[Update on ureteral reconstruction 2024]. / Update Harnleiterrekonstruktion 2024.

Ureteral strictures can occur along the entire course of the ureter and have many different causes. Factors involved in the development include, among other things, congenital anomalies, iatrogenic injuries during endoscopic as well as open or minimally invasive visceral surgical, gynecological, and urological procedures as well as prior radiation therapy. Planning treatment for ureteral strictures requires a detailed assessment of stricture and patient characteristics. Given the various options for ureteral reconstruction, various methods must be considered for each patient. Short-segment proximal strictures and strictures at the pyeloureteral junction are typically surgically managed with Anderson-Hynes pyeloplasty. End-to-end anastomosis can be performed for short-segment proximal and middle ureteral strictures. Distal strictures are treated with ureteroneocystostomy and are often combined with a Boari and/or Psoas Hitch flap. Particularly, the treatment of long-segment strictures in the proximal and middle ureter remain a surgical challenge. The use of bowel interposition is an established treatment option for this, offering good functional results but also potential associated complications. Robot-assisted surgery is increasingly becoming a minimally invasive treatment alternative to reduce hospital stays and optimize postoperative recovery. However, open surgical ureteral reconstruction remains an established procedure, especially after multiple previous abdominal operations.

A retrospective comparison between laparoscopic and open ureteroneocystostomy for management of benign lower ureteral strictures: An experience in tertiary care centre of Eastern India.

OBJECTIVES: The objective is to discover the etiopathogenesis of benign lower ureteric stricture in Eastern India and compare the outcome of open versus laparoscopic ureteroneocystostomy. MATERIALS AND METHODS: Retrospectively 52 patients who underwent laparoscopic (n = 28) or open ureteroneocystostomy (n = 24) for lower ureteral stricture between January 2018and December 2021 were included. The demography, aetiology, radiologic imaging, intraoperative & postoperative outcomes and follow-up data were collected and analysed. RESULTS: The mean duration of follow up was 14.3 months. Lower ureteric stricture were common in females. The most common cause of the stricture was iatrogenic injury (42%). Other causes were tuberculosis, post-endourological surgery, obstructing mega ureter, endometriosis and idiopathic. Laparoscopic surgery had longer mean operative time (228 vs 171 min), less blood loss (166 vs 246 ml), lower VAS score (6.1 vs 7.22) and less need of post-operative analgesia (1.86 vs 2.36 days). The hospital stay (5.36 vs 6.77 days) and post-operative complications (none vs 3) were also significantly lower in laparoscopic group. Open surgery and laparoscopic surgery had success rate of 100% and 96.6% each. CONCLUSIONS: Iatrogenic injury are the most common cause of ureteric stricture followed by tuberculosis. Laparoscopic approach is a feasible option in treatment of lower ureteric stricture as it offer comparable outcome to open procedure while offering the advantage of a minimal invasive technique. Stricture secondary to iatrogenic injury poses a different challenge due to presence of hard dense fibrosis. This is a complex reconstructive procedure and has a steep learning curve and demands high level of laparoscopic skill.

Long-term results of extended Boari flap technique for management of complete ureteral avulsion: A case report.

BACKGROUND: Ureteroscopy is well-established as a primary treatment modality for urolithiasis. Ureteral avulsion, particularly complete or full-length avulsion with a resultant long segment of the ureter left attached to the ureteroscope, is a rare but devastating complication of the procedure. Management of this complication is challenging. Moreover, general consensus regarding the optimal management is undetermined. We report our experience of managing a complete ureteral avulsion case via an extended Boari flap technique with long-term results. CASE SUMMARY: A 41-year-old female patient subjected to complete ureteral avulsion caused by ureteroscopy was referred to our hospital. A modified, extended Boari flap technique was successfully performed to repair the full-length ureteral defect. Maximal mobilization of the bladder and affected kidney followed by psoas hitch and downward nephropexy maximized the probability of a tension-free anastomosis. Meticulous blood supply preservation to the flap also contributed to the success. During the 4-year study period, no complications except for a mild urinary frequency and a slightly lower maximum urinary flow rate were reported. The patient was satisfied with the surgical outcomes. CONCLUSION: The extended Boari flap procedure is a feasible and preferred technique to manage complete ureteral avulsion, particularly in emergencies.

