Treatment of extensive ureteral strictures is always a surgical challenge. While uretero-ileoplasty or auto-transplantation techniques are often the techniques of choice, the Boari flap is an interesting option when the stenosis involves the distal portion of the ureter. The feasibility of the robot-assisted Boari flap has been poorly evaluated in the literature. The objective of this video was to present a robot-assisted Boari flap technique.

We present the case of Mrs B, 36 years old. Her main antecedent was cervix cancer treated by radiotherapy and curietherapy associated with a lombo-aortic lymph node dissection. Following this surgery, she developed a left iliac ureteral stenosis, which was initially treated by ureteral dilatation and catheterization. Unfortunately, the stenosis recurred rapidly after dilatation. On ureteropyelography, an extensive left ureteral stenosis of about 7 cm was found.  A robotic reconstruction was planned. The patient's consent was obtained for a buccal mucosal ureteroplasty, a Boari flap or a ureteroileoplasty depending on the intraoperative findings.

The patient is placed in Tredelenburg in the Egyptian position with the left side elevated. We start by placing the five ports on a supra-umbilical line with 2 trocars for the operating aid. The left ureter is located and dissected. Firefly fluorescence with intravenous injection of indocyanine green is used to visualize the ureteral vascularization. We opened the stenotic ureter at its anterior side, with a per operative ureteroscopy. The stenosis is finally about 10 cm long with no healthy portion of distal uretere, which does not allow to consider a ureteroplasty of oral mucosa. 
We decided to perform a ureteral reimplantation on a Boari flap. 


The bladder is completely freed to the endopelvic fascia. An opening is made on its anterior surface. 
The ureter is cutted above the stenosis, and opened on its antimesenteric side. A new injection of indocyanine green is made to ensure good vascularization of the section. A uretero-bladder anastomosis is then performed on the flap after placement of a ureteral catheter by 2 Quill 3/0 double needle suture. The bladder was then closed longitudinally by 2 V lock running sutures. 


The operative time was 240 minutes with minimal blood loss. There was no postoperative complication. The patient was discharged on postoperative day 3.
The bladder catheter was removed at post operative day 10 and the endoureteral catheter at 1 month. 

In our center, five patients underwent this type of procedure for extended ureteral stenosis. Of the 5 patients, 2 unfortunately had a stenosis of the uretero-vesical anastomosis. Both of these patients had undergone radiotherapy.

A uretero-vesical reimplantation on a Boari flap can be an interesting option in case of extensive ureteral stenosis. It offers good results with however a risk of anastomotic stenosis in irradiated patients.