AND PSOAS COMBINATION OF HITCH, BOARI P F SOAS MILLER BOOK-PDF-FILE/Yu Chap 07 (69-74).pdfChapter 7 Psoas Hitch, Boari Flap, and Combination of Psoas Hitch and Boari Flap 71 laterally

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  • 69

    PSOAS HITCH, BOARI FLAP,AND COMBINATION OF PSOAS

    HITCH AND BOARI FLAP7

    The psoas hitch procedure,Boari flap, and transureteroure-terostomy are useful operativeprocedures for reestablishing con-tinuity between the ureter andbladder. Of the three, the mostversatile and the one associatedwith the fewest complications isthe psoas hitch procedure. Thepsoas hitch is a means of extend-ing the bladders dome or lateralwall cephalad and anchoring thebladder to the surface of the psoasmuscle, thereby bridging a gapbetween the ureter and bladder.

    The psoas hitch procedure hasbeen used in a variety of clinicalsituations: when the distal ureteris scarred secondary to chronic in-fection or previous surgery, whenthe ureter has been damaged bytrauma, and even when a simpleantirefluxing reimplantation ofthe ureter is necessary.1

    There are clinical situationswhen the ureter has already beendamaged and severed from thebladder for which vesical-psoasfixation can be performed withoutfirst opening the bladder.

    Another possible application iswhen ureteral reimplantation iscontraindicated because of a dis-eased, fibrotic bladder; in this casethe bladder could be manipulatedcephalad to the psoas muscle fora psoas hitch procedure.

    PSOAS HITCH PROCEDURE

    With the bladder filled withsaline solution instilled througha Foley catheter, the surgeon caneasily define the perivesicalspaces between the bladder andpelvic walls.

    FIG. 7-1. The inferior and poste-rior peritoneal reflection is easilydissected from the bladder whilethe bladder is full. This maneuveris not always necessary; however,it provides maneuverability of thebladder dome for the psoas hitchprocedure.

    FIG. 7-2. As described in Chapter18, the surgeon defines a spacecalled the retroperitoneal pocket oneach side cephalad to the perivesi-cal space (see p. 169). The bladdershould first be deflated. 7-1

    7-2

    Sagittal View

    Bladder

    Prostategland

    Peritonealreflection

    Rectum

    Internalinguinal

    ring

    Bladder Prostate gland

    External iliacartery

    Peritoneum

    Retroperitonealpockets

    Development of Retroperitoneal Pockets

  • 70 Critical Operative Maneuvers in Urologic Surgery

    FIG. 7-4. When the surgeon suc-cessfully performs this maneuver,the following landmarks shouldbe adjacent to the fingers: medialto the fingers are the ureter, blad-der, and obliterated umbilicalartery; lateral to the fingers are theinternal inguinal ring, external il-iac vessels, and pelvic wall; infe-rior to the fingers are the psoasmuscle, genitofemoral nerve, andhypogastric vessels; and superiorto the fingers are the vas deferensand peritoneal shelf.

    By this one maneuver, the sur-geon exposes not only the psoasmuscle and genitofemoral nervebut also the proximal ureter abovethe obliterated umbilical artery.

    Depending on the configura-tion of the bladder and the thick-ness of its walls, sometimes thecontralateral obliterated umbilicalartery and superior vesical arterymust be divided to gain more ma-neuverability.

    FIG. 7-5. The bladder, intact oropened, can be stretched onto thepsoas muscle more laterally ormore superiorly depending on thesurgeons choice, and the gen-itofemoral nerve can be mobilized

    Psoas muscle Ureter

    Common iliacvessels

    Bladder

    Prostategland

    Obliteratedumbilical artery

    Internalinguinal

    ring

    Vas deferens

    Posteriorperitoneum

    Hypogastricartery

    Externaliliac vessels

    7-3

    7-4

    Obliteratedumbilical artery

    (medial ligament)Vas

    deferens

    Prostategland

    Bladder

    Peritoneum

    Region ofinternalinguinalring

    Hypogastricartery and vein

    External iliacartery and vein

    Top View

    Psoasmuscle

    Peritonealshelf

    Vasdeferens Bladder

    Prostategland

    Frontal View

    Obliteratedumbilical

    artery

    Ureter Hypogastricartery

    Entrance intoretroperitoneal

    pocket

    Entrance intoretroperitoneal

    pocket

    FIG. 7-3. The index and middlefingers are used to define a spacebetween the posterior peritoneumand the retroperitoneum.

  • Chapter 7 Psoas Hitch, Boari Flap, and Combination of Psoas Hitch and Boari Flap 71

    laterally if necessary. If the blad-der is contracted, the surgeon canbathe the bladder dome with localanesthetic (lidocaine 1%), whichwill make it much easier to stretchthe bladder cephalad to a greaterextent than expected for fixation.

    FIG. 7-6. The bladder is stretchedto its maximum and two stitches(0 Vicryl) are placed for vesical-psoas fixation. Full deep suturebites of the bladder are necessaryfor stabilization. Once fixed, thebladder is opened for the ureteralreimplantation.

