Ureteral Reconstruction

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 suture, retroperitoneal drainage, and preservation of the periureteric adventitial blood supply — "the ureter is a surgically forgiving structure with good vascular supply" (Turner-Warwick), but only when handled atraumatically.

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Preoperative Evaluation

• Define the stricture — etiology, location, and length before any repair.
  • Combine an antegrade nephrostogram with a retrograde pyelogram (an "up-and-down-o-gram") to delineate the segment.
  • Rule out malignancy in any at-risk stricture.
• Assess the renal unit — functional imaging (nuclear renography); < 20% function predicts a lower cure rate and may favour nephrectomy over a complex repair.
• Assess the bladder — capacity and function, since a psoas hitch, Boari flap, or ileal ureter depend on it. Where a stent is already in place, allow ~6 weeks of ureteral rest (stent out, percutaneous nephrostomy in) before reconstruction, and always evaluate the contralateral tract first.

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Matching the Repair to the Defect

Ureterolysis (for retroperitoneal fibrosis) and onlay graft/flap ureteroplasty are covered separately below — they relieve or patch a stricture rather than bridge a resected gap.

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Ureteroureterostomy

An end-to-end anastomosis for a short (2–3 cm) defect of the upper or mid-ureter; a spatulated repair tolerates up to 3–4 cm because the ureter can be mobilised. Only short defects are suitable — tension almost always causes stricture (a tension-free, watertight repair succeeds > 90%). Lower-ureteral strictures are better managed by ureteroneocystostomy.

Technique

1. Stay stitches (no-touch) — place 3-0 silk on the anterior ureter a few centimetres from the cut ends to preserve orientation and avoid handling the ureter directly (removed later).
2. Debride and spatulate — resect the damaged segment (debride generously after a high-velocity gunshot wound, > 2000 ft/sec, given the wide zone of devitalisation) and spatulate both ends 1.5 cm into healthy ureter on opposite sides, so the unspatulated end of one meets the spatulation of the other.
3. Posterior anastomosis — with 4-0/5-0 absorbable suture (braided polyglactin or polyglycolic acid), place knots at the lateral margin, not the apex, and start the running line in the middle of the wall; interrupt runs every two to four sutures, locking every third throw.
   • Take the break out of the table to reduce tension.
4. Insert a double-J stent over a guidewire into the renal pelvis.
5. Anterior anastomosis — roll the anterior edges together and complete the repair (running or interrupted; interrupted if tissue is tenuous, so one compromised bite doesn't jeopardise the whole repair).
6. Remove the silk stays and place a retroperitoneal drain.

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Transureteroureterostomy (TUU)

Transposes the injured ureter across the midline into the contralateral ureter — reserved for a long mid-distal defect with limited pelvic access that precludes a reimplant with psoas hitch or Boari flap; usually a delayed procedure. Because it risks converting a unilateral injury into a bilateral one, ileal interposition or ureteroureterostomy with renal mobilisation is generally preferred.

• Contraindications — absolute: insufficient donor length. Relative: nephrolithiasis, upper-tract urothelial malignancy, retroperitoneal fibrosis, chronic pyelonephritis, or abdominopelvic radiation (any process that risks both ureters). A preoperative VCUG must exclude recipient reflux.
• Technique — a midline incision (to the xiphoid for proximal reach); mobilise the donor ureter 10–12 cm, preserving adventitia; tunnel it through the retroperitoneum posterior to the small-bowel mesentery, cephalad/proximal to the inferior mesenteric artery; spatulate the donor 1.5 cm, make a matching medial ureterotomy in the recipient, and complete a tension-free, end-to-side anastomosis with 5-0 polyglactin over a stent.

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Ureteroneocystostomy

Ureteral reimplantation into the bladder for an injury or obstruction of the distal 3–4 cm (bridges a 4–5 cm defect); in children it is the definitive repair for VUR (operative indications: recurrent febrile UTIs, or persistent high-grade grade IV–V reflux) and for obstructing megaureter. Reimplant directly only if tension-free — otherwise add a psoas hitch or Boari flap. The approach may be intravesical, extravesical, or combined; refluxing and anti-refluxing anastomoses show no significant difference in renal function or stenosis. The governing rule is a submucosal tunnel-to-ureteral-diameter ratio of at least 5 : 1, with atraumatic handling and no angulation, twist, or kink.

