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1. Redo Boari flap
? Is a good approach for previous failed Boari flap
ureteric reimplantation

2. • A 51 year old female patient, housewife underwent TLH (07/08/2022) at
outside hospital for uterine fibroid and dysfunctional uterine bleeding.
• On POD -13 patient started urinary leakage per vagina, it was initially 1-2
pad per day.
• Patient readmitted and RGP done and she found to have left uretero-
vaginal fistula, DJ stent was placed (19/08/22).
• Catheter was removed after 1 week and 2 weeks later patient again started
continuous incontinence of urine per vagina.
• Then patient again underwent RGP and DJ stent change at outside hospital
but no improvement found.

3. • On 7/12/22 patient was planned for left ureteric reimplantation, in
the same hospital surgery was perfomed- laparotomy and left ureteric
reimplantation by Boari flap and ADK drain was placed.
• POD-2 drain amount was 700 ml serous colour and patient also
started per vaginal incontinence.
• They try to manage conservatively but persistent PV urinary
incontinence and increased drain amount, patient was referred to
BLK-MAX hospital on 16/02/22.

4. • Physical examination was unremarkable and Laboratory revealed…
Hb-
TLC-
Creatinine
Urine culture- sterile
Drain fluid creatinine

5. • CT KUB with contrast ( 18/01/22) s/o- left DJ stent seen in situ,
contrast extra- vasation seen from left ureter at level of crossing iliac
vessels.
• The extravasated contrast from the ureter is seen reaching in
perivesical region, posterior to the bladder Small left perinephric
collection 3*4*3 cm, no definite communication between this
collection and PCS system. Mild prominence of left PCS system
present.

6. • On 19/12/2022 USG guided left PCN tube was placed.
• After 4-5 days incontinence was stopped and drain output decreased
upto 50 ml/day.
• Catheter was removed and patient was discharged with drain and left
PCN tube in situ on 28/12/22

7. • Cystogram and nephrostogram s/o contrast extravasation from
previous ureteric reimplantation site.

10. • Catheter was removed and patient was discharged with drain and left
PCN tube in situ on 28/12/22 .
• After 2 weeks patient came to BLK MAX hospital with complain of
increased drain output 900 ml and PCN tube was accidentally out at
home

11. • After 2 weeks patient came to BLK MAX hospital with complain of
fever and increased drain output 900 ml and PCN tube was
accidentally out at home.
• But she didn’t have complains of urinary incontinence.

12. • After sepsis resolution and improvement in patient general condition,
• Patient was planed for laparotomy and Re-do Boari Flap and left
ureteric reimplantation.

13. Steps of Redo-Boari

14. • Intra-operative findings-
• There was dense adhesions present between peritoneum and ureter,
ureter was sloughed out at previous anastomosis.
• Whole Ureter was mobilised and renal descensus was done, new
Boari flap created and anastomosed with left ureter over DJ stent.
• SPC was placed, and 28 Fr ADK drain was placed.
• USG guided Left PCN tube also placed.

15. • POD-2 drain output was 50 ml, PCN Tube- 700, catheter output- 300
ml.
• Patient was discharge on POD -5 with drain, PCN, SPC, DJ stent,
Feeding tube and Catheter was removed.

16. • After 2 weeks patient came to follow up, left nephrostogram done,
there was no contrast extravasation at ureteric reimplantation site.

19. Discussion
• Reconstruction of the ureter using the Boari technique may be
associated with both early and late complications.
• Early complications include urinary leakage and bleeding.
• It has been suggested that the placement of a double-J stent may
prevent postoperative urinary leakage and promotes healing.
• Commonly described late complications are persistent reflux and
stricture of the anastomosis.

20. • Despite technical difficulties in dissecting and exposing the previously
re-implanted ureter and taking into consideration the patient’s
relatively normal bladder volume, we decided to form a new Boari
flap.
• A new flap was harvested without compromising the bladder
capacity.
• This technique was carried out successfully, without added
morbidities and with excellent anatomical and functional outcome,
on follow-up at 2 weeks.

21. Alternative methods in this scenario
1. Transuretero-ureterostomy
2. Ileal segment ureteric replacement
3. Auto-Renal Transplant
4. Re-do Boari
5. Renal-Descensus with Psoas Hitch