Endoureterotomy

Endoureterotomy is an endoscopic treatment for ureteral stricture in which the narrowed ureter is incised full-thickness from within the lumen and then stented while the ureter heals in an expanded configuration. It is the main endoscopic alternative to formal reconstruction for benign strictures, but its durability depends heavily on stricture biology: short, partial, nonischemic strictures do well; long, obliterative, ischemic, radiation-related, or recurrent strictures should usually move toward reconstruction.^[1][2][3][4]

This page covers endoscopic incision of ureteral strictures. For reconstructive alternatives, see Ureteroureterostomy, Ureteral Reimplantation, Buccal Mucosa Graft Ureteroplasty, and Upper Tract Reconstruction Principles. Endoscopic paclitaxel dilation is covered separately under Drug-Coated Balloon Therapy.

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Core Principle

The operation releases the scar ring by making a longitudinal full-thickness incision through mucosa, muscularis, and adventitia until periureteral fat is seen.^[5][6][7] A ureteral stent then splints the incised segment for roughly 4-8 weeks, allowing the lumen to re-epithelialize open rather than recontracting immediately.

The analogy is direct visual internal urethrotomy: both procedures are attractive because they are low morbidity, and both are vulnerable to recurrence when the stricture is long, ischemic, dense, or repeatedly treated.

Endopyelotomy is the same concept applied at the ureteropelvic junction (UPJ). It has a narrower role now that minimally invasive pyeloplasty is widely available.

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Historical Development

Era	Development	Relevance
Davis intubated ureterotomy	Open intubated ureterotomy concept	Established the principle that an incised ureter can heal over a splint
1980s	Antegrade percutaneous endopyelotomy	Moved UPJ incision into the endoscopic era
1992	Meretyk, Clayman, and colleagues reported a dedicated endoureterotomy series	Early 62% success and the beginning of stricture-specific endoscopic series[5]
1993	Acucise cutting balloon introduced	Fluoroscopy-guided incision without direct visualization[8]
1997	Ho:YAG laser endoureterotomy series reported	Helped establish laser incision as the dominant modern technique[9]
Modern era	Laser incision plus selective balloon dilation, steroid injection, dual stents, or metallic stents	Attempts to improve an operation whose core limitation is restenosis biology[10][11][12][13]

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Approaches

Approach	How It Is Done	Best Fit	Limitations
Retrograde ureteroscopic	Semirigid or flexible ureteroscope passed from bladder to stricture; incision under direct vision	Most native ureteral strictures; outpatient endoscopic workflow	Can be difficult across tight, proximal, or ureteroenteric strictures
Antegrade percutaneous	Nephrostomy access with antegrade ureteroscope/nephroscope	Proximal ureter, UPJ, transplant, or ureteroenteric strictures where retrograde access is poor	Requires percutaneous access and its morbidity
Combined antegrade-retrograde	Rendezvous access from both ends	Near-obliterative strictures where a wire cannot be passed safely	More complex; often a signal that reconstruction may be more durable
Acucise cutting balloon	Fluoroscopic balloon with electrocautery wire incises while inflated	Historical option for UPJ or ureteral strictures	No direct visualization, no biopsy, less control of incision depth; now largely replaced by laser[8][14][15]

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Energy Sources

Energy Source	Mechanism	Advantages	Drawbacks
Ho:YAG laser	Pulsed photothermal incision at 2100 nm	Precise, hemostatic, works through small flexible scopes, current standard	Requires direct vision and endoscopic access[6][9]
Electrocautery / hot wire	Electrical tissue incision	Widely available; historical experience	Thermal spread and less precise control than laser
Cold knife	Mechanical incision	No thermal injury	Harder to use in small tortuous ureteral lumens
Acucise	Balloon-mounted electrocautery wire	Fast and fluoroscopy-guided	Blind incision, bleeding risk, no biopsy, largely historical[8][14]
Thulium fiber laser	Emerging photothermal laser platform	Potentially precise cutting	Limited ureteral endoureterotomy outcomes data

