Evaluating and treating ureteral strictures is essential to preserve renal function and exclude malignancy. This tab covers the causes, work-up, and the full ladder of management — decompression, endourologic incision, and reconstruction (with the defect length each repair can bridge) — plus ureteroenteric anastomotic strictures.
Etiology
- Benign (mnemonic SIIRRII-PUF): Stones; endoscopic Instrumentation; Infection (tuberculosis); Renal-ablation injury; Radiation; Ischemia (trauma, surgical dissection); Idiopathic; and PeriUreteral Fibrosis (from abdominal aortic aneurysm or endometriosis).
- Endometriosis causes cyclic flank pain, dysuria, urgency, haematuria, and recurrent UTIs, though most ureteral obstruction is asymptomatic. Mild obstruction with good function may respond to hormonal therapy (GnRH agonist or medroxyprogesterone/danazol); severe obstruction needs surgery ± hysterectomy/BSO.
- Hysterectomy accounts for >50% of iatrogenic ureteral injuries — the ureter is most often occluded at the broad ligament and at the vaginal cuff/bladder trigone.
- Malignant — intrinsic (e.g. urothelial carcinoma) or extrinsic (e.g. cervical cancer).
Diagnosis and Evaluation
Flank pain is the usual symptom; check serum creatinine for baseline function. CT can identify obstruction, and an antegrade/retrograde pyelogram, CT urography, or diagnostic ureteroscopy defines the stricture's location and length. Assess differential function before treatment — endourologic therapy requires ≥25% function of the ipsilateral moiety (some sources 20%) for a reasonable success rate.
Management
Three tiers: decompression, endourologic procedures, and surgical repair.
Decompression
A ureteral stent works acutely for most intrinsic strictures, but extrinsic compression eventually needs percutaneous drainage or surgery; tandem (parallel) stents help in extrinsic obstruction. Stenting reduces ureteral contractility, and there is no clear consensus on metallic stents.
Endourologic Procedures
Best for strictures <2 cm with no prior intervention; the main contraindication is a stricture >2 cm (dilation alone usually fails).
- Balloon dilation — success 50–76% with unfavourable long-term outcomes; best for iatrogenic, non-anastomotic strictures (85% vs 50% for anastomotic). A stent is left 2–4 weeks, with diuretic renography ~1 month after removal.
- Endoureterotomy — incise lower strictures anteromedially (away from the iliac vessels) and upper strictures laterally/posterolaterally, using a cold knife, cutting electrode, or holmium laser.
Surgical Repair
The repair is chosen by the length and location of the defect:
| Repair | Defect bridged | Key point |
|---|---|---|
| Ureteroureterostomy | 2–3 cm | End-to-end, upper/mid ureter; tension-free (success >90%) |
| Ureteroneocystostomy | 4–5 cm | Distal ureter; add psoas hitch/Boari if not tension-free |
| Psoas hitch | 6–10 cm (some 5–8) | Lower ureter; fix bladder to psoas above the iliac vessels |
| Boari flap | 10–15 cm | Tubularised bladder pedicle; flap length:base ≤ 3:1 |
| Renal descensus | 5–8 cm | Mobilise the kidney inferiorly (up to ~8 cm extra) |
- Ureteroureterostomy suits short upper/mid defects; tension causes stricture, so lower strictures are better managed by ureteroneocystostomy. Ureterocalicostomy (ureteral stump sewn end-to-side into a calyx) is reserved for profound pelvis/UPJ damage.
- Ureteroneocystostomy may be intravesical, extravesical, or combined, tunnelled or not — refluxing vs anti-refluxing anastomosis shows no significant difference in renal function or stenosis (though a possible pyelonephritis risk in adults is unclear).
- Psoas hitch is preferred over ureteroureterostomy for lower-ureteral injuries (better blood supply); advantages over the Boari flap are simplicity, less vascular compromise, and fewer voiding problems; it is contraindicated with a small contracted bladder. The femoral nerve is most likely injured (also watch the genitofemoral nerve); contralateral superior-vesical-artery division adds bladder mobility.
