Open Boari Flap Teaching Simulation using a Porcine Model

Ureteral injury is an uncommon but serious complication of gynecologic surgery, with most injuries occurring in the distal 4-5 cm of the ureter. These injuries may require advanced reconstructive techniques, such as ureteroneocystostomy with a Boari flap, to achieve a tension-free repair. Due to the rarity of this complication, OB/GYN trainees have limited exposure to ureteral reimplantation and Boari flap creation. We developed and validated a high-fidelity simulation model for Boari flap creation with ureteral reimplantation using freshly harvested porcine bladders. Trainees (16 urogynecology fellows and two OB/GYN residents) first viewed an author-produced instructional video detailing procedural steps. Under supervision, participants then performed the procedure: distal ureter transection and spatulation; creation of a U-shaped bladder flap; formation of a submucosal tunnel; ureteral advancement and anastomosis; ureteral catheter placement; and two-layer bladder closure. Face validity and confidence in describing the steps of the procedure was assessed with pre- and post-simulation questionnaires. All participants reported increased confidence, with 56% agreeing and 44% strongly agreeing they felt confident describing the procedural steps after performing the simulation. Among 18 participants, 61% had never observed ureteral reimplantation, and none had performed it previously. The figure contains still images from the instructional video, illustrating key procedural steps from flap creation to final bladder closure. The accompanying video provides a detailed, step-by-step demonstration of the technique and serves as a visual guide to complement the hands-on simulation experience. This reproducible simulation fills a critical gap in surgical education by offering realistic, tactile exposure to Boari flap creation with ureteral reimplantation. Incorporating this model into OB/GYN training programs can improve procedural familiarity, technical skill, and understanding of this complex ureteral repair procedure.