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Ureteroenteric Anastomotic Stricture Repair

Ureteroenteric anastomotic strictures (UAS) are one of the most consequential late complications of radical cystectomy with urinary diversion, occurring in 3%–25% of patients and leading to progressive hydronephrosis, renal functional loss, and — if unrecognized — end-stage renal disease.[1] The dominant etiology is ischemia at the anastomotic margin rather than technical error; management therefore demands that any reconstructive effort restore a well-vascularized, tension-free mucosa-to-mucosa junction between healthy ureteral tissue and the bowel wall.[1][2]

Epidemiology and Etiology​

UAS develop at a cumulative rate of approximately 12% at 1 year, 16% at 3 years, and 19% at 5 years following robot-assisted radical cystectomy (RARC).[2] Left-sided strictures predominate (46%–68% of cases) and are more resistant to endoscopic treatment, possibly reflecting the greater tension required to route the left ureter beneath the sigmoid mesentery.[7][8]

Established risk factors include higher BMI, prior chemotherapy or pelvic radiation, postoperative urinary tract infection, urine leak, preoperative hydronephrosis, poor nutritional status (low Nutritional Risk Index), and elevated ASA score.[2][3][4][5][6] Paradoxically, stenting the ureteroenteric anastomosis at the index operation appears to increase stricture risk (OR 2.27), possibly by promoting inflammatory reaction at the anastomotic junction.[4] Shorter residual ureters — achieved by more generous distal ureteral resection during cystectomy — are associated with lower stricture rates, reinforcing the vascular compromise hypothesis: leaving a longer ischemic segment at the distal ureter increases the risk of anastomotic failure.[9]

Preoperative Evaluation​

  • Imaging: CT urography, MAG3 renography, retrograde pyelogram, or antegrade nephrostogram — the combination depends on diversion type and accessibility.[1]
  • Biopsy: Mandatory to exclude malignant recurrence at the anastomosis before committing to repair. For surgical cases, intraoperative frozen section analysis of ureteral margins is standard.[10]
  • Renal function: Split-function scintigraphy establishes whether the ipsilateral unit warrants reconstruction versus nephrectomy.
  • Ureteral rest: Many centers advocate 4 weeks of nephrostomy tube drainage prior to definitive repair to allow periureteral inflammation to subside before attempting revision.[8]

Endourological Approaches​

Endoscopic management is reasonable first-line therapy for short strictures (≤ 2 cm), patients who are poor surgical candidates, or as a bridge before surgical revision. Long-term patency is inferior to surgical repair — a 27-year single-institution comparative study demonstrated patency rates of 27% for endourological treatment versus 69% for open revision at 60 months (median patency 5 vs. 15.5 months, p = 0.003), though endourological approaches had substantially shorter hospital stays (2 vs. 14 days) and fewer complications.[11]

Balloon Dilation​

The most accessible endoscopic option. A meta-analysis of 33 studies found pooled technical success of 89%, but long-term patency (6–12 months) falls to approximately 54%.[12] Success is significantly better for strictures ≤ 2 cm and those presenting ≤ 3 months from onset. Technique: dilation to 18–24 Fr followed by stent placement for 4–6 weeks.

Holmium:YAG Laser Endoureterotomy​

The Ho:YAG laser allows precise full-thickness incision with simultaneous hemostasis via antegrade percutaneous or retrograde approach through the bowel loop.[13] Success rates range from 50%–80%; longer and ischemic strictures fail at higher rates. Stricture length and etiology are the dominant determinants of outcome.[13][7]

Laser Incision with Triamcinolone Injection​

A combined endoscopic technique that achieved 83.3% success at median 30-month follow-up:[14]

  1. Antegrade flexible ureteroscopy with biopsy
  2. Laser incision of the stricture and periureteral / peri-ileal tissues 1 cm proximal and 1 cm distal into fat
  3. Triamcinolone injection into the incised tissue planes
  4. Balloon dilation to 24 Fr
  5. Parallel Double-J stents or upside-down nephrostomy tubes for 6 weeks

All recurrences in this series occurred within 3 months of the procedure, supporting early re-assessment at 3 months.

