Curative effect analysis of spiral pedunculated bladder muscle flap in repairing long segment ureteral defects

In the past, the surgeons usually adopted ileal ureter plasty or ureter bladder flap plasty （Boari flap plasty） to restorelong-term ureteral mucosal avulsions and long or entire ureteral segment defects caused mostly by ureteroscope operations. But there are still certain difficulties in the restoration of long segment ureteral defects （〉20 cm） using traditional methods. In order to overcome traditional surgical approaches, we designed a new ureteroplasty operation using spiral pedunculated bladder muscle flap to restore long segment ureteral defects. METHODS Six patients who presented long segment ureteral defects caused in the course of ureteroscopic lithotripsy due to ureteropelvic junction stenosis and stones （length of defects： 21-25 cm, mean length： 22.5 cm）, were given general anesthesia, and made to lay in the horizontal position while indwelling triple lumen catheters. These patients had Gibson incision in the hypogastrium of the injured sides, and we could prolong the surgical incision up to the epigastrium or the flank abdomen moderately if necessary. We exposed the retroperitoneal space, transected the umbilical ligaments, peritoneal adhesions, spermaducts or the round ligaments to dissociate the bladder to the maximum extent possible. We could increase the mobility of the bladder by dissociating the contralateral superior vesical arteries along the anterior trunk of the internal iliac artery. We could also identify the stump of the distal ureter along the path between the ureter and bladder below the iliac vessels, and then we had to ligate or transfix the ureteral stump. We dissociated the ureteropelvic junction carefully, trimmed the stump to the inclined plane in order to facilitate the anastomose between the bladder muscle flap and the trimmed ureteral stump while locating and tracting it by the suture. Filling the bladder with 400 ml of normal saline solution along the catheter, we located the anterior wall of the bladder with the suture. Before designing the spiral pedunculated bladder muscle flap, we had to identify the superior vesical arteries and their branches of the injured sides along the anterior trunk of the internal iliac artery. Then, we trimmed the shape S bladder muscle flap along the arteries＇ track while stretching the bladder by pulling the suture. The basal width of the designed flap had to be more than or equal to 2 cm, and the length should be equivalent to the injured ureter. We thenhad to wind the bladder muscle flap