Transureteroureterostomy
Transureteroureterostomy (TUU) is a second-line ureteral reconstruction in which an obstructed, injured, or otherwise unusable donor ureter is passed across the midline retroperitoneum and anastomosed end-to-side into the contralateral recipient ureter. It preserves renal drainage without bladder reconstruction or bowel substitution, but it carries a unique hazard: a complication at the recipient ureter can threaten the previously healthy contralateral excretory axis.[1][2]
This page covers TUU as a salvage technique. For ipsilateral ureter-to-ureter repair, see Ureteroureterostomy. For distal bladder-based salvage, see Ureteral Reimplantation and Boari Flap & Psoas Hitch. For longer substitution, see Ileal Ureter Substitution.
Historical Position
TUU was described in the early 20th century and became an accepted reconstructive option through the experience of Hendren and Hensle, who reported 75 cases beginning in 1969. Their series, mostly pediatric, established the durable technical rules: avoid tension, angulation, and devascularization; keep the crossing retroperitoneal; and select a recipient ureter that is normal.[3]
Modern series confirm that TUU can be durable in adults and children, but its role remains selective. It is not a convenience operation for ordinary distal ureteral injury. It is chosen when ipsilateral reconstruction, bladder-based repair, or bowel substitution would be worse for the patient.[1][2][4]
Indications
TUU is indicated when ipsilateral reconstruction is not feasible because of anatomy, tissue quality, prior failure, oncologic resection, radiation, bladder limitations, or the need for urinary diversion without bowel.[1][2][4]
Benign disease
In the largest adult Mayo Clinic series, benign disease accounted for 67% of cases.[2] Benign indications include:
- failed ureteral reimplantation, especially after multiple prior procedures,
- undiversion from cutaneous ureterostomy or conduit back to native urinary tract,
- creation of a continent ureteral conduit for intermittent catheterization,
- massively dilated megaureter not amenable to standard reimplantation,
- ureteral necrosis or extensive devascularization,
- ureterocystoplasty when one ureter is used for bladder augmentation,
- salvage of failed ileal conduit with TUU and cutaneous ureterostomy.[3][4][5]
Malignant disease
TUU is useful during radical pelvic surgery when unilateral distal ureter is resected with tumor and ipsilateral bladder-based repair is undesirable or impossible. Reported settings include colorectal, cervical, ovarian, and bladder malignancy, often after prior multimodal therapy.[6][7][8][9][10]
Oncologic indications include:
- unilateral distal ureteral involvement during multivisceral pelvic resection,
- renal-sparing radical resection when ureteroneocystostomy would be under tension or in an irradiated field,
- palliative urinary diversion for advanced pelvic malignancy, often with terminal loop cutaneous ureterostomy.[11][12]
Iatrogenic ureteral injury
TUU is considered when the injured ureter cannot be reconstructed ipsilaterally because of extensive distal ureteral loss, hostile pelvis, prior radiation, inadequate bladder capacity, or failed reimplantation.[1][6]
Contraindications
The recipient ureter is the gatekeeper. If it is abnormal, TUU risks converting unilateral disease into bilateral obstruction.
Absolute contraindications
- recipient ureter stricture, tumor involvement, stone disease, or poor drainage,
- clinically important vesicoureteral reflux into the recipient system,
- bilateral ureteral disease,
- retroperitoneal fibrosis or hostile crossing bed that would compress the donor ureter,
- inability of the donor ureter to reach the recipient ureter without tension.
Relative contraindications
- history of nephrolithiasis, because long-term stone disease occurred in 12.7% in the Mayo Clinic series,[2]
- prior pelvic radiation, especially with malignancy and chemotherapy,
- solitary functional renal unit on the recipient side,
- active infection, urinoma, or unstable patient who needs drainage first,
- uncertain oncologic margin or need for further pelvic radiation across the planned crossing.
Prior radiation is not an absolute contraindication. In the Mayo Clinic series, 25.4% had received radiation, but complications were more common in malignant and radiated settings.[2]
Preoperative Planning
TUU planning should prove three things before incision:
- The donor kidney is worth saving. Use renal functional imaging, serum creatinine, infection history, symptoms, and patient goals.
- The recipient ureter is normal. Evaluate contralateral drainage, stone history, reflux risk, malignancy involvement, and prior surgery.
- The donor ureter can cross safely. Cross-sectional imaging and prior operative history should suggest that a straight, noncompressive retroperitoneal route is possible.
Useful studies:
- CT urogram or MR urogram for anatomy, tumor, radiation field, stones, and hydronephrosis,
- retrograde or antegrade pyelography to define donor and recipient ureteral caliber,
- renal scan when renal functional salvage is uncertain,
- cystoscopy when bladder involvement, prior reimplantation, or diversion planning matters.