    FIG. 7-7. If the bladder has beenopened by a horizontal incision2before the psoas hitch procedure,the surgeon places two fingersinto the bladder dome andstretches the bladder maximallyin the cephalad lateral directionfor placement of the anchoringstitches. Whether the bladder isclosed or opened, the importantpoint is to stretch the bladdercephalad as far as possible withtension to gain maximal length.

    FIG. 7-8. The ureter and the fixedbladder wall should overlap atleast 4 to 6 cm. Ureteral reimplan-tation can be accomplished in atunneled fashion or by the Le Ducmethod (see p. 129).

    To ensure an antirefluxing sys-tem, a 4:1 ratio of the tunnel lengthto ureteral width is optimal.

    After spatulating the ureter, thesurgeon should anchor the ureterto the full thickness of the bladderwith interrupted stitches (2-0 to4-0 Vicryl).

    FIG. 7-9. A stent and a Malecotsuprapubic tube are brought outthrough the bladder and abdo-men and fixed in place. Alterna-tively, self-retaining stents and aFoley catheter through the urethrafunction just as well but may pro-duce irritative symptoms postop-eratively. A drain is placed in theperivesical space.

    7-7 7-9

    7-6

    7-5

    12

    3

    Psoasmuscle

    Genitofemoralnerve

    Variationsin bladderposition forpsoas hitch

    Bladder

    Psoashitch

    Ureter

    Psoas Hitch withUreteral Reimplantation

    4:1ratio

    Submucosaltunnel

    7-8

  • Superiorvesicalartery

    Bladder

    Peritoneal reflection

    Bladderflap

    Psoas muscle

    4 cm

    Bladder

    Tunnelingof ureter

    Psoasmuscle

    72 Critical Operative Maneuvers in Urologic Surgery

    BOARI FLAP

    If performed properly, the Boariflap procedure provides excellentreconstruction for reconstitutionof a gap between the ureter andthe bladder.

    It is a second choice to thepsoas hitch procedure because theBoari flap involves more variablesthat must be overcome for a suc-cessful result.2,3

    The preliminary exposure isidentical to the operation for thepsoas hitch: isolation of the retro-peritoneum and the proximal ure-ter and clearing of the upper halfof the bladder from its peritonealreflection.

    FIG. 7-10. In contrast to the psoashitch procedure, with the Boariflap the preservation of the supe-rior vesical arteries is important,especially for the ipsilateral side(A).

    The flap for Boari tubulariza-tion must be thought of as awedge of vesical wall. The longerthe flap created, the wider the

    base must be to maintain goodvascularity. The base must be atleast 4 cm wide; otherwise the tipof the flap is at risk for ischemia(B).

    FIG. 7-11. An end-to-end anasto-mosis between the ureter and thebladder flap will invariably re-sult in a stricture. The impor-tance of a generous overlap of 3to 4 cm between the ureter andthe flap is important for a goodreconstruction.

    The posterior bladder at the flapbase is first fixed with anchoringstitches to the psoas muscle (ar-row). The surgeon can then per-form a tunneling or a Le Ducureteral reimplantation.4

    FIG. 7-12. The flap is reapproxi-mated around the ureter, and astent, suprapubic tube, and drainare placed.

    Additional fixation stitches onthe Boari flap ensure that no ten-sion is placed on the anastomoticsite and that no retraction of theflap occurs.4

    7-10

    7-11

    7-12

    A

    B

    Ureter

    Flapclosure

    Fixationstitches

  • Chapter 7 Psoas Hitch, Boari Flap, and Combination of Psoas Hitch and Boari Flap 73

    COMBINATION OF PSOAS HITCHAND BOARI FLAP

    FIG. 7-13. If a vesical-psoas fixa-tion has already been completedand the ureter still cannot be over-lapped even after mobilizing thekidney and ureter (see pp. 49-50),the surgeon has the option of per-forming a combined psoas hitchand Boari flap procedure.

    FIGS. 7-14 AND 7-15. The combina-tion procedure requires that thebase of the Boari flap be 4 cm orgreater in width and that thepsoas fixation stitches be widerapart than the usual placement.

    In this situation we have notused flaps greater than 4 cm inlength; the longer the flap, thegreater the chance of ischemia andsubsequent contracture.

    7-13

    7-14

    7-15

    Bladder

    4 cmin width

    Psoas muscle

    Genitofemoralnerve

    Combination ofPsoas Hitch and Boari Flap

    Kidney

    Stent

    Fixation stitchesfor psoas hitch

    Stent diversionthrough bladderand fixed to skin

    Fixationstitchfor Boariflap

    Ureteraltunnel

    Suprapubiccatheter

  • 74 Critical Operative Maneuvers in Urologic Surgery

    K E YP O I N T S

    PSOAS HITCH The perivesical space is defined

    and the retroperitoneal pocketsare created to isolate the psoasmuscle and the proximal ureter.

    The peritoneal reflection is dis-sected from the bladder.

    If necessary, the contralateralobliterated umbilical artery andeven the superior vesical arteryare divided for greater maneu-verability.

    Bladder wall or dome is bathedin local anesthetic (lidocaine 1%)before a gradual stretch of thebla