18 F-FDG PET/CT Imaging of Boari Flap Mimicking Urothelial Cancer Recurrence.

A 63-year-old man underwent distal ureterectomy as a treatment for urothelial carcinoma of the ureter. Reconstruction of the urinary system was accomplished by tubularizing part of the bladder roof (Boari flap). A year later, metastatic evaluation with 18 F-fluorodeoxyglucose positron emission tomography/computed tomography ( 18 F-FDG PET/CT) showed high metabolic activity in the reconstructed area. Thorough evaluation confirmed the presence of a bladder diverticulum (the Boari flap) with no evidence of malignancy. We present the first 18 F-FDG PET/CT images of a Boari flap in the literature.

Laparoscopic ureteral reimplantation with a Boari flap for long-segment ureteric avulsion or ureteric strictures: our experience.

BACKGROUND: This study was designed to evaluate the feasibility of laparoscopic ureteral reimplantation with a Boari flap for long-segment ureteric avulsion or ureteric strictures of the middle and lower ureters. By observing its curative effect and prognosis, we can provide a safer and reliable treatment option for patients with middle and lower ureteral injury. METHODS: In this study, of the eight cases under study, five were diagnosed with long-segment ureteric strictures, one had long-segment ureteric avulsion, one was diagnosed with ureteral rupture caused by surgical injury of appendicitis, and the remaining one underwent ureterostomy after ureteral injury. The location of ureteral injury was in the middle lower segment. All eight patients underwent laparoscopic ureteral reimplantation with a Boari flap from January 2018 to October 2021. In this study, two patients were treated with a Boari bladder flap with psoas hitching. All procedures were performed by the same surgeon with over 20 years of experience in urological surgery. RESULTS: The mean length of ureteric avulsion or ureteric strictures was 7.94 cm (range, 4-15 cm). Laparoscopic ureteral reimplantation with a Boari flap was performed successfully between 120 and 240 min. The mean duration of postoperative hospital stay was 6 days, and no major complications related to the procedure in the perioperative period occurred. Postoperative follow-up showed no obvious hydronephrosis on computed tomography urography or urinary ultrasound in all eight patients. Postoperative reexamination did not reveal any significant hydronephrosis, urinary tract infection, or ureteral reflux, and none of the postoperative renal functions were abnormal. CONCLUSIONS: Laparoscopic ureteral reimplantation with a Boari flap is safe and feasible for experienced physicians. In our case, the length/width ratio of bladder flap is more than 4:1, with good blood supply and no obvious complications, it provides a longer alternative length.

Long-Term Outcome of Non-antireflux Robotic-Assisted Robot-Assisted Laparoscopic Ureter Reimplantation in Ureteral Obstruction.

Purpose: Although robot-assisted laparoscopic ureter reimplantation (RALUR) is a recognized alternative to open and laparoscopic ureter reimplantation in treating distal ureteral obstruction, there are limited data on long-term efficacy and safety outcomes of non-antireflux RALUR. We assessed patients undergoing RALUR, evaluating operative, functional, and safety determinants. Materials and Methods: All consecutive patients undergoing non-antireflux RALUR between April 2015 and January 2020 were included in this retrospective cohort study. The primary outcome endpoint was recurrent distal ureteral obstruction. Results: Mean follow-up was 41.3 months (95% confidence interval, 33.3-49.2; range 2-82). Among the 26 included patients, none developed recurrent distal ureteral obstruction. Kidney function in terms of serum creatinine level (72.0 µmol/L vs 71.0 µmol/L, p = 0.988) and glomerular filtration rate (92.0 mL/min vs 91.0 mL/min, p = 0.831) was stable between the preoperative period and the last follow-up. Renal pelvis dilatation decreased significantly postoperatively, from grade 2 to grade 0 (p < 0.001). Most patients (73.1%) remained free from any clinical symptoms of reflux during the follow-up. No recurring urinary tract infections were reported. The rate of postoperative complications (Clavien-Dindo grade ≥II) was 23.1%. All complications resolved without sequelae. Conclusions: Non-antireflux RALUR appears to be safe and effective in the management of distal ureteral obstruction. There was no recurrent ureteral obstruction after RALUR in our cohort during a mean follow-up of more than 3 years. Non-antireflux reimplantation did not seem to have any notable impact on renal function during the follow-up period.