Technique (extravesical, Lich-Gregoir — the adult workhorse)

1. Expose the bladder — extraperitoneally, with a urethral Foley and the bladder filled by gravity (or left distended after cystoscopy).
   • The obliterated umbilical artery is a useful landmark: the ureter runs just beneath it, and the artery may be ligated and divided to aid exposure.
2. Isolate the ureter — pass a vessel loop posterior to it for atraumatic traction and dissect caudally toward the bladder hiatus, preserving the periureteric adventitia.
3. Create the detrusor trough — incise the detrusor along the intended tunnel with electrocautery, dissecting outside Waldeyer's sheath down to the urothelium, which shows as a translucent bluish layer when the bladder is full.
4. Raise detrusor flaps — dissect them off the urothelium perpendicular to the tunnel (blunt + electrocautery); repair any small urothelial violation with a 5-0 chromic figure-8.
5. Spatulate the ureter 1.5 cm and lay it in the trough, then anastomose transmural ureter to bladder urothelium with 3-0 absorbable suture.
6. Insert a double-J stent into the renal pelvis, letting the distal curl fall into the bladder.
7. Close the detrusor over the ureter with 2-0 polyglactin interrupted sutures to build the tunnel — not so tightly as to obstruct — and place a retroperitoneal drain.

Technique (intravesical, transvesical — e.g. Politano-Leadbetter)

1. Cannulate the ureter — open the bladder, intubate the ureter with a 3.5- or 5-Fr feeding tube secured with 4-0 silk, and score the urothelium circumferentially around the orifice, leaving a cuff.
2. Mobilise the intramural ureter — dissect sharply within Waldeyer's sheath, then free the extravesical ureter off the peritoneum (cauterising the small superior-vesical-artery branches), keeping caudal traction on the feeding tube.
3. Create the neohiatus — make a transmural incision in the posterior bladder wall over a right-angle clamp, transfer the ureter to it, and close the original hiatus with running 2-0 polyglactin.
4. Submucosal tunnel — dissect a tunnel from the neohiatus toward the original hiatus with tenotomy scissors, draw the ureter through, and spatulate its distal end.
5. Anastomose — anchor the distal posterior ureter to the neohiatus with interrupted 4-0 chromic at the 6-, 5-, and 7-o'clock positions (catching deep muscle and urothelium), then approximate the orifice urothelium to the spatulated ureter at 12 o'clock with 5-0 chromic, closing the urothelium over the tunnel with a running 5-0 chromic.
6. Check and close — pass a feeding tube proximal to the hiatus to confirm there is no kink or twist, then close the bladder in two layers (running 3-0 urothelium, 2-0 seromuscular) over a stent.

Named variants (compact)

Cross-trigonal (Cohen) is reserved for when anatomy precludes the others, because it does not recreate normal intramural anatomy and hampers future endoscopic upper-tract access.

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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

1. Identify and mobilise the ureter — medial to the medial umbilical ligament, or anterior to the common-iliac bifurcation; encircle it with a vessel loop, mobilise while preserving the periureteric adventitia, then ligate/transect distally (frozen section from the cut edge if a mass is suspected) and place a 12-o'clock stay suture.
2. Mobilise the bladder — fill it with 200–300 mL of saline, divide the urachus and the ipsilateral medial umbilical ligament; dividing the contralateral superior vesical artery adds mobility.
   • Confirm the dome reaches ≥ 2–3 cm above the ipsilateral common iliac vessels.
3. Oblique cystotomy — two stay sutures 4–5 cm apart (medial one more superior), incised between them; lateral relaxing incisions or downward nephropexy add reach if still under tension.
4. Fix to the psoas — three to five slowly-absorbing 2-0 sutures through the full detrusor thickness (not mucosa) into the psoas tendon (incorporate the psoas minor tendon if present), above the common iliac artery; avoid the genitofemoral and femoral nerves.
5. Deliver the ureter at the superolateral dome (a less-mobile point that keeps the course straight and kink-free), reimplant it (tunnelled nonrefluxing preferred, not mandatory), stent, and close the bladder in two layers with a drain.

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Boari Flap

A tubularised anterior-bladder-wall flap that bridges a larger mid-to-distal gap (≤ 10–15 cm) when the ureter and bladder cannot otherwise reach; frequently combined with a psoas hitch. A small-capacity bladder is the main limitation.

• Flap design — at least 4 cm wide at the base and 3 cm at the tip (or three times the ureteral diameter), with length = defect + 3–4 cm if a nonrefluxing tunnel is planned; keep the length : base ratio ≤ 3 : 1 to avoid flap ischemia (an oblique or S-shaped incision buys length if capacity allows).
• Technique — fill the bladder, outline and incise the flap across its narrow (distal) end; protect the contralateral ureter with a 5-Fr catheter; psoas-hitch the ipsilateral posterior wall.
  • Create a 3-cm submucosal tunnel, draw the ureter through with an 8-Fr feeding tube so the flap overlaps the ureter ≥ 3 cm, spatulate obliquely, and complete the anastomosis with 4-0 Vicryl.
  • If the ureter is still too short, mobilise the kidney within Gerota fascia for another 4–5 cm, or accept a refluxing anastomosis.
• Close over a double-J stent and 18-Fr Foley in two layers; cover with peritoneum, drain retroperitoneally, and prescribe anticholinergics. Cystogram at ≥ 10 days before removing the stent and catheter. (A voiding-diary capacity ≥ 300 cc predicts adequate post-flap function.)

