An ileal ureter, which introduces the bowel into the urinary tract, is used for wide ureteral defects or other surgically complex cases that require more drastic reconstruction efforts. Patients with baseline renal insufficiency (serum creatinine ≥2), liver dysfunction, bladder dysfunction, radiation enteritis, or infammatory bowel disease should not undergo this procedure. After the patient has undergone adequate bowel preparation and oral antibiotic treatment, a segment of ileum (located at least 15 cm from the ileocecal valve) is excluded with its vascular supply intact. The segment is then anastomosed to the renal pelvis and posterior wall of the bladder. It is important to maintain normal proximal-to-distal orientation of the ileal segment so that peristalsis occurs in the correct direction. The open ends of bowel created by the ileal resection are reanastomosed to restore continuity, and the mesenteric window is closed to prevent bowel strangulation.

Finally, autotransplantation may be employed as a last resort in the case of very large ureteral defects. In this procedure, the kidney is harvested as in a donor nephrectomy, then anastomosed to the patient’s own iliac vessels, as in a recipient operation.