Rate of recurrent hydronephrosis after laparoscopic ureteroneocystostomy for ureteral endometriosis.

STUDY OBJECTIVE: To investigate the short-term outcomes of laparoscopic ureteroneocystostomy in patients with ureteral endometriosis (UE). DESIGN: Retrospective cohort study of consecutive patients who underwent surgery for the ureter endometriosis with hydronephrosis. SETTING: A private hospital that provide primary, secondary and tertiary care. PATIENTS: 30 consecutive patients with UE who underwent laparoscopic ureteroneocystostomy at our institution between May 2008 and April 2020. INTERVENTIONS: Laparoscopic ureteroneocystostomy, if necessary, hysterectomy, salpingo-oophorectomy, cystectomy, partial bladder resection, or partial bowel resection were performed. MEASUREMENTS AND MAIN RESULTS: The most common chief complaint was pelvic pain (40%). Endometriosis affected only the left ureter in 56.7% of patients, only the right ureter in 33.3%, and both ureters in 6.7%. Involvement of the ipsilateral ovary was confirmed in 64.3%. The most frequent location of UE was 1-3 cm above the UVJ (46.7%). A psoas hitch was performed in 7 patients (23.3%), and the Boari flap was used in 9 patients (30%). Hysterectomy was performed in 12 patients (40%), and 6 of them had a concomitant bilateral salpingo-oophorectomy (20%). In addition, 3 patients (10%) underwent partial bowel resection, and 2 patients (6.7%) underwent partial bladder resection. After surgery, 24 of 27 patients (80.0%) were free of sever hydronephrosis after surgery. Hydronephrosis recurred in a single patient (3.3%), but the grade of hydronephrosis improved significantly after surgery (P < 0.001). At 6 months of follow up, 4 patients (13.3%) experienced urinary tract infections and 2 patients (6.7%) reported dysuria. Patients reported a regression of dysmenorrhea symptoms (P < 0.001). CONCLUSION: This study shows that ureteroneocystostomy provides good results in terms of relapses and symptom control in patients with ureteral endometriosis.

Desmoid fibromatosis involving the ureter: A rare presentation with intraoperative challenges.

Following failed retrograde and antegrade ureteric stenting, a 35-year-old male patient underwent an elective boari flap for marked proximal hydroureteronephrosis due to a periureteric mass in the right iliac fossa. Intraoperative vascular surgical assistance was required for control of arterial bleeding due to friable vessel wall. Histopathology demonstrated desmoid fibromatosis.

Robot-Assisted Ureteral Reimplantation: A Single-Center Comparative Study.

Background: Aim of this study was to report a single-center experience with robot-assisted ureteral reimplantation (RAUR) and to compare its outcomes with those of open ureteral reimplantation (OUR). Materials and Methods: Patients who underwent RAUR or OUR for ureteral disease between 2016 and 2020 were identified. Data collected included baseline, pathologic, perioperative, and postoperative features. The RAUR outcomes were compared with those of OUR. Results: Overall, 21 (42.8%) patients underwent RAUR, and 28 (57.2%) underwent OUR. The two groups were similar in terms of baseline and pathologic characteristics. There was a statistically significant difference in favor of RAUR for median operative time (216 vs 317 minutes, p = 0.01) and median blood loss (35 vs 175 mL, p = 0.001). No difference was observed in overall complication rate (33.3% vs 46.4%, p = 0.9), as well as major complications (Clavien-Dindo≥III grade) rate between RAUR and OUR groups. Median length of stay was shorter for RAUR (2 vs 6 days; p = 0.001), as well as median catheterization time (16 vs 28 days; p = 0.005). Conclusions: RAUR is a safe and effective minimally invasive surgical procedure for the management of mid to distal ureteral strictures. It can recapitulate the success rate of the gold standard OUR while offering a benefit in terms of lower surgical morbidity and faster postoperative recovery.

