These are the operative techniques for repairing a ureteral defect or stricture, chosen by the length and location of the defect. The clinical indications, defect-length comparison, and contraindications are covered in the Urinary Tract Obstruction topic; this page is the operative reference. The unifying principles of any ureteral repair are a spatulated, tension-free, stented, watertight anastomosis with fine absorbable monofilament, retroperitoneal drainage, and preservation of the periureteric adventitial blood supply.
| Repair | Defect bridged | Typical use |
|---|---|---|
| Ureteroureterostomy | 2–3 cm | Short upper/mid-ureteral defect |
| Ureteroneocystostomy | 4–5 cm | Distal-ureteral injury/obstruction |
| Psoas hitch | 6–10 cm | Lower-ureteral defect (adds bladder mobilisation) |
Ureteroureterostomy
An end-to-end anastomosis for a short (2–3 cm) defect of the upper or mid-ureter. Only short defects are suitable — tension on the anastomosis almost always causes stricture (success of a tension-free, watertight repair is >90%). Lower-ureteral strictures are better managed by ureteroneocystostomy.
Technique
- Stay stitches — place 3-0 silk at 12 o'clock on the proximal and distal ureter, a few centimetres from the cut ends, to preserve orientation (removed later).
- Spatulate both ureters for 1–1.5 cm — the proximal at 6 o'clock and the distal at 12 o'clock — guided by the stay sutures so the spatulations face each other.
- Posterior anastomosis — with 4-0 absorbable monofilament (Monocryl or PDS), take an outside-in bite on the proximal ureter at one corner of the cut apex (6 o'clock) and a corresponding inside-out bite on the distal ureter just lateral to 6 o'clock; tie, cut the tail, and park the needle on a rubber-shod clamp. Repeat on the opposite side of the apex.
- Insert a double-J stent — pass a guidewire through the proximal ureter into the renal pelvis and advance the stent over it, removing the wire once the stent is in the pelvis. To seat the distal end in the bladder, cut a side hole in the stent and pass the floppy wire end into the bladder and the firm end through the distal stent and the cut hole, then advance the stent over the wire and remove it.
- Anterior anastomosis — place a U-stitch at 12 o'clock, then run each arm to complete the closure, tying to the long tails of the U-stitch.
- If tissue quality is tenuous, use an interrupted anastomosis — it allows more precise closure and protects the repair if a single bite is compromised.
- Remove the silk stay sutures and place a surgical drain.
Postoperative Care
Leave a Foley catheter for 1–2 days. Remove the drain after 24–48 hours of minimal output (if the case was not entirely retroperitoneal, check the drain-fluid creatinine first to exclude a urine leak). Remove the double-J stent at 4–6 weeks.
Ureteroneocystostomy
Ureteral reimplantation into the bladder for an injury or obstruction of the distal 3–4 cm of the ureter (bridges a 4–5 cm defect). Perform a direct reimplant only if it is tension-free; otherwise add a psoas hitch or Boari flap. The approach may be intravesical, extravesical, or combined, and tunnelled or non-tunnelled — refluxing and anti-refluxing anastomoses show no significant difference in renal function or stenosis.
Technique (extravesical)
- Cystotomy — make a 1–1.5 cm vertical cautery incision on the anterior bladder; place 4-0 chromic inside-out stay bites at the four quadrants and tag them with snaps.
- Spatulate the ureter for 1–1.5 cm at 6 o'clock.
- Cephalad anastomosis — with 3-0 absorbable monofilament, take an outside-in bite on the bladder at the lower aspect of the cystotomy and an inside-out bite on one side of the ureteral 6-o'clock apex; repeat on the contralateral side; tie and park the needles on shods.
- Insert a double-J stent over a guidewire into the renal pelvis, allowing the distal curl to fall into the bladder.
- Caudal anastomosis — place a U-stitch from the ureteral 12 o'clock to the upper aspect of the cystotomy.
- Complete the anastomosis by running each suture distally (outside-in on the ureter, inside-out on the bladder), tying to the U-stitch.
- Place a surgical drain.
Psoas Hitch
A psoas hitch bridges a defect of the lower third of the ureter (6–10 cm), adding up to ~5 cm of length over a simple reimplant by anchoring the bladder to the psoas. It is preferred over ureteroureterostomy for lower-ureteral injuries (whose blood supply may not survive transection) and over the Boari flap for its simplicity, lower vascular risk, and fewer voiding problems. It is contraindicated with a small, contracted bladder.
Technique
- Identify the ureter — medial to the medial umbilical ligament, or anterior to the common-iliac bifurcation.
- Mobilise the ureter — encircle it with a vessel loop, mobilise proximally and distally while preserving the periureteric adventitia, then ligate and transect it distally (and proximally above any mass/fistula, sending a frozen section from the cut edge for a mass); place a 12-o'clock stay suture.
- Mobilise the bladder — fill it with 200–300 mL of saline, dissect the peritoneum off, and divide the median umbilical ligament (urachus) and ipsilateral medial umbilical ligament; dividing the contralateral superior vesical artery adds further mobility. The aim is tension-free fixation of the bladder to the psoas ≥2–3 cm above the common iliac vessel.
- Cystotomy — place two stay sutures 4–5 cm apart in an oblique orientation (medial suture more superior) and make a 4–5 cm oblique incision between them.
- Evaluate tension — with an index finger inside the bladder, elevate its cranial aspect to the intended psoas fixation point; if it does not reach without tension, extend the incision for a longer flap.
- Fixation to psoas — use two or three 3-0 absorbable monofilament sutures through the full detrusor thickness (excluding mucosa) and the psoas tendon, above the common iliac artery and the femoral branch of the genitofemoral nerve — taking care to avoid the genitofemoral and femoral nerves.
- Perform the ureteroneocystostomy, insert a stent, close the bladder, and place a surgical drain.
Complications
- Early — nerve injury (the femoral nerve is most likely), bowel injury, iliac-vein injury, and urosepsis.
- Late — urinary fistula and ureteral obstruction.
Key Exam Points
- Match the repair to the defect: ureteroureterostomy (2–3 cm) → ureteroneocystostomy (4–5 cm) → psoas hitch (6–10 cm) → Boari flap (10–15 cm).
- Every ureteral anastomosis must be spatulated, tension-free, stented, and watertight, with preserved adventitial blood supply and retroperitoneal drainage.
- Ureteroureterostomy is only for short upper/mid defects; tension causes stricture (success >90% when tension-free).
- Refluxing and anti-refluxing reimplants show no significant difference in renal function or stenosis.
- The psoas hitch is anchored to the psoas tendon above the iliac vessels; the femoral nerve is the most likely nerve injury.
- Remove the ureteral stent at 4–6 weeks and confirm healing with imaging.