Ureteral strictures may arise from multiple etiologies, including trauma, surgery, infections, and malignancy. An accurate diagnosis is imperative so that the etiology, location, length, and possible involvement of surrounding structures are obtained before an operative repair. Computed tomography, intravenous urography, retrograde pyelography, and functional assessment of the involved kidney should all be done. We prefer to combine the antegrade nephrostogram with the retrograde pyelogram to obtain an “up-and-down-o-gram” of the involved segment. This delineates the location and length of the stricture in order to plan the appropriate surgical approach. Function of the involved renal unit must be established, preferably through nuclear medicine imaging before surgery because less than 20% function may indicate a lower success rate for cure, and nephrectomy may be considered. It is essential to rule out malignant etiologies for the ureteral stricture in patients at risk.

The options for surgical treatments of ureteral stricture range from minimally invasive endoscopic techniques (long-term indwelling stent, percutaneous drainage, balloon dilation, laser incision, endoureterotomy) to more complex surgical options, including open and laparoscopic technique, which is the subject of this chapter.

The choice of repair is dependent on the location of the stricture. Distal strictures located below the iliac vessels are best managed with ureteral reimplant into the bladder (see later). Strictures of the proximal to midureter may be managed with pyeloplasty (see later), primary ureteroureterostomy, transureterostomy, bowel interposition (see later), nephrectomy (see later), and cutaneous ureterostomy.

Patient position and incision depend again on the location of the diseased segment. For proximal strictures, the flank incision, tip of the 12th rib incision, and subcostal and midline incision all provide adequate exposure. A periumbilical midline incision and Gibson incision provide ample exposure for midureteral strictures. Distal strictures needing reimplantation into the bladder are best managed with the infraumbilical midline incision, Gibson incision, or Pfannenstiel incision. Advantages to the tip of the 12th rib incision, Gibson incision, and Pfannenstiel incisions are the ability to stay extraperitoneal.

For the next three procedures, after reconstruction, place a standard stent (6-Fr double-J ureteral stent) for 6 weeks. Place a suction drain in the vicinity of the repair but not directly on it and drain the bladder with a Foley catheter. Consider the use of tissue sealant and an omental wrap (see later discussion).

Ureteroureterostomy

“The ureter is a surgically forgiving structure with good vascular supply” (Turner-Warwick). Despite this, meticulous surgical dissection and careful technique are required. A spatulated repair can be used in strictures of up to 3 to 4 cm in length because of the ability to mobilize the ureter.

For the proximal to midureteral stricture, place the patient in the supine position and make either a midline incision or tip of the 12th rib incision. Place a Bookwalter abdominal retractor in position for adequate exposure.

Incise the white line of Toldt and mobilize the colon, exposing the ureter in the retroperitoneum. The ureter may be identified lying anterior to the bifurcation of the common iliac artery ( Fig. 35.1, A ) but can occasionally be pulled medial in cases of fibrosis.

( A–H ) Ureteroureterostomy procedure.

Mobilize the ureter and place stay sutures (3-0 silk, 18 inch) on the anterior portion of the ureter to help with tissue handling and to identify the anterior portion for the reconstruction after mobilization. These stay sutures also help one avoid handling the ureter and to provide an anastomosis with the no-touch technique (see Fig. 35.1, B and C ). Resect the damaged area (see Fig. 35.1, D ) and spatulate the two ends for 1.5 cm into good ureter (see Fig. 35.1, D and E ). Perform a tension-free, watertight anastomosis using 4-0 and 5-0 polyglycolic acid suture. Do not place suture knots at the apex; rather, put them at the lateral suture margin, starting the running suture line in the middle of the wall and not at the apex (see Fig. 35.1, F ). Interrupt runs of two to four sutures, locking every third throw. After completing the posterior anastomosis, roll the anterior edges together to complete the repair (see Fig. 35.1, G and H ).

Postoperatively, remove the Foley catheter on day 1. If the suction drain output increases, replace the Foley back into the bladder. Remove the suction drain 24 hours after the Foley catheter is removed to ensure a watertight repair.