to explain progressive bladder dysfunction (6)
Stages	Patient perception	Keywords	Pathophysiological changes
I	Decreased flow	Things slow down	Obstruction, detrusor hypertrophy
II	Dysfunctional bladder	The overactive bladder	Detrusor overactivity
III	Diapers	The rebellious child	Urge incontinence
IV	Drained bladder	The heart attack	Acute urinary retention
V	Dead bladder	The heart failure	Chronic urinary retention and detrusor underactivity

ce of metabolic effects due to absorption of urine. However, it may not be possible to bridge every gap with a Boari flap and the usual length that can be bridged is 12-15cm.(1) 

Accessing very proximal parts of the proximal ureter (L2-L3) and switching from Boari flap to ileal ureter, if the former is not feasible, can pose surgical challenge during a robotic reconstruction. This stems from the fact that the Boari flap is typically performed in the lithotomy / supine with trendelenberg position to provide complete access to the bladder to harvest a broad and long flap, whereas, accessing the proximal ureter in this position is difficult. Also, if one needs to change the plan due to non-feasibility of a Boari flap, then transposing the bowel thorough the mesentery of descending colon and anastomosing it with the left ureter is quite difficult in the lithotomy position. 

One of the options for proximal ureteric strictures (L3-L4) is to take consent for both the procedures and position the patient into a lateral position with 15-20 degrees of tilt and place the robotic ports on both sides of the abdomen, with the 2 cephalad ports being placed on the side of surgery and other the 2 being on the opposite side, making sure that the caudad most port is 2-3cm lateral to obliterated umbilical ligament, allowing for complete bladder drop. This position and port placement allows for access to all the 5 quadrants of the abdomen that may need to accessed during a Boari or a ileal ureter. 

The proximal extent of the ureteric stricture can be accessed with robot in the standard configuration for any kidney procedure, after which it is re-targeted into the pelvis and the bladder is completely dropped, contralateral obliterated ligament is cut and a psoas hitch is performed. Now, with a measuring tape, the defect is measured and feasibility of Boari flap to bridge the defect is assessed. If possible a broad based flap usually 10-12 cm in length can be created. If the defect is long, a 12 mm port can be placed in the ipsilateral lumbar area and an ileal segment can be isolated with help of stapling device and ileal replacement can be performed. 

Such a patient position and port placement enables access to many quadrants of the abdomen and makes the surgery truly multi-quadrant. Also, it allows for easy switching between Boari and ileal ureter as and when needed providing a “universal” port and patient position.

by Dr Siddharth Yadav, VMMC & SJH, New Delhi