MANG Boari Flap
– A bladder flap is usually not needed in patients with distal
ureteral strictures because a psoas hitch is adequate in most cases.
– If a Boari flap is necessary, the incision, ureteral dissection, and
initial bladder mobilization are the same as for patients undergoing a
– The bladder flap is indicated when, despite all attempts to create
adequate length, it is clear that a tension-free anastomosis cannot be
– A psoas hitch should accompany the Boari flap to help decrease the
length of flap that is necessary
1. After the bladder has been mobilized and a psoas hitch performed,
the site for the base of the flap should be identified on a fixed
portion of the bladder and the length of flap needed is measured.
2. A stay suture is placed at each end of the base of the flap, which
should be approximately 3 to 5 cm wide.
2a. To ensure adequate vascularity of the flap, the base should be
wider when a longer flap is necessary.
3. A stay suture is placed at each end of the apex of the flap, which
should be approximately 3 cm in width.
4. If needed, a longer flap can be created using a spiral incision in
5. The flap developed by incising the bladder wall using electrocautery.
6. The flap is then brought up to the ureter, which may be anastomosed
to the apex using a direct or tunneled (submucosal) technique.
7. A feeding tube or stent should then be placed.
8. The bladder is closed and the flap is rolled into a tube over the
stent using a running 3-0 absorbable suture on the mucosa and
interrupted 2-0 sutures on the muscularis and adventitia.
9. A perivesical drain is placed
– radiographic evaluation of the bladder and ureter should be
performed prior to removal of the ureteral and urethral catheters