Robot-assisted Boari flap and psoas hitch ureteric reimplantation: technique insight and outcomes of a case series with ≥1 year of follow-up.

OBJECTIVE: To describe step-by-step surgical techniques and report outcomes of the largest single-centre series of patients with distal ureteric disease exclusively treated with robot-assisted ureteric reimplantation with Boari flap (RABFUR) and psoas hitch (RAPHUR), with a minimum follow-up of 1 year and complete postoperative data. PATIENTS AND METHODS: A total of 37 patients with distal ureteric disease were treated between 2010 and 2018. Of these, 81% and 19% underwent RAPHUR and RABFUR, respectively. Intra-, peri- and postoperative outcomes were assessed. The 90-day postoperative complications were reported according to the standardised methodology proposed by the European Association of Urology Ad Hoc Panel. Functional outcomes (creatinine, estimated glomerular filtration rate [eGFR]) and postoperative symptoms (visual analogue pain scale) were assessed. RESULTS: The median operating time and blood loss were 180 min and 100 mL, respectively. There were no conversions to open surgery and no intraoperative transfusions. The median length of stay, bladder catheter indwelling time and stent removal were 4, 7 and 30 days, respectively. The median follow-up was 24 months. Overall, 10 patients (27%) had postoperative complications and of these, eight (22%) and two (5.4%) were Clavien-Dindo Grade I-II and III, respectively. At the last follow-up, the median postoperative creatinine level and eGFR were 0.9 mg/dL and 73.5 mL/min/1.73 m2 , respectively. At the last follow-up, five (13.5%) and three (8%) patients had Grade 1 hydronephrosis and mild urinary symptoms, respectively. The study limitations include its retrospective nature. CONCLUSION: In the present study, we present our RABFUR and RAPHUR techniques. We confirm the feasibility and safety profile of both approaches in patients with distal ureteric disease relying on the largest single-centre series with ≥1 year of follow-up.

[Lower urinary tract urodynamics after reconstruction of the pelvic part of the ureter].

INTRODUCTION: The problem of impaired urodynamics of the lower urinary tract after reconstructive surgery of the pelvic ureter remains almost unexplored in modern literature. There are only a few publications about the effect of operations in the area of the ureterovesical segment on bladder function. AIM: To study the function of bladder after replacing the pelvic ureter with bladder flap, small intestine or appendix. MATERIALS AND METHODS: We performed a retrospective analysis of reconstructive operations of the distal ureter, which were performed in 273 patients. Boari flap or its modifications were used in 142 (52%) cases; ureteroappendicocystanastomosis - 23 (8.4%) patients, and replacement of the pelvic ureter with small intestine in 105 (38.5%) cases. A follow-up urodynamics was carried out on the 10-14th day of the postoperative period, after 3 months, then after 6 and 12 months. We evaluated: uroflowmetry, cystometry, and pressureflow study. RESULTS: In 75 (53%) of 142 patients who underwent Boari flap or its modifications, varying degrees of disturbance of bladder urodynamics were observed. After isoperistaltic intestinal ureteroplasty in 2 (2.5%) of 79 patients, detrusor hyperactivity was observed, which was regressed following conservative therapy. Urodynamics of bladder did not suffer after appendicoplasty. CONCLUSION: Deformation, denervation and devascularization of detrusor are the main causes of bladder dysfunction after flap operations. Ileal ureter substitution with isoperistaltic position of the graft provides physiological passage urine from the kidney to the bladder, following good bladder function. The inclusion of antiperistaltic ileal loop in the urinary tract negatively affects the urodynamics.