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Retrograde Laser Technique

1. Cystoscopy and retrograde pyelography define stricture location, length, severity, and upstream dilation.
2. Safety wire placement across the stricture is attempted. A completely impassable segment should prompt antegrade access, rendezvous strategy, or reconstruction rather than blind force.
3. Ureteroscopy confirms the stricture endoscopically. Suspicious lesions should be biopsied before incision; malignant strictures are not endoureterotomy disease.
4. Incision planning uses the ureteral level, cross-sectional vascular anatomy and endoscopic orientation to select a line away from adjacent vessels and bowel. There is no universal lateral/posterolateral incision for all ureteral levels.
5. Laser incision is made with a small Ho:YAG fiber, commonly 200-365 microns, through the full scar thickness until periureteral fat is visible.^[9][16]
6. Balloon dilation may be added after incision, typically to open the released scar ring and confirm full expansion.^[11][16]
7. Adjunctive triamcinolone has been used off-label in selected protocols. Its incremental benefit and optimal dose are not established by the uncontrolled combination-treatment series; it is not a routine requirement.^[2][12]
8. Stenting splints the incision. Standard double-J stents are common; larger-caliber endoureterotomy stents or dual ipsilateral stents have been used to increase luminal scaffolding.^[2][13][17]
9. Drainage and follow-up depend on approach and extravasation. Stents are usually removed after 4-8 weeks.

Incision Direction

At the UPJ, Sampaio and Favorito's vascular anatomy work supports avoiding deep anterior incision because prominent anterior vessels were common, while the posterior surface was often vessel-free only within a limited segment. A lateral incision is generally the safest practical rule.^[18]

For upper ureteral strictures, a posterolateral incision is commonly described; for distal strictures, an anteromedial line is described to avoid nearby vessels. These are orientation guides, not universally safe planes. At the iliac crossing, in a transplant, after diversion or after prior reconstruction, establish the actual vascular and bowel relationships before a full-thickness incision.^[32]

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Patient Selection

Endoureterotomy is best framed as a selection-sensitive treatment, not as a universal stricture repair.

Feature	Favors Endoureterotomy	Favors Reconstruction
Length	<=1-2 cm	>2 cm, especially >3 cm
Etiology	Nonischemic, stone-related, short iatrogenic narrowing	Radiation, devascularization, ureteroenteric ischemia, dense fibrosis
Lumen	Partial stricture; wire can pass	Obliterated or near-obliterated segment
Renal function	Adequate function and potentially recoverable drainage	Poor function warrants individualized assessment of reconstruction, drainage or nephrectomy; no split-function cutoff alone selects the operation
Prior treatment	First endoscopic attempt	Failed prior endoureterotomy or repeated dilation
Hydronephrosis	Mild or moderate	Severe chronic dilation
Patient priority	Lowest morbidity and accepts recurrence risk	Maximal durable patency

Classic series repeatedly found worse outcomes with long strictures, ischemic strictures, compromised ipsilateral renal function, and ureteroenteric strictures.^{[1][2][3][4][19]}

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Outcomes: Native Benign Ureteral Strictures

Series	N	Technique	Success	Key Lesson
Meretyk et al.	13	Endoureterotomy	62%	Early dedicated series; steroid injection appeared promising[5]
Singal et al.	22	Ho:YAG laser	76%	Length and etiology drove results[9]
Wolf et al.	38 benign strictures	Mixed endoureterotomy	80% 3-year success	Poor renal function and ureteroenteric strictures performed worse[2]
Richter et al.	27	Endoureterotomy	89.5% with intact vascularity	Vascular compromise reduced success[19]
Razdan et al.	50	Ureteroscopic endoureterotomy	74%	Strictures >2 cm did poorly; stent strategy mattered[3]
Gnessin et al.	35	Ho:YAG laser	82% symptomatic; 78.7% radiographic	Nonischemic success 100% vs 64.7% ischemic[1]
Corcoran et al.	34	Ho:YAG plus balloon	85%	Many patients required more than one endoscopic procedure[4]
Ou et al.	95 endourologic treatments	Mixed endoscopic	51.6%	95.7% success in a separate 47-patient reconstruction group; retrospective selection limits causal comparison[10]

The practical synthesis is that success can reach roughly 75-85% in carefully selected short nonischemic native strictures, but broader real-world cohorts fall lower when long, complex, ischemic, or recurrent strictures are included.