Endoureterotomy by Intraluminal Invagination (Lovaco Technique)​

A combined percutaneous antegrade and endoscopic retrograde approach that allows direct visualization and full-thickness incision of the strictured segment. Intraluminal invagination creates distance between the stricture and retroperitoneal vessels or bowel, improving safety. Reported success was 80% at a median follow-up of 51 months in 25 patients.[15]

Cold-Knife Percutaneous Antegrade Incision​

A wire-mounted cold knife is pulled retrogradely through the stricture under fluoroscopic control via nephrostomy access, followed by stenting for 6–8 weeks. Primary success approximately 74%; failures are associated with radiogenic ureteral injury.[16]

Surgical Revision​

Open Revision​

Open ureteroenteric reimplantation achieves success rates of 80%–91% and remains the historical reference standard.[1][7][10] Core steps:

  1. Mobilization and identification of the ureter above the anastomosis
  2. Excision of the strictured segment and periureteral fibrotic tissue back to bleeding, healthy ureter
  3. Spatulation of the healthy ureteral end
  4. Reimplantation into the bowel segment using Nesbit (end-to-side, refluxing) or Wallace (bilateral conjoined, refluxing) anastomosis
  5. Double-J stent placement across the new anastomosis

A retroperitoneal approach via low lombotomy incision has been described for isolated right-sided UAS, with mean operative time of approximately 50 minutes and no perioperative complications, avoiding the morbidity of transperitoneal re-entry into a previously operated field.[20]

Robot-Assisted Repair​

Robotic UAS revision has become the preferred approach in experienced centers. A multicenter comparison found robotic repair achieved comparable stricture-free rates to open revision (80% vs. 90%, p = 0.42) with significantly lower overall complication rates (37% vs. 70.6%, p = 0.026), fewer high-grade complications (4.6% vs. 23.5%, p = 0.031), and shorter hospital stays (3 vs. 6 days, p = 0.018).[23]

Technical steps for robotic revision:[21][10][22]

  1. Patient positioning: 30° Trendelenburg; port placement mirrors robotic prostatectomy configuration
  2. Access: Supraumbilical Hasson mini-laparotomy for pneumoperitoneum
  3. Adhesiolysis: Careful dissection around the bowel diversion, respecting mesenteric vasculature
  4. ICG-guided stricture localization: Intraluminal injection of indocyanine green (2.5 mg/mL) through the nephrostomy catheter illuminates the anastomotic segment under near-infrared fluorescence
  5. Ureteral mobilization and stricture excision: Complete resection back to healthy, perfused tissue
  6. Frozen section analysis: Confirms benign margins at the ureteral cut end
  7. Spatulation and reimplantation: Nesbit (unilateral) or Wallace (bilateral) anastomosis using continuous 4-0 barbed suture (Stratafix) over a Double-J stent

For the Sarychev / Klein technique, the anastomosis is completed intracorporeally using the same V-lock barbed running suture used in primary diversion, with real-time ICG verification of ureteral perfusion before completing the repair.[10]

Advanced Reconstruction for Complex Cases​

When ureteral length is insufficient for primary reimplantation after adequate stricture excision, the following adjuncts apply in escalating order of complexity:

AdjunctIndicationNotes
Boari-like bowel advancement flapInsufficient ureteral length after excisionUsed in ~15% of robotic and ~27% of open cases; a flap from the bowel segment bridges the gap without requiring additional tissue harvest.[8][22]
Downward nephropexyPan-ureteral tensionMobilization and inferior fixation of the ipsilateral kidney gains 3–5 cm of additional reach.[26]
Ileal interposition / bypassPan-ureteral loss or hostile ureteral bedA new ileal segment is anastomosed from the proximal healthy ureter to the conduit or neobladder; robotic ileal bypass series report 100% technical success in small cohorts.[24]
Buccal mucosal graft ureteroplastyLong stricture with adequate remaining ureteral plateOnlay augmentation avoids bowel harvest; outcomes appear comparable to BMG for primary ureteral reconstruction in early series.[25]

Anastomotic Technique Considerations for Prevention​

These principles apply to initial ureteroenteric construction and inform decisions during revision:

VariableRecommendationEvidence
Suture techniqueInterrupted preferredRunning anastomosis HR 1.9 for stricture vs. interrupted (p = 0.05); surgeon experience further modulates outcome independent of technique choice.[17][27]
Bricker vs. WallaceBoth acceptable; Wallace lower per-anastomosis stricture in some seriesBricker 3.6%–5.9% vs. Wallace 0%–3.7% per unit, though bilateral failure risk with Wallace if one side scars.[18][19]
Refluxing vs. antirefluxRefluxing technique preferred for primary diversionLe Duc nonrefluxing yields 3× higher stricture rate vs. refluxing Wallace (14.2% vs. 2.4% at 10 years for undilated ureters).[5]
Ureteral lengthMore generous distal ureteral resectionShorter ureters have lower stricture rates, confirming ischemic etiology of distal ureteral segment.[9]
Perioperative stentingSelective useRoutine stenting may paradoxically increase stricture risk (OR 2.27) in some series.[4]

