Successful Boari Flap ureteroneocystostomy for distal ureteral necrosis after renal transplantation

Introduction Renal transplantation has been shown to improve the quality of life and overall survival in patients compared to long-term dialysis. However, the procedure is still often followed by surgical and medical complications.1 Urinary fistulas are one of the most frequent complications occurring within the first month after the transplant, occurring in 2%–4.7% of cases.2 It is usually associated with ischemic necrosis of the distal ureter which only receives vascularization through its superior pedicle originating from the renal artery. There are numerous ways to ensure urinary continuity in fistula cases, through either endoscopic or surgical methods. Even though there is a place for an endoscopic approach, the immediate success rate is 69% with a longerterm success rate of only 58% due to recurrent infections or stenosis.3 Surgical interventions for early complications offer a more consistent and durable solution that can prevent renal allograft injury due to pyelonephritis and hydronephrosis to re-establish urinary drainage range from simple re-anastomosis to more complex procedures which make use of the recipient bladder.3 Unlike vascular anastomosis, the optimal method for urinary anastomosis has not been universally decided. Different studies have reported multiple approaches to treat the problem and Boari Flap method was seldom reported to be used for the complication even though certain conditions may theoretically support the use of the method more than others. Reconstruction of the urinary tract by using the bladder may be beneficial if the transplant ureter lacks a sufficient blood supply at the time of transplantation.4 In this report, we present a case of urinary fistula due to distal ureteral ischemic necrosis in a 28-years-old male treated with a Boari Flap ureteroneocystostomy. Case presentation A 28 years old male underwent a kidney transplantation due to stage V chronic kidney disease. A week after the procedure, he complained of urinary leakage from the surgical site. The patient also Introduction Renal transplantation has been shown to improve the quality of life and overall survival in patients compared to long-term dialysis. However, the procedure is still often followed by surgical and medical complications.1 Urinary fistulas are one of the most frequent complications occurring within the first month after the transplant, occurring in 2%–4.7% of cases.2 It is usually associated with ischemic necrosis of the distal ureter which only receives vascularization through its superior pedicle originating from the renal artery. There are numerous ways to ensure urinary continuity in fistula cases, through either endoscopic or surgical methods. Even though there is a place for an endoscopic approach, the immediate success rate is 69% with a longerterm success rate of only 58% due to recurrent infections or stenosis.3 Surgical interventions for early complications offer a more consistent and durable solution that can prevent renal allograft injury due to pyelonephritis and hydronephrosis to re-establish urinary drainage range from simple re-anastomosis to more complex procedures which make use of the recipient bladder.3 Unlike vascular anastomosis, the optimal method for urinary anastomosis has not been universally decided. Different studies have reported multiple approaches to treat the problem and Boari Flap method was seldom reported to be used for the complication even though certain conditions may theoretically support the use of the method more than others. Reconstruction of the urinary tract by using the bladder may be beneficial if the transplant ureter lacks a sufficient blood supply at the time of transplantation.4 In this report, we present a case of urinary fistula due to distal ureteral ischemic necrosis in a 28-years-old male treated with a Boari Flap ureteroneocystostomy. Case presentation A 28 years old male underwent a kidney transplantation due to stage V chronic kidney disease. A week after the procedure, he complained of urinary leakage from the surgical site. The patient also