Ureteral Reimplantation, Psoas Hitch, and Boari Flap.

Introduction: Ureteral reimplantation is indicated for patients with congenital distal ureteral strictures, for iatrogenic intraoperative distal ureteral injuries, and for those who require distal ureterectomy for transitional cell carcinoma. Methods: Using the da Vinci system from Intuitive, we demonstrate distal ureterectomy with reimplantation. Both a refluxing extravesical reimplant and nonrefluxing extravesical reimplant are shown. We also demonstrate modifications, including psoas hitch and Boari flap. Results: Robotic ureteral reimplantation with psoas hitch and Boari flap are demonstrated in a reproducible manner. Additional topics covered include the delineation of diseased ureter vs healthy ureter, the applications of indocyanine green, and the use of interoperative ureteral stents. Conclusions: Robotic ureteral reimplantation is safe and feasible when performed with proper technique. Ureteroscopy and near-infrared fluorescence technology facilitate improved detection of diseased ureteral segments. Key points include the maintenance of principles of open surgery such as a tension-free, watertight, and stented anastomosis.

Laparoscopic Ureteral Reimplantation for the Management of Long-segment Ureteral Defect in Gynecologic Surgeries.

OBJECTIVE: To demonstrate techniques of laparoscopic ureteral reconstruction for long-segment ureteral defects in gynecologic surgeries. DESIGN: Step-by-step demonstration of a laparoscopic ureteral reimplantation using the Boari flap and ileal interposition. SETTING: Gynecologic diseases often involve the ureter; hence, knowledge of ureteral reconstruction techniques is imperative in gynecologic surgeries. The important aspect of ureteral reconstruction is to ensure tension-free anastomosis; therefore, various methods are required depending on the length of the ureteral defect [1]. The Boari flap and ileal interposition are preferred for repairing 8-cm to 12-cm and >12-cm ureteral defects, respectively. These methods have traditionally required large incisions [2,3]. Laparoscopic ureteral reimplantation using the Boari flap and ileal interposition has been reported to be as safe as the open technique and superior in terms of postoperative recovery in urologic surgeries [3,4]; however, to the best of our knowledge, it has not been reported in the field of gynecology. To our knowledge, this is the first report to demonstrate the techniques of laparoscopic Boari flap and ileal ureter replacement in gynecologic surgeries. The technique was approved by our institutional review board. INTERVENTIONS: The first case involved an intra-abdominal desmoid tumor, whereas the second case involved recurrent endometrial cancer. In both cases, long-segment ureteral resection was required to achieve complete tumor clearance. Laparoscopic ureteral reimplantation was performed successfully, without any complications, using the Boari flap in the first case and ileal interposition in the second. CONCLUSION: Laparoscopic ureteral reimplantation is technically feasible for the management of long-segment ureteral defects.

Management of iatrogenic ureteral injury: Ureteral reimplantation with a bilateral Boari flap.

Reconstruction of the ureter is still regarded as a sophisticated approach demanding absolute dedication of the urologists. Similarly, iatrogenic ureteral injuries, as well as strictures, are quite common complexities of the pelvic and gynecological surgeries which if left untreated could lead to short as well as long-term issues. Presently, a case of a post-caesarian section along with hysterectomy of 40 years old woman has been presented that has resulted in distal left ureteral injury. A bilateral Boari flap was performed for the mobilization of the bladder.

Extended Boari-flap reconstruction in isolated tuberculous pan-ureteral stricture.

