Ureteroneocystostomy (Ureteral Reimplant) 
George E. Koch, Niels V. Johnsen  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
 
For distal ureteral injuries, healthy ureter 
proximal to the injury should be reimplanted directly 
into the bladder whenever possible. The bladder can 
be mobilized and secured close to the proximal ureter 
using the psoas hitch technique and reconstructed 
with a Boari flap as needed to bridge the gap to 
healthy ureter. A drain should be left at the site of the 
repair and a foley catheter placed for 1-2 weeks. 
 
Ureteroneocystostomy 
proceeds 
in 
the 
following steps:  
● Exploration, identification, and debridement 
of the injured distal ureter 
● Mobilization of the bladder and direct 
anastomosis if appropriate 
● Dissection of the psoas muscle and creation 
of a psoas hitch if appropriate 
● Incision of the bladder and creation of a Boari 
flap as needed 
 
Steps:  
1. If the site of the injury is apparent it should be 
exposed and evaluated. If the site of the injury is 
not apparent, the colon should be medialized 
along the White Line of Toldt to expose the 
retroperitoneum. The ureter can then be 
identified and exposed by beginning dissection at 
a known ureteral landmark, like the iliac 
bifurcation, and tracing it to the site of injury. 
Alternatively, for distal injuries, the bladder can 
be opened and the associated ureteral orifice 
cannulated with a wire or ureteral catheter or 
instilled with saline or methylene blue to help 
identify the injury. Be sure to open the bladder 
longitudinally and off midline so the incision can 
be incorporated into a Boari flap if needed (see 
below.) 
 
Mobilize the ureter without damaging its blood supply, which 
runs within the tissue around the ureter. Source: Burks FN, 
Santucci RA. Therapeutic Advances in Urology. 
https://doi.org/10.1177/1756287214526767 
 
2. Once identified, the injured tissue should be 
inspected. Bruised or discolored tissue raises 
concern for devitalization and should be 
debrided. 
 
Debride any devitalized or bruised ureter tissue. Source: Burks 
FN, Santucci RA. Therapeutic Advances in Urology. 
https://doi.org/10.1177/1756287214526767 
 
3. The bladder is next mobilized by incising the 
bilateral 
medial 
umbilical 
ligaments 
and 
developing the Space of Retzius. The peritoneal 
wings on either side of the bladder can also be 
incised for further mobilization. The bladder can 
be filled and emptied via a foley catheter as 
needed to aid in mobilization. 
Ureteroneocystostomy (Ureteral Reimplant) 
George E. Koch, Niels V. Johnsen  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The bladder (shown here in a male) should be dissected off the 
surrounding peritoneal and retroperitoneal / retropelvic 
attachments, in the plane shown by the Red line. Take care not 
to damage the ureters or other surrounding structures. In the 
male, the seminal vesicles should remain attached to the 
bladder during dissection and the surgeon should be aware of 
the entry site of the vas deferens.  
 
4. If the bladder and ureter reach each other without 
tension, the ureter can be reimplanted without 
further bladder reconstruction. 
 
At the area where the ureter will enter the bladder wall, a 
hemostat is passed through all layers into the lumen of the 
bladder. Source: Burks FN, Santucci RA. Therapeutic 
Advances in Urology. 
https://doi.org/10.1177/1756287214526767 
 
 
A submucosal tunnel is made for about 1cm and a separate 
incision in the mucosa is made. Source: Burks FN, Santucci 
RA. Therapeutic Advances in Urology. 
https://doi.org/10.1177/1756287214526767 
 
 
A suture is passed through the tip of the spatulated ureter and 
the ureter is passed through the tunnel with gentle traction on 
the suture. Source: Burks FN, Santucci RA. Therapeutic 
Advances in Urology. 
https://doi.org/10.1177/1756287214526767 
 
Ureteroneocystostomy (Ureteral Reimplant) 
George E. Koch, Niels V. Johnsen  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The mucosa of the spatulated ureter is anastomosed to the 
mucosa of the bladder with interrupted 4-0 or 5-0 absorbable 
suture. Source: Burks FN, Santucci RA. Therapeutic Advances 
in Urology. 
https://doi.org/10.1177/1756287214526767 
 
5. If the bladder reaches healthy ureter with some 
tension, it can be affixed to the psoas muscle to 
reduce tension on the anastomosis. The 
contralateral bladder pedicle can be further 
mobilized by ligating the superior vesical artery. 
6. The psoas muscle is identified and exposed. 
7. A longitudinal cystotomy is made off midline so 
a hand can then be placed in the bladder to push 
it up towards the psoas muscle to ensure a psoas 
hitch will effectively close the gap to healthy 
ureter. This can also be done with a handheld 
retractor. 
 
The longitudinal cystotomy, shown here after completed 
anastomosis, is made such that it could be converted into a 
Boari flap if needed, as described further below. Source: Burks 
FN, Santucci RA. Therapeutic Advances in Urology. 
https://doi.org/10.1177/1756287214526767 
 
8. The bladder is then pulled cranially and the 
posterior aspect is affixed to the psoas muscle 
and tendon using 2-0 absorbable suture, being 
careful to take longitudinal bites and avoid deep 
bites of the psoas, which endangers the femoral 
and genitofemoral nerves. 
 