Surgical Technique
TUU can be performed open, laparoscopically, or retroperitoneoscopically. Open TUU remains the most established approach for trauma, malignancy, and complex pediatric reconstruction.[1][2][13]
Exposure
- A midline transperitoneal incision is common for open TUU because it exposes both ureters and the retroperitoneal crossing route.
- Open the retroperitoneum bilaterally.
- Identify the diseased donor ureter and the healthy recipient ureter.
- Keep the recipient ureter mobilization minimal to preserve blood supply.
Donor ureter preparation
- Mobilize the donor ureter proximally with its adventitia intact.
- Divide the donor ureter at or below the level of disease.
- Ligate or excise the distal stump depending on disease and contamination.
- Spatulate the donor ureter enough to match the recipient ureterotomy.
- Confirm that the donor ureter can reach across the midline without stretch.
Retroperitoneal crossing
The donor ureter is brought across the midline through a wide, straight retroperitoneal route. For left-to-right crossings, the ureter passes posterior to the inferior mesenteric artery and sigmoid mesocolon or through a safe sigmoid-mesentery window. For right-to-left crossings, the route must avoid compression by the sigmoid mesentery.[1][10]
Technical goals:
- no tension,
- no angulation,
- no twist,
- no mesenteric compression,
- no sharp turn at either end of the crossing,
- no devascularization from excessive donor mobilization.
Recipient ureterotomy and anastomosis
- Make a longitudinal ureterotomy, usually 1.5-2 cm, on the medial or anteromedial recipient ureter.
- Perform a mucosa-to-mucosa end-to-side anastomosis using interrupted or running absorbable suture, commonly 4-0 or 5-0.
- Stent the donor ureter across the anastomosis. Some surgeons also stent the recipient ureter.
- Retroperitonealize the anastomosis and cover with peritoneum or omentum when possible.
- Place a retroperitoneal drain.
- Remove the ureteral stent commonly at 4-6 weeks, individualized by tissue quality and leak risk.
Stenting is strongly favored. In one pelvic malignancy series, the complications occurred in the unstented patients: leaks and stenosis resolved with percutaneous nephrostomy.[9]
TUU avoids bladder or bowel reconstruction, but it creates shared dependence on the recipient ureter. A narrow recipient ureterotomy, kinked crossing, ischemic recipient ureter, or unstented tenuous anastomosis can threaten both renal units.
Surgical Approaches
| Approach | Role | Notes |
|---|---|---|
| Open | Standard approach for complex pediatric, trauma, oncologic, and reoperative cases | Most outcome data; best exposure and recipient ureter control[1][2][3] |
| Laparoscopic | Selected pediatric or benign cases | Piaggio and Gonzalez reported a 4-trocar transperitoneal pediatric technique with discharge on postoperative days 2-4[13] |
| Retroperitoneoscopic | Selected salvage diversion cases | Kaiho et al. described retroperitoneoscopic TUU with cutaneous ureterostomy to salvage failed ileal conduit diversion[5] |
| TUU plus cutaneous ureterostomy | Frail, hostile abdomen, palliative malignancy, failed conduit | Single-stoma cutaneous drainage can avoid bowel interposition[11][12] |
Robotic TUU is conceptually feasible, but the evidence base remains much smaller than open TUU and far smaller than robotic reimplantation, Boari flap, or oral mucosal graft ureteroplasty.
Directionality
TUU can be performed right-to-left or left-to-right. In the Mayo Clinic series, 47.6% were right-to-left and 52.4% were left-to-right, with comparable use across indications.[2]
Practical differences:
- Left-to-right crossing is often easier because the left ureter has a long retroperitoneal course and can cross above the aortic bifurcation.
- Right-to-left crossing must respect the sigmoid mesentery and avoid compression or angulation behind it.
- The direction should be chosen by donor reach, recipient health, disease field, and future risk to the recipient side, not by surgeon habit.