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Ileal Ureter Replacement

Intestinal interposition is a last resort — exhaust ureteroureterostomy, psoas hitch, Boari flap, and TUU first — because of the metabolic burden. It is not for the acute setting.

• Contraindications — baseline renal insufficiency (creatinine > 2 mg/dL), inflammatory bowel disease, radiation enteritis, and bladder dysfunction/outlet obstruction. Poor candidates: GFR < 60, affected kidney < 20% function, or low bladder compliance (< 15 cm H₂O/cc) and capacity (< 50 cc) — favour nephrectomy or diversion (± augmentation) instead.
• Intact isoperistaltic segment — a midline xiphoid-to-pubis incision; measure the defect, avoid the terminal ileum (B12/bile-salt malabsorption), and isolate an isoperistaltic segment tagged with long-distal/short-proximal stays.
  • A left-sided replacement needs a 5-cm window in the left-colon mesentery.
  • Anastomose the proximal end to the renal pelvis and the distal end to the posterior bladder dome with full-thickness 3-0 absorbable suture; reflux prevention is generally unnecessary, and a psoas hitch/Boari flap shortens the bowel needed.
  • Drain both anastomoses; a "reverse-7" L-shaped segment can replace both ureters.
• Yang-Monti tube — reconfigures a short, wide segment into a long, narrow tube: detubularise a 2–3 cm segment along its antimesenteric border and retubularise it in the opposite axis over a 16-Fr catheter (≈ 8–10 cm of length; join segments for a double/triple Monti).
  • Its shorter bowel requirement minimises metabolic derangement and eases a nonrefluxing anastomosis.

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Ureterolysis

Frees the ureters from retroperitoneal fibrosis (RPF), which centres on the distal aorta at L4–L5 and encases the ureters. Because RPF is 10–20% malignant (and 30–40% idiopathic), biopsy the retroperitoneal mass before or during the procedure. Idiopathic RPF is treated medically (corticosteroids) first; ureterolysis is reserved for medical failure.

• Technique — a midline xiphoid-to-pubis incision; mobilise both colons along the white line of Toldt, start from normal ureter and free it from the fibrosis (it changes from constricted white to healthy pink as flow returns).
  • Because RPF is generally bilateral, perform bilateral ureterolysis, and protect the ureters from recurrence by intraperitonealisation or a 360° omental wrap (based on the gastroepiploic arteries).
  • Confirm relief with a Whitaker test; laparoscopic ureterolysis is an option, and autotransplantation is the fallback if lysis is not feasible.

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Graft and Flap Ureteroplasty

For a partially-obliterating stricture that retains a residual lumen to sew onto. Options include buccal mucosa, preputial skin, or bladder-mucosa grafts (and bladder/bowel flaps). Make an anterior ureterotomy 1.5 cm into normal ureter proximally and distally, place the tissue as a ventral onlay (or dorsal, using the psoas as a graft bed) with 4-0/5-0 polyglycolic-acid suture, and wrap a ventral onlay in omentum as a vascular bed.

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Complications

• Ureteroneocystostomy — early obstruction is usually edema (also spasm, hematoma, kink) and mostly transient/conservatively managed; obstruction persisting beyond 3 weeks suggests angulation, kink, ischemia, or scar and often needs reoperation.
  • Contralateral VUR occurs in 3–18% (the commonest complication of a unilateral reimplant — observed, as most resolve).
  • Delayed obstruction can appear up to 10 years later, so image long-term.
• Ureteroureterostomy / TUU — urine leak (most cease with drainage), anastomotic stricture, and silent hydronephrosis (surveillance ultrasound).
• Boari flap — urine leak, anastomotic stricture, rare pseudodiverticulum, and (usually insignificant) reflux; protect the contralateral ureter intraoperatively.
• Psoas hitch — the femoral nerve is the most likely injury (also the genitofemoral nerve); iliac-vein or bowel injury, urosepsis, and late fistula or obstruction.
• Ileal ureter — metabolic abnormalities, malignancy (endoscopic surveillance from postoperative year 3), and redundancy → stasis, UTI, hydronephrosis, and acidosis; guard the (especially left-sided) mesentery against tension/ischemia.

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Postoperative Care

Leave a Foley for 1–2 days (removed POD 1 after UU/TUU; replace it if drain output rises); remove the drain 24 h after the catheter with minimal output. Remove the double-J stent at 4–6 weeks, confirming healing with imaging. After a Boari flap, get a cystogram at ≥ 10 days; after an ileal ureter, a cystogram at 10–14 days, an antegrade nephrostoureterogram at 3–6 weeks before stent removal, and a urogram at 3 months.