Boari flap with Psoas Hitch

Singh P, Toh CC, Ashani M.

Department of Urology, Hospital Kuala Lumpur , Malaysia

Abstract

Introduction

Injury to the ureter and bladder are relatively rare occurrences and provoke
significant diagnostic dilemmas. Etiologies include external trauma, such as
automobile accidents or gunshot wounds, and iatrogenic injuries during pelvic
surgery or endoscopy. When lower urinary tract injury goes unrecognized,
presenting symptoms can be vague and often delay diagnosis. Such delays may
result in prolonged hospital stays and deterioration of renal function and have
significant impact on a patient’s quality of life. Reconstruction of these injuries
can be challenging depending on the mechanism and location of injury. Overall
functional outcomes of reconstruction for ureteral or bladder injuries is excellent.
The principles of ureteric reconstruction are not different from those of
reconstructive urology in the rest of the urinary system. The importance of
ensuring good vascular supply, complete excision of pathological lesions, good
drainage and a wide spatulated and tension-free anastomosis of mucosa to mucosa
remain paramount. Although time of diagnosis is the most single most adverse
factor affecting outcome, the majority of ureteric injuries still present
postoperatively, and delays in diagnosis are the rule rather than the exception.
Successful management requires early and definitive intervention using
endoscopic means or percutaneous drainage and stenting where possible. Failing
this, a number of open surgical options to foreshorten the course of the ureter
should be implemented. Most ureteric injuries below the pelvic brim can be
treated easily with a ureteroneocystostomy using a bladder elongation procedure
or a Boari flap. Mid and upper ureteric injuries above the pelvic brim, however,
can be repaired with a spatulated ureteroureterostomy if the defect is small. In
those with extensive ureteral loss, measures such as mobilizing the kidney,
transureteroureterostomy, renal autotransplantation and ureteral substitution using
small bowel may be required. Artificial ureteral substitutes may be an alternative
in selected cases

Case

19 years old female with no previous medical illness, with history motor vehicle
accident whom was a pillion rider, sustained unstable pelvic fracture, open right
tibia fibula fracture. She referred to urology one-month post MVA which she
developed abdominal pain and ileus. Abdominal CT scan showed left ureteric
injury with posterior pelvic collection, which was subsequently drained with
percutaneous pigtail and nephrostomy. Inview patient had pelvic and open right
tibia fibula fracture surgery was postponed until patient general condition improve
prior to reconstructive surgery which will give a good outcome post operative
recovery. Laparotomy reconstructive of left ureter with Boari flap and Psoas Hitch
performed 5 months post MVA. Post-operative patient recovered well.

Reconstruction of Boari Flap intraoperative

Discussion

Ureteral injuries (UI) due to trauma are rare as the ureter is well protected
in the retroperitoneum by the bony pelvis, psoas muscles and vertebrae [10,11],
Anatomically, the ureter is 22 to 30 cm in length and is divided into three
portions: the proximal ureter (upper) is the segment that extends from the
ureteropelvic junction to the area where the ureter crosses the sacroiliac joint, the
middle ureter courses over the bony pelvis and iliac vessels, and the pelvic or
distal ureter (lower) extends from the iliac vessels to the bladder (Fig. (Fig.1).1).
The terminal portion of the ureter may be subdivided further into the juxtavesical,
intramural, and submucosal portions.
Managing ureteral injuries is dictated by multiple factors like mode of
injury, location, extent, time of presentation, other associated problems and very
importantly hemodynamic status of the patient. With patients in shock, staged
repair is the best choice. Urine can be drained percutaneously in the mean time.
Extravasation of urine in perirenal and periureteral space leads to fibrosis, to
avoid this it is mandatory to achieve watertight closure of renal pelvis and
ureter.8 This further reduces chances of fistula formation.
In diagnosing ureteral injuries from trauma, the most important factor is a
high index of suspicion [27]. Typically there are no classic signs or symptoms for
ureteral injuries, but should be suspected in all cases of penetrating abdominal
injury and in cases of blunt deceleration trauma, particularly in children in whom
the kidney and renal pelvis can be torn from the ureter, secondary to their hyper-
extensible vertebral column [10,11,28]. Although some authors advocate that
hematuria is the hallmark of any GU lesion, it is present in only half (43%) of
those with UI, indicating that hematuria is not a sensitive indicator of ureteral
trauma [10,13,17,28-30]. Therefore, any patient that presents with gross
hematuria, flank pain or ecchymosis should undergo more extensive investigation
[16,20,28,29].
Unfortunately, there is no imaging modality best suited to diagnose acute
ureteral injury. The use of ultrasound has gained widespread use in trauma but has
proven unreliable in evaluating ureteral injuries, particularly because of their
small caliber and retroperitoneal location. According to the European Association
of Urology guidelines, computed tomography (CT) and an intra-operative single-
shot intravenous pyelogram (IVP) are the most useful diagnostic tools, but some
authors have argued against the reliability of single-shot IVP [10,11,17,30-34].
Complete IVP (which includes all excretory phases) has proven a reliable study in
the stable trauma patient for diagnosing ureteral trauma but is often impractical
given the precarious nature of most trauma victims [35-39]. Retrograde
pyelography is believed to be the most accurate method of diagnosis but is not
feasible in hemodynamically unstable patients. For the stable patient who can
undergo a CT scan, delayed excretory phase images have the benefit of not only
showing extravasation of contrast media from the ureteral injury, which may be
subtle, but can also illustrate accompanying lesions, particularly involving the
kidney [12,30,32,33]. In the delayed setting, a CT may also diagnose missed
ureteral injuries (i.e. ascites, urinomas, hydronephrosis and contrast
extravasation).
Injuries identified in the early phase may be surgically repaired over a
stent using fine absorbable sutures, assuming a tension free, healthy tissue
anastomosis can be achieved. Large ureteric injuries present a significant problem,
especially in the upper and mid zones, as they may require significant
reconstruction [13,17,19,36,41-46]. Successful repair methods for acute ureteric
injuries are based on certain principles: ureteric debridement and careful
mobilization, spatulated, tension-free, water-tight anastomosis over a stent (5-0
absorbable suture under magnification), isolation of the ureteric repair from
associated injuries and adequate drainage of the retroperitoneum [19,30,36,42,43].
 Failure of prompt diagnosis can lead to several complications including
renal failure, sepsis and death. More common complications include the formation
of urinomas, periureteral abscess, fistulas and strictures. However, these
complications are readily preventable and can occur less than 5% of the time with
proper stenting and/or placement of a nephrostomy tube [10,17,43]. Surgical
repair is typically recommended for delayed complications such as fistulas and
strictures. The early diagnosis of ureteral injury is extremely important and
directly related to the patient's prognosis [8,24,25,30,41,52-62]. In the articles
reviewed, late diagnoses including missed injuries were correlated with higher
rates of morbidity and mortality.

Conclusion:

Ureteral injuries (UI) due to trauma are unusual. However, failure to take this type
of injury into consideration can have dire consequences, as complications from
missed injuries are a cause of severe morbidity and mortality. The largest review
of the literature regarding traumatic ureteral injuries and several things are
evident. First, penetrating injuries are more common than blunt ureteral injuries in
adults. Second, the upper third of the ureter is more often injured than the middle
and lower third. Third, associated injuries are frequently present. Fourth, CT scan
and retrograde pyelography accurately identify ureteral injuries when performed
in concert, lastly, delay in diagnosis is associated with a worse prognosis.

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