Outcomes
Adults
| Series | Population | Outcomes |
|---|---|---|
| Iwaszko et al. 2010 | 63 adult TUU patients, mean follow-up 5.8 years | 96.4% patency in 54/56 with imaging; GFR improved from 62.8 to 71.8 mL/min; complications 23.8%; subsequent urologic intervention 10.3%; stone disease 12.7%[2] |
| Sugarbaker et al. 2003 | 11 patients with pelvic malignancy | Good renal function maintained in most; 1 major complication requiring ureteronephrectomy of the crossed system[10] |
| Richter et al. 2007 | 15 patients during multivisceral resection | 12/15 uncomplicated; 3 unstented patients developed leak or stenosis, resolved with percutaneous nephrostomy[9] |
| Joung et al. 2008 | 28 TUU vs 17 ipsilateral reconstructions for non-urologic pelvic malignancy | Similar complication rates; less voiding dysfunction after TUU than ureteroneocystostomy with psoas hitch[8] |
| Strup et al. 1996 | 10 complex ureteral problems | 1 stricture and 1 leak; good renal function at mean 77.9-month follow-up[6] |
Pediatric
| Series | Population | Outcomes |
|---|---|---|
| Hendren and Hensle 1980 | 75 cases, mostly pediatric | Low complication rate; many patients had no other reconstructive path[3] |
| Mure et al. 2000 | 69 childhood/adolescent TUUs, median follow-up 6 years | 79.4% good results with no upper tract dilation; all initially normal donor ureters remained normal; 78.4% of dilated donor ureters improved or normalized; serious complications 4.3%[4] |
| Piaggio and Gonzalez 2007 | 3 laparoscopic pediatric TUUs | All successful at 6 months; discharge postoperative days 2-4[13] |
TUU with cutaneous ureterostomy
| Series | Setting | Outcomes |
|---|---|---|
| Rainwater et al. 1991 | 67 patients over 25 years | Renal function improved or remained stable in 75%; common complications included urine leakage, stomal stenosis, and calculus formation[11] |
| Thrasher and Wettlaufer 1991 | 8 patients with advanced pelvic malignancy | No complications; hydronephrosis improved and creatinine stabilized; mean survival 5 months[12] |
Complications
| Complication | Incidence Signal | Management |
|---|---|---|
| Overall postoperative complications | 23.8% in the Mayo adult series, more common with malignancy[2] | Depends on complication and oncologic context |
| Anastomotic leak | Higher in unstented or hostile oncologic cases[9] | Drainage, stent, percutaneous nephrostomy |
| Anastomotic stricture or obstruction | 3.6% long-term obstruction signal in Mayo imaging cohort[2] | Balloon dilation, stent, revision, nephrostomy |
| Stone disease | 12.7% in long-term Mayo follow-up[2] | Surveillance, ureteroscopy, PCNL, spontaneous passage |
| Ischemic stenosis of common trunk | Rare but serious pediatric complication[4] | Reoperation or diversion |
| Renal deterioration requiring nephrectomy | Rare, about 1.5% in pediatric series[4] | Nephrectomy when salvage fails |
| Stomal stenosis with cutaneous ureterostomy | Reported in TUU plus cutaneous ureterostomy series[11] | Stomal revision, dilation, or diversion revision |
Malignancy patients have higher complication rates than benign patients, likely reflecting prior radiation, chemotherapy, advanced disease, and more hostile pelvic dissection.[2]
Renal Function
Across series, TUU generally preserves renal function when the recipient ureter remains patent:
- Mayo adult series: GFR improved from 62.8 to 71.8 mL/min (p=0.04).[2]
- Kawamura pelvic malignancy series: median eGFR was maintained after reconstruction.[7]
- Rainwater TUU plus cutaneous ureterostomy series: renal function improved or remained stable in 75%.[11]
- Pediatric Mure series: all initially normal donor ureters remained normal, and most dilated donor ureters improved or normalized.[4]
The functional lesson is selection-dependent: TUU can preserve function, but only if both kidneys drain through a healthy recipient ureter without compression, reflux-related injury, stone obstruction, or anastomotic narrowing.
Advantages
- Avoids bowel interposition and its mucus, metabolic, stone, and bowel-harvest morbidity.
- Preserves bladder integrity and can avoid cystotomy.
- Maintains urethral voiding when the bladder is usable.
- Can shorten operative time compared with ileal conduit in palliative settings.[12]
- Can be combined with cutaneous ureterostomy, reimplantation, continent diversion, or undiversion.[3][4][11]
- Works in either right-to-left or left-to-right direction when anatomy permits.[2]
Limitations
- Risks the contralateral renal unit by making it the recipient drainage path.
- Requires a normal recipient ureter.
- Requires enough donor ureter length to cross without tension.
- Is poorly suited to bilateral ureteral disease, retroperitoneal fibrosis, recipient-side stones, or recipient ureter tumor.
- Long-term stone risk is real and requires surveillance.[2]
- Minimally invasive TUU data remain limited compared with open TUU.
