An endoureterotomy consists of stricture incision under direct vision through a ureteroscope. Several different technologies can be employed, including cold knife incision, electrocautery, and holmium laser ablation. All require a full-thickness cut through the wall of the ureter into the periureteral fat. The optimal direction of the incision depends on the level of the ureter that is affected. Incisions into the pelvic ureter should be made in an anteromedial direction, so as to avoid the iliac vessels. Meanwhile, incisions into the upper ureter should be made in a posterolateral direction, so as to avoid the aorta and inferior vena cava.

Surgical Treatment. Open or laparoscopic excision of a ureteral stricture should begin with careful ureteral mobilization to minimize the risk of damage to the periureteral blood supply. Debridement of the scarred and fibrotic area should then proceed until a bleeding edge is reached. Finally, the ureter should be reconstructed in a manner that is tension-free, spatulated, and water-tight. A ureteral stent should be placed to ensure adequate postoperative drainage. The optimal method of reconstruction depends on the location and length of the excised segment. Several different options are available, as described in Plate 10-36.