Postoperative Surveillance​

Following endoscopic or surgical repair, recommend: CT at 3 months and 1 year, renal ultrasound at 6 and 9 months, then annually.[14] Most recurrences after endoscopic management occur within the first 3 months. Late recurrences after surgical repair necessitate long-term follow-up given the risk of silent contralateral development.[28]

Decision Algorithm​

UAS confirmed (biopsy negative for malignancy)
│
├─ Poor surgical candidate OR short stricture (≤ 2 cm)
│   └─ Endoscopic: combined laser incision + triamcinolone injection (83% success)
│       └─ Failure → surgical revision
│
└─ Surgical candidate
    ├─ Robotic repair (preferred): ICG-guided excision + Nesbit/Wallace reimplantation
    │   ├─ Adequate ureteral length → direct reimplantation
    │   ├─ Insufficient length → Boari-like bowel flap (~15% of cases)
    │   └─ Pan-ureteral loss → ileal bypass
    └─ Open repair (equivalent success, higher morbidity)
        └─ Retroperitoneal low lombotomy if isolated right-sided, virgin retroperitoneum

References​

1. Lobo N, Dupré S, Sahai A, Thurairaja R, Khan MS. Getting Out of a Tight Spot: An Overview of Ureteroenteric Anastomotic Strictures. Nat Rev Urol. 2016;13(8):447–55. doi:10.1038/nrurol.2016.104

2. Ahmed YE, Hussein AA, May PR, et al. Natural History, Predictors and Management of Ureteroenteric Strictures After Robot Assisted Radical Cystectomy. J Urol. 2017;198(3):567–574. doi:10.1016/j.juro.2017.02.3339

3. Citgez S, Bulbul E, Ozden SB, et al. Benign Ureteroenteric Anastomotic Stricture Predictors in Radical Cystectomy Patients: A Critical Analysis Focusing on the Nutritional Risk Index and Postoperative Urinary Tract Infection. Urol Oncol. 2025;S1078-1439(25)00271-6. doi:10.1016/j.urolonc.2025.07.011

4. Ramahi YO, Shiekh M, Shah AA, et al. Uretero-Enteric Strictures After Robot Assisted Radical Cystectomy: Prevalence and Management Over Two Decades. Clin Genitourin Cancer. 2023;21(2):e19–e26. doi:10.1016/j.clgc.2022.10.006

5. Hautmann RE, de Petriconi R, Kahlmeyer A, Enders M, Volkmer B. Preoperatively Dilated Ureters Are a Specific Risk Factor for the Development of Ureteroenteric Strictures After Open Radical Cystectomy and Ileal Neobladder. J Urol. 2017;198(5):1098–1106. doi:10.1016/j.juro.2017.05.069

6. Amin KA, Vertosick EA, Stearns G, et al. Predictors of Benign Ureteroenteric Anastomotic Strictures After Radical Cystectomy and Urinary Diversion. Urology. 2020;144:225–229. doi:10.1016/j.urology.2018.06.024

7. 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):1226–30. doi:10.1097/01.ju.0000086701.68756.8f

8. Bearrick EN, Findlay BL, Fadel A, et al. Open and Robotic Uretero-Enteric Stricture Repair: Early Outcomes and Complications. J Endourol. 2024;38(10):1021–1026. doi:10.1089/end.2024.0021

9. Das A, Zeng E, Risk M, et al. Shorter Ureters Lead to Fewer Strictures Following Cystectomy and Urinary Diversion. Urology. 2024;184:272–277. doi:10.1016/j.urology.2023.12.005

10. Sarychev S, Klein J. Robotic Ureter Reimplantation After Urinary Diversion. Urology. 2024;189:e10–e11. doi:10.1016/j.urology.2024.02.043

11. van Son MJ, Lock MTWT, Peters M, van de Putte EEF, Meijer RP. Treating Benign Ureteroenteric Strictures: 27-Year Experience Comparing Endourological Techniques With Open Surgical Approach. World J Urol. 2019;37(6):1217–1223. doi:10.1007/s00345-018-2475-4