Comparison With Alternatives
| Feature | TUU | Ureteroneocystostomy / Psoas Hitch | Ileal Conduit or Ileal Ureter |
|---|---|---|---|
| Best use | Ipsilateral reconstruction not feasible; recipient ureter normal | Distal ureteral injury or stricture with usable bladder | Bladder absent/nonfunctional, long ureteral loss, hostile native ureter |
| Bladder surgery | Avoided | Required | Often bypassed or reconstructed with bowel |
| Bowel harvest | Avoided | Avoided | Required |
| Voiding function | Preserved if bladder intact | Usually preserved, but pelvic reconstruction may affect voiding | Diversion or bowel-substitution physiology |
| Contralateral risk | Yes | No | No direct recipient-ureter risk |
| Metabolic/mucus burden | None | None | Present with bowel |
| Main limitation | Recipient ureter becomes shared risk point | Requires bladder capacity and mobility | Bowel morbidity and long-term metabolic surveillance |
Special Settings
Oncologic resection
TUU can allow renal-sparing radical pelvic resection when a distal ureter must be removed en bloc with tumor. It is particularly useful when ureteroneocystostomy would land in an irradiated or scarred bladder field, or when preserving normal voiding is important.[7][8][9][10]
Palliative diversion
In advanced pelvic malignancy with short life expectancy or hostile abdomen, TUU with terminal loop cutaneous ureterostomy can decompress both kidneys through one stoma while avoiding bowel interposition.[12]
Pediatric reconstruction
TUU remains useful after multiple failed reimplantations, for undiversion, for complex megaureter, and for selected continent catheterizable reconstructions. The pediatric threshold for using TUU is shaped by lifelong contralateral risk, so recipient ureter normality and growth-friendly geometry matter.[3][4]
Operative Pearls
- Treat recipient ureter selection as the key decision, not a formality.
- Cross the donor ureter in a straight retroperitoneal path; no kinks, twists, or mesenteric pinch points.
- Keep the recipient ureter minimally mobilized.
- Make the recipient ureterotomy generous enough to avoid a functional bottleneck.
- Stent the donor side across the anastomosis; consider recipient stenting in tenuous repairs.
- Keep the anastomosis above the pelvic brim when possible in irradiated oncologic cases.[13]
- Counsel patients that a successful TUU can be durable, but failure may affect both kidneys.
References
1. de'Angelis N, Schena CA, Marchegiani F, et al. 2023 WSES guidelines for the prevention, detection, and management of iatrogenic urinary tract injuries during emergency digestive surgery. World J Emerg Surg. 2023;18(1):45. doi:10.1186/s13017-023-00513-8.
2. Iwaszko MR, Krambeck AE, Chow GK, Gettman MT. Transureteroureterostomy revisited: long-term surgical outcomes. J Urol. 2010;183(3):1055-1059. doi:10.1016/j.juro.2009.11.031.
3. Hendren WH, Hensle TW. Transureteroureterostomy: experience with 75 cases. J Urol. 1980;123(6):826-833. doi:10.1016/s0022-5347(17)56151-0.
4. Mure PY, Mollard P, Mouriquand P. Transureteroureterostomy in childhood and adolescence: long-term results in 69 cases. J Urol. 2000;163(3):946-948. doi:10.1016/s0022-5347(05)67859-7.
5. Kaiho Y, Ito A, Numahata K, Ishidoya S, Arai Y. Retroperitoneoscopic transureteroureterostomy with cutaneous ureterostomy to salvage failed ileal conduit urinary diversion. Eur Urol. 2011;59(5):875-878. doi:10.1016/j.eururo.2009.06.003.
6. Strup SE, Sindelar WF, Walther MM. The use of transureteroureterostomy in the management of complex ureteral problems. J Urol. 1996;155(5):1572-1574.
7. Kawamura J, Tani M, Sumida K, et al. The use of transureteroureterostomy during ureteral reconstruction for advanced primary or recurrent pelvic malignancy in the era of multimodal therapy. Int J Colorectal Dis. 2017;32(1):135-138. doi:10.1007/s00384-016-2672-9.
8. Joung JY, Jeong IG, Seo HK, et al. The efficacy of transureteroureterostomy for ureteral reconstruction during surgery for a non-urologic pelvic malignancy. J Surg Oncol. 2008;98(1):49-53. doi:10.1002/jso.21086.
9. Richter S, Kollmar O, Lindemann W, Schilling MK. Transureteroureterostomy allows renal sparing radical resection of advanced malignancies with rectosigmoid invasion. Int J Colorectal Dis. 2007;22(8):949-953. doi:10.1007/s00384-006-0235-1.
10. Sugarbaker PH, Gutman M, Verghese M. Transureteroureterostomy: an adjunct to the management of advanced primary and recurrent pelvic malignancy. Int J Colorectal Dis. 2003;18(1):40-44. doi:10.1007/s00384-002-0399-2.
11. Rainwater LM, Leary FJ, Rife CC. Transureteroureterostomy with cutaneous ureterostomy: a 25-year experience. J Urol. 1991;146(1):13-15. doi:10.1016/s0022-5347(17)37702-9.
12. Thrasher JB, Wettlaufer JN. Transureteroureterostomy and terminal loop cutaneous ureterostomy in advanced pelvic malignancies. J Urol. 1991;146(4):977-979. doi:10.1016/s0022-5347(17)37979-x.
13. Piaggio LA, Gonzalez R. Laparoscopic transureteroureterostomy: a novel approach. J Urol. 2007;177(6):2311-2314. doi:10.1016/j.juro.2007.02.004.