The Boari Flap has been in the urologist’s armamentarium for tension free reconstruction of mid and proximal ureteral defects for over 70 years. However, complications can occur because of compromised blood supply due to having incisions on 3 sides of the flap, and relying on the flap base as the only source of blood supply. Rates of ureteral stricture and anastomotic leak are quoted as high as 10 to 20%. We present our technique of a modified Psoas hitch that does not compromise blood supply, and can be as effectively as a Boari Flap in bridging long ureteral defects and ureteral substitutions.

We retrospectively reviewed all patients who underwent our modification of the Psoas hitch performed by a single surgeon from 2008 to 2019. Our modification includes creating a semi-oblique cystotomy on the lowest part of the anterior and contralateral aspect of the bladder after complete release of the anterior surface of bladder. The contralateral superior vesical pedicle is sacrificed to allow for additional mobility if necessary. A series of short relaxing incisions at the different tethering levels in the pseudo flap segment are made until the bladder is able to reach the healthy ureter, and the ureter is anastomosed in a nonrefluxing or refluxing technique.

Patient demographics and characteristics are summarized in Table 1. Sixteen patients underwent this modified technique. Mean follow up was 20.4 months. Four (25%) patients had prior radiation, 3 (18.8%) underwent hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis at the same time of surgery, and 1 (6.3%) underwent repair of a transplant ureteral stricture. 8 cases involved intraoperative consults for which there was no preoperative planning. There was 1 with postoperative leak, and no patients had obstructive hydronephrosis to suggest flap ischemia. The mean length of the flap was 8.65 cm (2 cm to 16 cm).

In our experience with the modified Psoas hitch, we are able to offer patients another option for bridging large ureteral defects that is associated with low rates of complications with this simple technique.

Our modification of the Psoas hitch is reliable and can be used to reconstruct long ureteral strictures as well as serve as a substitution for patients with transplant ureteral strictures. It can be performed easily with a lower complication rates than traditional Boari Flap. This procedure is especially suitable in complex patients with high morbidity (such as prior radiation and peritoneal carcinomatosis) with decreased tissue vascularity.

Wein, Alan J. et al. 1894-1968 Campbell. Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Elsevier Saunders, 2012.
Rassweiler, Jens J. et al. “Ureteral Reimplantation for Management of Ureteral Strictures: A Retrospective Comparison of Laparoscopic and Open Techniques.” European Urology, Volume 51, Issue 2, 512 – 523.