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Ureteroenteric Anastomotic Strictures

Ureteroenteric anastomotic strictures are harder endoscopic targets because ischemia, scarring, prior diversion, and altered anatomy are common. Endoscopic treatment is often reasonable as a first attempt because morbidity is low, but open or robotic revision remains the durability benchmark.

Series	Technique	Success	Note
Wolf et al.	Mixed endoureterotomy	32% 3-year success	Markedly worse than benign native strictures[2]
Lin et al.	Acucise	30%	Limited durability for ureteroenteric disease[20]
Touiti et al.	Acucise	50-75%	Results varied by anastomotic site[15]
Laven et al.	Endoureterotomy vs open revision	50% vs 80%	Open revision had better success[21]
Gomez et al.	First-line endourologic management	71.4%	Supports an initial low-morbidity attempt in selected patients[22]
Katims et al.	Laser incision, triamcinolone, balloon dilation, parallel stents	20/24 strictures (83.3%) in 21 patients	Uncontrolled combination protocol; does not isolate steroid benefit[12]

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Transplant and UPJ Settings

Transplant Ureteral Strictures

Transplant strictures are anatomically and biologically distinct. Gdor et al. reported successful Ho:YAG laser endoureterotomy in all 5 transplant-kidney strictures <=10 mm, while balloon dilation alone succeeded in only 1 of 3 patients in the same report.^[23] These are small numbers, but they reinforce the general pattern: very short strictures are the best endoscopic candidates.

Endopyelotomy for UPJ Obstruction

Endopyelotomy has lower durability than pyeloplasty. A comparative effectiveness study found higher failure after endopyelotomy than open pyeloplasty, while minimally invasive pyeloplasty was more durable than endopyelotomy.^[24] Contemporary review data place retrograde endopyelotomy success below pyeloplasty, with best results in short stenoses, modest hydronephrosis, preserved renal function, and no major crossing-vessel concern.^[25][26]

In practical terms, endopyelotomy is now a selective option for favorable adult UPJ obstruction, failed patients who cannot tolerate reconstruction, or those prioritizing the lowest morbidity after counseling. Pyeloplasty remains the durability standard.

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Adjunctive Measures

Adjunct	Rationale	Evidence Signal
Balloon dilation after incision	Expands the released scar ring and confirms lumen caliber	Often combined with Ho:YAG incision; balloon-only long-term success is modest[11][27]
Triamcinolone injection	Reduces fibroblast proliferation and collagen deposition in the incised bed	Off-label; observational association and a small combination-treatment series do not establish its independent benefit[2][12]
Larger stents	Splint the incision more aggressively	Wolf et al. associated >=12F stenting with better results in strictures >1 cm[2]
Dual ipsilateral stents	Increase scaffold diameter without a custom endoureterotomy stent	Mohyelden et al. reported better long-term success with two 7F stents than one stent in bilharzial strictures[13]
Covered metallic stents	Longer-term internal scaffold for patients unfit for reconstruction or after endoscopic release	Allium and other covered stents show improving but still selective evidence[28][29][30]

Metal stents should be understood as maintenance or salvage tools, not a simple replacement for reconstruction in healthy surgical candidates. A 2025 meta-analysis pooled different devices and cohorts; such comparisons do not establish that Allium is superior for an individual patient. A 310-case Allium series reported declining success over 3 years, underscoring the need for surveillance.^[28][30]

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Complications

Complication	Comment
Extravasation / urinoma	Expected risk after full-thickness incision; usually managed with stenting, drainage, or nephrostomy if needed
Bleeding	More concerning with blind cutting-balloon incision; uncommon with controlled laser incision
UTI / fever	Treat with culture-directed antibiotics and ensure drainage
Ureteral perforation	Usually stented; risk rises with tight strictures and difficult access
Vascular injury	Rare but serious; incision direction matters, especially near the UPJ and iliac vessels
Recurrent stricture	Main long-term failure mode; recurrence risk depends on selection
Need for secondary procedure	Repeat endoscopy, chronic stent, nephrostomy, or definitive reconstruction may be required

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Timing of Failure and Follow-Up

Most failures declare themselves early. Gnessin et al. reported all failures within 9 months, and Wolf et al. observed no benign-stricture failures beyond 11 months.^[1][2] That pattern supports close surveillance during the first postoperative year.