12. 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

13. Singal RK, Denstedt JD, Razvi HA, Chun SS. Holmium:YAG Laser Endoureterotomy for Treatment of Ureteral Stricture. Urology. 1997;50(6):875–80. doi:10.1016/S0090-4295(97)00511-6

14. 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

15. Lovaco F, Serrano A, Fernández I, Pérez P, González-Peramato P. Endoureterotomy by Intraluminal Invagination for Nonmalignant Ureterointestinal Anastomotic Strictures. J Urol. 2005;174(5):1851–6. doi:10.1097/01.ju.0000176807.96225.1d

16. Poulakis V, Witzsch U, de Vries R, Becht E. Antegrade Percutaneous Endoluminal Treatment of Non-Malignant Ureterointestinal Anastomotic Strictures Following Urinary Diversion. Eur Urol. 2001;39(3):308–15. doi:10.1159/000052459

17. Roth S, van Ahlen H, Semjonow A, Oberpenning F, Hertle L. Does the Success of Ureterointestinal Implantation in Orthotopic Bladder Substitution Depend More on Surgeon Level of Experience or Choice of Technique? J Urol. 1997;157(1):56–60.

18. Krafft U, Mahmoud O, Hess J, et al. Comparative Analysis of Bricker Versus Wallace Ureteroenteric Anastomosis and Identification of Predictors for Postoperative Ureteroenteric Stricture. Langenbecks Arch Surg. 2022;407(3):1233–1240. doi:10.1007/s00423-021-02413-4

19. Kouba E, Sands M, Lentz A, Wallen E, Pruthi RS. A Comparison of the Bricker Versus Wallace Ureteroileal Anastomosis in Patients Undergoing Urinary Diversion for Bladder Cancer. J Urol. 2007;178(3 Pt 1):945–8. doi:10.1016/j.juro.2007.05.030

20. Kalemci S, Kizilay F, Simsir A. A New Technique in the Treatment of Ureteroenteric Anastomosis Stricture: Repair With Low Lombotomy Incision (Retroperitoneal Approach). Int J Clin Pract. 2021;75(6):e14155. doi:10.1111/ijcp.14155

21. Rich JM, Tillu N, Grauer R, et al. Robot-Assisted Repair of Ureteroenteric Strictures After Cystectomy With Urinary Diversion: Technique Description and Outcomes From the European Robotic Urology Section Scientific Working Group. J Endourol. 2023;37(11):1209–1215. doi:10.1089/end.2023.0204

22. Ghodoussipour S, Ahmadi N, Goh A, et al. Robotic Repair of Ureteroenteric Stricture Following Radical Cystectomy: A Multi-Institutional Experience. Urology. 2022;161:125–130. doi:10.1016/j.urology.2021.11.020

23. Ajami T, Musquera M, Palou J, et al. A Multicenter Study of Perioperative and Functional Outcomes of Open vs. Robot Assisted Uretero-Enteric Reimplantation After Radical Cystectomy. World J Urol. 2025;43(1):74. doi:10.1007/s00345-024-05435-x

24. Li H, Mou Y, Liu Z, et al. Robotic Ureteroileal Bypass Repair for Post-Cystectomy Bricker Ureteroenteric Anastomotic Strictures: Stepwise Approach and Clinical Outcomes. Ann Surg Oncol. 2026;33(5):4850–4857. doi:10.1245/s10434-026-19224-w

25. Bello D, Van Shufflin M, Hofer MD. Expanding the Armamentarium: Perspectives on Buccal Mucosal Grafts and Appendiceal Flaps in Ureteral Reconstructive Surgery. J Clin Med. 2025;14(21):7681. doi:10.3390/jcm14217681

26. Mauck RJ, Hudak SJ, Terlecki RP, Morey AF. Central Role of Boari Bladder Flap and Downward Nephropexy in Upper Ureteral Reconstruction. J Urol. 2011;186(4):1345–9. doi:10.1016/j.juro.2011.05.086

27. Large MC, Cohn JA, Kiriluk KJ, et al. The Impact of Running Versus Interrupted Anastomosis on Ureterointestinal Stricture Rate After Radical Cystectomy. J Urol. 2013;190(3):923–7. doi:10.1016/j.juro.2013.02.091

28. Reus C, Brehmer M. Minimally Invasive Management of Ureteral Strictures: A 5-Year Retrospective Study. World J Urol. 2019;37(8):1733–1738. doi:10.1007/s00345-018-2539-5