Attachment of the mobilized bladder to the psoas muscle, taking 
care to avoid injury to the femoral and genitofemoral nerves: 
see the diagram under the “Pitfalls” section. Source: Burks FN, 
Santucci RA. Therapeutic Advances in Urology. 
https://doi.org/10.1177/1756287214526767 
 
9. If the bladder is still unable to reach healthy 
ureter without tension after this psoas hitch, a 
Boari flap can be performed. 
10. A U-shaped flap is marked out on the anterior 
surface of the bladder with the pedicle at the 
cranial-most aspect of the bladder and the tip of 
the “U” towards the bladder neck. The length of 
the flap should be longer than the measured 
distance to healthy ureter as it will contract due 
to vasospasm and edema. The width should be at 
least half the length of the flap to ensure adequate 
blood supply. 
Ureteroneocystostomy (Ureteral Reimplant) 
George E. Koch, Niels V. Johnsen  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Schematic of a Boari flap. The length of the flap (Red distance) 
should be 20% longer than the gap between the end of the ureter 
and the bladder (Blue distance.) The width of the flap (Green 
distance) should be at least ½ of its length and taper slightly 
towards the tip to avoid ischemia.  
 
 
The planned Boari flap. Source: Burks FN, Santucci 
RA. Therapeutic Advances in Urology. 
https://doi.org/10.1177/1756287214526767 
 
11. The detrusor flap should be developed as a full 
thickness flap including serosa, muscle, and 
mucosa. 
12. A full-thickness 1-2 cm hole is made in the 
posterior aspect of the Boari flap and the ureter is 
then reimplanted by pulling it through the hole. 
If the ureter does not reach the posterior aspect of 
the flap, it can be reimplanted into the proximal 
tip of the tabularized flap, however, the flap’s 
blood supply may not be as robust in this 
location. Finally, some advocate for creating a 
short submucosal tunnel for reimplantation as 
shown in the figures. 
 
The Boari flap, shown after ureter implantation and before 
tubularization and closure. Source: Burks FN, Santucci 
RA. Therapeutic Advances in Urology. 
https://doi.org/10.1177/1756287214526767 
 
13. The ureter should be spatulated to match the 1-2 
cm cystotomy and then a circumferential 
mucosa-to-mucosa anastomosis should be done 
with interrupted 4-0 or 5-0 absorbable suture.A 
ureteral stent should be placed before closing the 
bladder. 
 
Ureteroneocystostomy (Ureteral Reimplant) 
George E. Koch, Niels V. Johnsen  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The open Boari flap after completed anastomosis, in this case 
to both ureters (Black arrows.) Stents are visible within the flap. 
The most cranial extent of the bladder, the base of the flap, is 
shown by the Blue arrow. The balloon of a urethral catheter 
inside the bladder is shown by the Purple arrow. 
 
14. The bladder is then closed and the Boari flap 
tubularized by closing the bladder in 2 layers 
using 3-0 absorbable suture for the mucosa and 
2-0 absorbable suture for the detrusor muscle and 
serosa. 
 
The completed Boari flap, after closure and tubularization of 
the bladder and flap in two layers. The suture line is shown by 
the Green arrows. The two ureters are shown by the Black 
arrows. The outline of the bladder is shown by the Black dotted 
line.  
 
 
Illustration of the closed Boari flap. Source: Burks FN, 
Santucci RA. Therapeutic Advances in Urology. 
https://doi.org/10.1177/1756287214526767 
 
15. The peritoneum should be mobilized when 
possible and secured over the suture lines. 
16. A drain should be left at the site of the repair and 
a foley catheter placed. 
17. A leak test is performed with at least 150cc of 
saline instilled into the bladder via the foley 
catheter before closing the abdomen. 
18. The stent is removed after 6 weeks with flexible 
or rigid cystoscopy. In settings without 
cystoscopy, some surgeons will use a foley 
catheter to pass the stent’s string out the urethra 
prior to closing the bladder. This allows the stent 
to be removed later by simply pulling on the 
string. However, patients sometimes have 
difficulty managing a string coming from the 
urethra. This is especially true for children or 
people with diminished mental capacity. It is not 
infrequent in such occasions for the string to be 
pulled causing premature removal of the stent.  
 
Pitfalls:  
● The femoral and genitofemoral nerves are both at 
risk of injury when performing a psoas hitch. The 
femoral nerve runs posterolateral to the muscle 
and the genitofemoral nerve runs anteromedial. 
Suturing the bladder to the psoas muscle using 
transverse or deep suture throws risks injury to 
these 
nerves 
and 
resultant 
postoperative 
numbness, paresthesias, and nerve palsies. 
Ureteroneocystostomy (Ureteral Reimplant) 
George E. Koch, Niels V. Johnsen  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Care must be taken when doing a psoas hitch to avoid damage 
to the femoral nerve posterolaterally (Black arrow) or the 
genitofemoral nerve anteromedially (Red arrow) on the psoas 
muscle. 
 
● Mobilizing a short or narrow Boari flap risks 
inadequate length of the tubularized flap due to 
tissue contracture. Avoid this by measuring the 
distance from healthy ureter to bladder and then 
taking a flap that is at least 20% longer, with a 
pedicle at least half the length of the flap. 
 
 
George E. Koch MD  
Vanderbilt University Medical Center 
USA 
 
Niels V. Johnsen MD, MPH 
Vanderbilt University Medical Center 
USA 
 