A 53-year-old female presented with left loin pain and imaging showed left pan-ureteral stricture secondary to tuberculosis. The renal unit was salvaged by percutaneous nephrostomy. She was planned for ileal ureteric replacement. An extended Boari flap was constructed for her as the bladder capacity was good and Boari bladder flap reached the renal pelvis without tension. Follow-up nephrostogram revealed wide pyelovesical junction with prompt drainage. She completed antituberculous treatment. Extended Boari flap is rarely used for upper ureteric reconstruction. It should be considered as an option for complete ureteric reconstruction in the unilateral pan-ureteral stricture in selected cases.

[Usefulness of indocyanine green (ICG) in robotic reconstructive surgery.] / Utilidad de indocianina verde en cirugía reconstructiva robótica.

The experience with robotic reconstructive surgery has been reported previously. Many studies have demonstrated that the use of robotic surgery for those procedures is safe and effective. However, the characteristics related to those cases, make reconstructive surgery a very complex procedure that is usually managed in some referral centers only. Indocyanin green (ICG) is a substance that could be visualized using near-infrared fluorescence (NIRF). This fluorescence could help the surgeon for orientation and evaluation of viability of the tissues. OBJECTIVE: This article describes the literature and our experience using ICG for reconstructive surgery of the ureter. METHODS: We describe the literature and our approach for the evaluation and treatment of the ureteral stricture using ICG. CONCLUSION: The use of ICG has demonstrate to be safe, easy to perform and reproducible. In this article, we showed the ICG usefulness for complex reconstructive cases. Prospective studies with long follow up and bigger simple will permit a better evaluation of its results.

La experiencia con la cirugía reconstructiva asistida por robot ha sido reportada previamente. Dichos estudios han demostrado que el uso del robot en este tipo de procedimientos es seguro y eficaz. Sin embargo, las características de este tipo de casos hacen que la cirugía reconstructiva sea altamente compleja y por ende realizada solo en algunos centros de referencia. La ausencia de tacto durante la cirugía robótica hace que el cirujano dependa de ciertas claves visuales para su orientación. La indocianina verde (ICV) es un tinte que puede ser visualizado usando fluorescencia cercana a la luz infrarroja (FCLI). Dicha fluorescencia puede ser utilizada tanto para la orientación del cirujano como para la evaluación de la viabilidad de tejidos.OBJETIVO: En este artículo describimos el uso reportado en la literatura y nuestra experiencia utilizando ICV en cirugía reconstructiva, principalmente ureteral.MÉTODOS: Describimos nuestro abordaje en la evaluación y tratamiento de pacientes con estrechez ureteral usando ICV. A la vez, hacemos una revisión de los estudios previos realizados sobre este tema.CONCLUSIÓN: El uso de ICV ha demostrado ser seguro, fácil de realizar y repetir. La literatura y nuestra experiencia demuestra su utilidad en casos reconstructivos complejos. Estudios prospectivos a largo plazo y mayor escala permitirán evaluar mejor estos resultados.

[Surgical reconstruction of the ureter]. / Rekonstruktionsmöglichkeiten des Harnleiters.

Defects in ureteral continuity and function can originate from various etiologies such as stricture, radiotherapy, tuberculosis, tumor, trauma or perforation due to iatrogenic injury. The surgical options for the management of ureteral defects are complex and depend on the location of the defect. The aim of the surgical management of ureteral stricture is the reconstruction of an anti-refluxive and nonobstructive flow of urine to preserve kidney function. There are numerous possibilities for the reconstruction of ureteral defects ranging from ureteroneocystostomy with or without psoas-hitch- or Boari-flap to ileal ureteral replacement. Nearly all these techniques can either be done in open surgery or in a laparoscopically or robotic-assisted manner. The technique of robotic-assisted reconstruction of ureteral defects is challenging but offers a great opportunity. The aim of this article is to provide an overview of current surgical procedures in ureteric reconstruction.

Laparoscopic ureteroneocystostomy for mid and lower ureteric strictures: Experience from a tertiary center.