Typical follow-up includes:

• stent removal at 4-8 weeks,
• renal ultrasound or CT urogram after stent removal,
• functional drainage study when symptoms, renal function, or imaging are equivocal,
• low threshold for earlier imaging if flank pain, fever, rising creatinine, or recurrent hydronephrosis develops,
• continued longer-term surveillance for ureteroenteric, ischemic, transplant, or metal-stent cases.

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Endoureterotomy vs Reconstruction

Endoureterotomy offers shorter operative time, less blood loss, faster recovery, and outpatient feasibility. Its cost is durability. Ou et al. found overall success of 51.6% for endourologic treatment compared with 95.7% for surgical reconstruction in benign ureteral strictures, in a retrospective, predominantly stone-related cohort. Treatment groups were selected rather than randomized, so these figures do not establish the causal effect for otherwise identical strictures.^[10] Zi et al. similarly found that balloon dilation could approximate reconstructive approaches early but lost ground at 12 and 24 months.^[31]

Scenario	Usually Better Choice
Short (<=1-2 cm), benign, partial, nonischemic stricture	Endoureterotomy reasonable first
Long (>2 cm) proximal/mid stricture	BMG ureteroplasty, augmented anastomotic repair, appendix, or ileal substitution depending anatomy
Upper/mid complete transection or short excisable stricture	Ureteroureterostomy
Distal stricture	Ureteral reimplantation, psoas hitch, Boari flap, or selective non-transecting reimplant
Radiation-induced, ischemic, recurrent, or obliterated stricture	Reconstruction favored
Ureteroenteric anastomotic stricture	Endoscopic attempt is reasonable in selected cases; revision remains the durability standard
Poor operative candidate	Endoureterotomy, balloon dilation, chronic stent, nephrostomy, or metallic stent may be pragmatic

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Operative Pearls

• Confirm benign disease before incision; biopsy suspicious strictures.
• Do not force a wire through an obliterated segment; use antegrade/rendezvous access or reconstruct.
• A therapeutic incision releases the full scar thickness, but only along a planned safe line; avoid uncontrolled extension into adjacent structures.
• Match incision direction to the ureteral level and actual vessels; a lateral/posterolateral rule is unsafe for every distal stricture.
• Counsel patients that low morbidity is paired with lower durability than reconstruction.
• Treat failure as useful information: recurrent narrowing after a proper endoureterotomy should usually trigger definitive reconstruction rather than serial incision.
• For ureteroenteric strictures, counsel on recurrence and revision options. Steroid-containing combination protocols remain incompletely validated.
• Preserve future reconstruction options by avoiding devascularizing or traumatic repeated instrumentation.

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Summary

Endoureterotomy is a valuable minimally invasive option for short, benign, partial, nonischemic ureteral strictures with preserved renal function. Ho:YAG laser incision under direct vision is the modern standard, combined with stenting and, selectively, balloon dilation. Steroid injection is an off-label adjunct with uncertain incremental benefit. The operation can achieve 75-85% success in favorable native strictures, but real-world durability is substantially lower than reconstruction when complex strictures are included. Its best role is therefore selective: first-line endoscopic management for favorable strictures, a low-morbidity first attempt for selected ureteroenteric anastomotic strictures, and a palliative or temporizing option for patients who are poor reconstructive candidates.

