Management of Benign Ureteric Stricture

1. Aetiology

• Ischaemia / surgical dissection trauma
• Endoscopic instrumentation (ureteroscopy, PCNL)
• Impacted ureteric calculus (>2 months impaction: ~24% stricture rate)
• Radiation
• Infection (tuberculosis, schistosomiasis)
• Periureteral fibrosis (AAA, endometriosis, retroperitoneal fibrosis)
• Post-renal transplant (ischaemic, BK virus, CMV)
• Idiopathic

2. Diagnostic Evaluation

3. Management Algorithm

Fig. 89.25 - Campbell-Walsh-Wein Urology

• Stricture <2 cm AND >20% ipsilateral function → Endourological (endoureterotomy, direction of incision varies by location)
• Stricture >2 cm AND >20% function → Open or laparoscopic surgical repair
• Stricture >2 cm AND <20% function → Consider nephrectomy (laparoscopic); select paediatric patients and those with renal insufficiency may still warrant repair
• Transplant patients on immunosuppression → Prefer balloon dilation first

4. Endourological Options

A. Ureteral Stent Placement

• Effective for acute decompression of intrinsic strictures (88% success at 26 months for intrinsic obstruction)
• Extrinsic compression eventually requires percutaneous drainage or surgery
• Stents alone rarely produce long-term cure but are useful in:
  • Patients unfit for surgery or with poor prognosis
  • Temporisation while awaiting definitive repair
  • Patients on systemic therapy for malignancy
• Tandem stenting (two parallel stents): useful when single stent fails; 0% failure in one series for benign extrinsic obstruction
• Metal stents (thermoexpandable or full metallic): for long-term palliation in select patients; complications include encrustation, migration, and infection; exchange at 12-month intervals

B. Balloon Dilatation

• Overall success rate 16-83%; highest for early post-transplant strictures, early post-PCNL/ureterolithotomy strictures, and proximal well-circumscribed strictures
• Lower success at the vesicoureteric junction (VUJ) and in ischaemic strictures
• Long strictures (≥3 cm) respond poorly
• Technique: access via interpolar calyx, use hydrophilic wire to cross stricture, exchange for stiff wire, dilate with 6-8 mm balloon at high pressure until waist disappears; leave ureteric stent as splint for 4-6 weeks
• Failure of balloon dilatation does not preclude subsequent surgery - it is therefore the procedure of choice for transplant ureteric strictures
• Cutting balloon angioplasty: for resistant strictures; primary patency 55%, secondary patency 78% in post-transplant ureter

C. Endoureterotomy (Incision of stricture)

• Incision direction:
  • Distal and middle ureter: anterolateral incision
  • Proximal ureter: lateral incision (avoids iliac vessels and gonadal vessels medially)
• Incision is full-thickness to periureteral fat, encompassing 2-3 mm of normal tissue proximally and distally
• Post-incision stenting with large-diameter stents (8-12 Fr) improves results
• Triamcinolone injection after endoureterotomy may improve outcomes
• Success rates: 66-83% at >12 months follow-up for strictures <2 cm
• Poor results with retrograde approach for strictures >2 cm
• Stone-related strictures may have lower success (~56%)

• Percutaneous nephrostomy is established first, infection/compromised function is allowed to resolve, then percutaneous tract is dilated to allow a flexible ureteroscope

5. Open / Laparoscopic / Robotic Surgical Repair

Distal Ureteral Strictures

Mid-Ureteral Strictures

• Uretero-ureterostomy (end-to-end anastomosis): for short gaps after adequate mobilisation, spatulated anastomosis over a stent
• Transureteroureterostomy (TUU): when ureteral length is insufficient to reach the bladder; donor ureter tunnelled under sigmoid mesentery to recipient ureter; contraindicated if recipient ureter is diseased or donor ureter is too short; relative contraindications include nephrolithiasis, RPF, urothelial malignancy, prior pelvic radiation

Proximal Ureteral Strictures / Long/Panureteral Strictures

• Ileal ureter substitution: entire ureter replaced with an isoperistaltic segment of ileum; used for long or panureteral strictures (e.g., post-TB multiple strictures); contraindicated in renal insufficiency (metabolic acidosis risk), bowel disease, prior pelvic radiation
• Renal mobilisation (renal decensus): frees up to 8 cm of length; kidney mobilised and fixed inferiorly on its vascular pedicle; can be combined with Boari flap for panureteral strictures
• Appendix ureteroplasty / buccal mucosa graft ureteroplasty: augmentation techniques for long strictures not amenable to resection; robotic-assisted buccal mucosa graft ureteroplasty is gaining traction (recent systematic review PMID: 41408485)

Laparoscopic / Robotic Approach

6. Special Situations

Post-Transplant Ureteric Stricture

• Affect 1-9% of transplants; most strictures >3 months post-transplant are ischaemic
• Priority: decompress with nephrostomy/stent first
• Retrograde stenting can be technically difficult due to location of neoureteral orifice
• Antegrade nephrostomy provides best access
• Endourological: holmium laser endoureterotomy 67-83% success at 44-58 months
• Balloon dilatation: success 16-81% (best with early-onset short strictures)
• Surgical: open ureteric reimplantation for failed endoscopic treatment

Retroperitoneal Fibrosis

• Ureteral stents, balloon dilation, or steroids (corticosteroids reduce fibrous tissue) as initial treatment
• Ureterolysis (surgical) for definitive treatment in non-responders

Radiation-induced strictures

• Tend to be ischaemic and respond poorly to balloon dilation
• Ileal replacement is often required for definitive repair

7. Summary of Success Rates

• A 2025 meta-analysis (PMID: 41408485) comparing robotic vs. laparoscopic/open buccal mucosa graft ureteroplasty shows robotic approaches are safe and effective for complex strictures.
• A 2025 systematic review/meta-analysis (PMID: 40465801) on segmental metal ureteral stents for long-term maintenance therapy found no significant difference between stent types across years, supporting their role in patients unfit for surgery.
• A 2024 systematic review (PMID: 38185833) confirmed endourological management as the first-line approach for transplant ureteric strictures, with surgical revision reserved for failures.