PURPOSE: The purpose of this study is to evaluate our experience of laparoscopic ureteroneocystostomy for mid and lower ureteral stricture in a tertiary center in North India. MATERIALS AND METHODS: A total of 20 laparoscopic ureteroneocystostomy were performed with or without bladder flap procedures in 20 patients (13 females and 7 males) with various etiologies such as ureteric stricture, ureterovaginal fistula, endometriosis, and distal ureteric tumor at our hospital in a time frame from August 2013 to January 2017. Eight cases each presented after laparoscopic/open hysterectomy and postureterorenoscopic stone removal while two cases each presented secondary to endometriosis and distal ureteric tumor. Simple laparoscopic ureteroneocystostomy in 4, psoas hitch in 9, and Boari flap was done in 7 cases. RESULTS: The mean patient age was 44.2 years (range 19-65), mean surgical time was 184.25 min (115-250 min.), mean amount of bleeding was 153.25 mL (90-250 mL), and mean hospital stay was 3.05 days (2-7 days). Female-to-male ratio was 1.3:0.7. There was one conversion to open during laparoscopic Boari reimplant because of inadvertent injury to external iliac vein. The mean follow-up was 22.35 months (6-45). All the patients were asymptomatic with the resolution of hydronephrosis on ultrasound and without any significant obstruction on renal scan. CONCLUSIONS: Laparoscopic ureteroneocystostomy with or without bladder flap (Boari) provides good functional outcomes with excellent success rates and minimal morbidity comparable to open surgery in patients with ureteric stricture.

Minimally Invasive Management of Concomitant Vesicovaginal and Ureterovaginal Fistulas After Transabdominal Hysterectomy: Laparoscopic Vesicovaginal Fistula Repair With Ureteroneocystostomy Using a Boari Flap.

STUDY OBJECTIVE: To demonstrate a laparoscopic approach for repair of concomitant vesicovaginal and ureterovaginal fistulas as a troublesome complication of transabdominal hysterectomy (TAH). DESIGN: Video presentation with narration demonstrating a laparoscopic approach for repair of a vesicovaginal fistula and ureter reimplantation using a bladder (Boari) flap (Canadian Task Force Classification III). SETTING: Mothers and Children Hospital, Shiraz University of Medical Sciences. The local Institutional Review Board deemed this video exempt from formal approval. INTERVENTIONS: This 55-year-old woman had a history of continuous urine leakage from the vagina for 10 days after undergoing a complicated TAH. She had sustained an injury to the posterior bladder wall and right ureteral transection during TAH, which had been recognized and managed by ureteroneocystostomy into the posterior bladder wall over a double-J stent and bladder repair. A 4-week course of conservative therapy failed to manage her continuous urine leakage. After cystoscopic evaluation and catheterization of the fistula tract and left ureter, 4-port transperitoneal laparoscopy was performed. The right ureter was identified, divided, and mobilized. The vesicovaginal pouch was entered, the posterior wall of the bladder was opened at the level of the fistula, and the fistula tract was dissected. Once the bladder was separated from the vaginal cuff, both were repaired with absorbable sutures, and an omental flap was interposed between them. The Retzius space was developed, and a 7 × 2-cm bladder (Boari) flap was harvested from the anterior bladder wall to bridge the gap between the bladder and the ureter. After the bladder flap was tabularized, it was anastomosed to the right ureter, and the anterior bladder wall was closed. The total operating time was 250 minutes. Excellent laparoscopic visualization and magnification, along with the presence of a catheter in the fistula tract, allowed for meticulous dissection in the retrovesical space between the bladder and the vaginal cuff, as well as resection of the fistula tract with minimal manipulation of the bladder, without the need for a large cystotomy. The Foley and the ureter catheters were removed at 2 and 4 weeks after the operation, respectively. Intravenous pyelography at 3 months postsurgery showed no hydronephrosis, and the patient remained symptom-free during the follow-up period. CONCLUSION: With adequate laparoscopic experience and patient counseling, complex genitourinary fistulas can be approached with a minimally invasive technique. The laparoscopic approach provides excellent exposure to a poorly exposed area of the retrovesical space while minimizing bladder manipulation.