- Transureteroureterostomy (TUU) transposes the injured ureter across the midline (through a tunnel under the sigmoid mesentery, proximal to the IMA) into the contralateral ureter — usually a delayed procedure. Absolute contraindication: insufficient donor length; relative: nephrolithiasis, urothelial malignancy, retroperitoneal fibrosis, chronic pyelonephritis, or abdominopelvic radiation (any process risking both ureters). A preoperative VCUG must exclude recipient reflux. Because it risks converting a unilateral injury into a bilateral one, ileal interposition or ureteroureterostomy with renal mobilisation are preferred.
- Ileal ureter substitution uses ileum for very long defects (not in the acute setting); contraindications are renal insufficiency (creatinine >2 mg/dL), inflammatory bowel disease, radiation enteritis, and bladder dysfunction/outlet obstruction. Use a segment ≥15 cm from the ileocecal valve; complications include metabolic abnormalities and malignancy (endoscopic surveillance from postoperative year 3). Other options are the Monti tube or appendix; autotransplantation is the final option before nephrectomy.
For the full operative technique of ureteroureterostomy, ureteroneocystostomy, and the psoas hitch, see the Ureteral Reconstruction procedure page.
Ureteroenteric Anastomotic Stricture
Strictures occur in 3–25% after continent diversion, most within 2 years. Risk rises with the dissection technique, bowel segment, anastomosis type, and side — higher on the left (the left ureter passes under the sigmoid mesentery and may angulate at the IMA); a refluxing anastomosis lowers the stricture risk and is preferred for continent reservoirs. Chronic non-obstructive hydronephrosis is common, so a fall in function or loss of reflux on loopogram should prompt diuretic renography. Endourologic management (long-term patency ~50%) is used first, reserving surgery for failures and strictures >1 cm; antegrade access is preferred (unlike de novo ureteral strictures). Endourologic success is far lower for left-sided strictures (19% vs 41% right) and for strictures >1 cm (6% vs 50%) — favouring primary repair on the left.
Retrocaval Ureter
A retrocaval (circumcaval) ureter passes behind the IVC, producing a characteristic S-shaped/"fish-hook" course and right-sided obstruction. It results from persistence of the posterior cardinal vein (which normally regresses, with the subcardinal vein becoming the infrarenal IVC). (The source cross-references the pediatric ureteral-anomalies chapter; the embryologic cause is added here from standard teaching.)
Self-Test
1. What are the causes of ureteral stricture disease? Benign: stones, instrumentation, infection (TB), renal-ablation injury, radiation, ischemia, idiopathic, and periureteral fibrosis. Malignant: intrinsic (urothelial carcinoma) or extrinsic (e.g. cervical cancer).
2. What are the management options for ureteral stricture disease? Decompression; endoscopic (balloon dilation, endoureterotomy); and surgical repair — ureteroureterostomy, ureteroneocystostomy, psoas hitch, Boari flap, renal descensus, transureteroureterostomy, ileal ureter, or autotransplantation.
3. What are the contraindications to transureteroureterostomy? Absolute: insufficient donor-ureter length. Relative: history of nephrolithiasis, urothelial malignancy, retroperitoneal fibrosis, chronic pyelonephritis, radiation — i.e. any process that may affect both ureters.
4. What investigation is needed before transureteroureterostomy? A VCUG to exclude reflux in the recipient ureter.
5. What are the contraindications to ileal ureter substitution? Baseline renal insufficiency (creatinine >2 mg/dL), bladder dysfunction/outlet obstruction, inflammatory bowel disease, and radiation enteritis.
6. What is the preferred endoscopic approach for a ureteroenteric stricture? Antegrade.
7. What are the risk factors for failure of endourologic management of a ureteroenteric stricture? A left-sided stricture and a stricture >1 cm.
8. Persistence of which structure results in a retrocaval ureter? The posterior cardinal vein.