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References

1. Gnessin E, Yossepowitch O, Holland R, Livne PM, Lifshitz DA. Holmium laser endoureterotomy for benign ureteral stricture: a single center experience. J Urol. 2009;182(6):2775-2779. doi:10.1016/j.juro.2009.08.051.

2. Wolf JS Jr, Elashry OM, Clayman RV. Long-term results of endoureterotomy for benign ureteral and ureteroenteric strictures. J Urol. 1997;158(3 Pt 1):759-764. doi:10.1097/00005392-199709000-00016.

3. Razdan S, Silberstein IK, Bagley DH. Ureteroscopic endoureterotomy. BJU Int. 2005;95 Suppl 2:94-101. doi:10.1111/j.1464-410X.2005.05207.x.

4. Corcoran AT, Smaldone MC, Ricchiuti DD, Averch TD. Management of benign ureteral strictures in the endoscopic era. J Endourol. 2009;23(11):1909-1912. doi:10.1089/end.2008.0453.

5. Meretyk S, Albala DM, Clayman RV, Denstedt JD, Kavoussi LR. Endoureterotomy for treatment of ureteral strictures. J Urol. 1992;147(6):1502-1506. doi:10.1016/s0022-5347(17)37608-5.

6. Emiliani E, Breda A. Laser endoureterotomy and endopyelotomy: an update. World J Urol. 2015;33(4):583-587. doi:10.1007/s00345-014-1405-3.

7. Seseke F, Heuser M, Zoller G, Plothe KD, Ringert RH. Treatment of iatrogenic postoperative ureteral strictures with Acucise endoureterotomy. Eur Urol. 2002;42(4):370-375. doi:10.1016/s0302-2838(02)00322-6.

8. Chandhoke PS, Clayman RV, Stone AM, et al. Endopyelotomy and endoureterotomy with the Acucise ureteral cutting balloon device: preliminary experience. J Endourol. 1993;7(1):45-51. doi:10.1089/end.1993.7.45.

9. Singal RK, Denstedt JD, Razvi HA, Chun SS. Holmium:YAG laser endoureterotomy for treatment of ureteral stricture. Urology. 1997;50(6):875-880. doi:10.1016/S0090-4295(97)00511-6.

10. Ou Y, Zhang G, Zhu X, et al. Evaluation of risk factors, treatment options, and prognostic-related factors in patients with benign ureteral strictures: an 8-year single-center experience. Int J Urol. 2023;30(10):847-852. doi:10.1111/iju.15211.

11. Wang B, Gao W, Yang K, et al. Analysis of the efficacy and risk factors for failure of balloon dilation for benign ureteral stricture. J Clin Med. 2023;12(4):1655. doi:10.3390/jcm12041655.

12. Katims AB, Edelblute BT, Tam AW, et al. Long-term outcomes of laser incision and triamcinolone injection for the management of ureteroenteric anastomotic strictures. J Endourol. 2021;35(1):21-24. doi:10.1089/end.2020.0593.

13. Mohyelden K, Hussein HA, El Helaly HA, Ibrahem H, Abdelwahab H. Long-term outcomes of two ipsilateral double-J stents versus single double-J stent after laser endoureterotomy for bilharzial ureteral strictures. J Endourol. 2021;35(6):775-780. doi:10.1089/end.2020.0956.

14. Cohen TD, Gross MB, Preminger GM. Long-term follow-up of Acucise incision of ureteropelvic junction obstruction and ureteral strictures. Urology. 1996;47(3):317-323. doi:10.1016/S0090-4295(99)80445-2.

15. Touiti D, Gelet A, Deligne E, et al. Treatment of uretero-intestinal and ureterovesical strictures by Acucise balloon catheter. Eur Urol. 2002;42(1):49-54. doi:10.1016/s0302-2838(02)00070-2.

16. Gao X, Chen J, Wang W, et al. Step-by-step technique for the endoscopic treatment of ureteric stricture. BJU Int. 2021;128(6):692-696. doi:10.1111/bju.15558.

17. Gerber GS, Kim JC. Ureteroscopic endopyelotomy in the treatment of patients with ureteropelvic junction obstruction. Urology. 2000;55(2):198-202. doi:10.1016/s0090-4295(99)00530-0.

