Ureteric rebuild - the ladder

1: reimplant, short low gaps

1. Cut out the diseased end. Fill the bladder.
2. Cut 3 cm through bladder muscle only.
3. Open mucosa at the far end.
4. Lay the spatulated ureter in.
5. Close muscle over it. That tunnel stops reflux.
6. Catheter 7-10 days.

2: psoas hitch, gains 5-8 cm

1. Free the bladder: cut the OPPOSITE side umbilical artery, +/- superior vesical.
2. Oblique cut across the bladder top.
3. Finger inside pushes bladder up to psoas.
4. 3-6 stitches, vertical, into psoas tendon. Vertical misses the nerve along psoas. Shallow misses the leg nerves.
5. Hitch BEFORE joining, or the ureter kinks.
6. Stent out 7-14 days.

3: Boari flap, gains 12-15 cm

1. Bladder flap on a pedicle (superior vesical artery). Base 4 cm wide. Tip 3 cm. Length = gap + 3-4 cm.
2. Fix tip to psoas.
3. Ureter through the back of the flap. Spatulate.
4. Join mucosa to mucosa, 4/0. No tension.
5. Roll the flap closed over a catheter.
6. Cystogram at 2 weeks. Then catheter out.

4: ileal ureter / kidney swap

1. Know the concept only. Full-length gaps.