18. Sampaio FJ, Favorito LA. Ureteropelvic junction stenosis: vascular anatomical background for endopyelotomy. J Urol. 1993;150(6):1787-1791. doi:10.1016/s0022-5347(17)35896-2.

19. Richter F, Irwin RJ, Watson RA, Lang EK. Endourologic management of benign ureteral strictures with and without compromised vascular supply. Urology. 2000;55(5):652-657. doi:10.1016/s0090-4295(00)00484-2.

20. Lin DW, Bush WH, Mayo ME. Endourological treatment of ureteroenteric strictures: efficacy of Acucise endoureterotomy. J Urol. 1999;162(3 Pt 1):696-698. doi:10.1097/00005392-199909010-00017.

21. Laven BA, O'Connor RC, Gerber GS, Steinberg GD. Long-term results of endoureterotomy and open surgical revision for the management of ureteroenteric strictures after urinary diversion. J Urol. 2003;170(4 Pt 1):1226-1230. doi:10.1097/01.ju.0000086701.68756.8f.

22. Gomez FD, Thomas A, Sempels M, et al. Outcomes following first-line endourologic management of ureteroenteric anastomotic strictures after urinary diversion: a single-center study. Urology. 2017;102:38-42. doi:10.1016/j.urology.2016.10.009.

23. Gdor Y, Gabr AH, Faerber GJ, Wolf JS Jr. Holmium:yttrium-aluminum-garnet laser endoureterotomy for the treatment of transplant kidney ureteral strictures. Transplantation. 2008;85(9):1318-1321. doi:10.1097/TP.0b013e31816c7f19.

24. Jacobs BL, Lai JC, Seelam R, et al. The comparative effectiveness of treatments for ureteropelvic junction obstruction. Urology. 2018;111:72-77. doi:10.1016/j.urology.2017.09.002.

25. Kolvatzis M, Corrales M, Moretto S, Quara A, Traxer O. Long-term results of retrograde endopyelotomy: a narrative review. World J Urol. 2025;43(1):260. doi:10.1007/s00345-025-05618-0.

26. Khan F, Ahmed K, Lee N, et al. Management of ureteropelvic junction obstruction in adults. Nat Rev Urol. 2014;11(11):629-638. doi:10.1038/nrurol.2014.240.

27. Lu C, Zhang W, Peng Y, et al. Endoscopic balloon dilatation in the treatment of benign ureteral strictures: a meta-analysis and systematic review. J Endourol. 2019;33(4):255-262. doi:10.1089/end.2018.0797.

28. Bian X, Hu H, Tian C, et al. Comparison of different segmental metal ureteral stents as maintenance therapy across different years in ureteral stricture management: a systematic review and meta-analysis. Int J Surg. 2025;111(7):4746-4755. doi:10.1097/JS9.0000000000002384.

29. Kowalski F, Kuffel B, Pozniak M, et al. Endourological treatment of ureteral strictures with the use of self-expanding stents: is it possible to completely cure the stricture endoscopically? A report on the experience with implantation of 35 stents with a two-year follow-up period; a retrospective study. World J Urol. 2025;43(1):201. doi:10.1007/s00345-025-05574-9.

30. Gao X, Chen J, Chen G, et al. Self-expanding metal ureteral stent for treating ureteral strictures: three-year follow-up results from 310 cases. Int J Surg. 2025;111(8):4986-4992. doi:10.1097/JS9.0000000000002578.

31. Zi D, Cao W, Chen F, Zhu L. Management for benign ureteral stricture: comparison of robot-assisted laparoscopy, conventional laparoscopy, and balloon dilation. J Endourol. 2023;37(8):868-875. doi:10.1089/end.2023.0047.

32. Yarak N, Zouari S, Karray O, et al. The “Cut-to-the-Light” Technique Laser Endoureterotomy for Complete Ureteral Obstruction Resurfaces! A New Application of an Old Technique. Res Rep Urol. 2022;14. doi:10.2147/RRU.S371856.