Skip to main content

Ureterolysis for Retroperitoneal Fibrosis

Ureterolysis is the surgical liberation of the ureter from encasing fibrotic tissue, with intraperitoneal transposition and omental wrapping to prevent re-entrapment.[1] It is the definitive surgical intervention for retroperitoneal fibrosis (RPF) complicated by refractory ureteral obstruction. For the underlying disease, classification, medical therapy, and follow-up framework, see Retroperitoneal Fibrosis (RPF).

The surgical management of RPF encompasses three domains: (1) temporary urinary drainage (ureteral stenting, percutaneous nephrostomy), (2) definitive ureterolysis (open, laparoscopic, robotic), and (3) vascular surgery for associated inflammatory aortic aneurysms. Medical therapy remains the cornerstone of RPF management; surgical intervention plays a critical role in managing obstructive complications and refractory disease but does not prevent disease progression, recurrence, or systemic manifestations.[2]

Temporary Urinary Drainage — Ureteral Stenting vs PCN​

Urgent drainage is indicated for an infected obstructed system, acute kidney injury or threatened renal function. Mild hydronephrosis with stable function may permit closely monitored medical treatment; hydronephrosis alone does not dictate an identical intervention for every patient.[3] Both ureteral stenting and percutaneous nephrostomy (PCN) are effective initial options with similar observed complication rates (21% vs 17.9%, p = 0.79) in a 30-patient retrospective drainage cohort, not a trial establishing equivalence.[4][5]

  • Ureteral stenting is the most commonly performed interventional procedure (~ 38% of patients) and is typically attempted first. Successful stent placement at the first attempt occurs in ~ 79% of cases; of those, 80% can be managed with stenting alone throughout the treatment course.[6][4]
  • PCN is used when stenting fails or when the obstruction is too severe for retrograde access. Over time, both techniques may be needed in the same patient — they are complementary, not competing.[4]
  • The treatment goal is freedom from stent / nephrostomy combined with withdrawal of glucocorticoids and preservation of renal function. Medical management with temporary stenting achieves resolution of obstruction without ureterolysis in ~ 69% of patients, with a median stent duration of 16 months.[7][2]

Ureterolysis — Indications and Technique​

Ureterolysis is reserved for patients with refractory ureteral obstruction — those who fail medical therapy, have persistent hydronephrosis despite stenting, experience severe stent-related symptoms, or are nephrostomy-dependent.[8][1]

Indications​

Based on the available literature, ureterolysis should be considered in:[8][1][3]

  • Stent failure — persistent obstructive hydronephrosis despite stenting (40% in one series; severe stent symptoms were slightly more common at 44%).[8]
  • Severe stent-related symptoms — intractable pain, recurrent infections, or quality-of-life impairment from chronic stenting (44% of cases).[8]
  • Nephrostomy dependence — inability to transition from PCN to stent or stent-free status (10% of cases).[8]
  • Medication intolerance or failure — inability to tolerate glucocorticoids / immunosuppressants, or lack of radiographic response.[7]
  • Diagnostic uncertainty — when tissue biopsy is needed to exclude malignancy, ureterolysis can serve a dual therapeutic and diagnostic purpose.[2]

Technique​

The standard procedure involves:[2][1]

  • Free the ureters from the fibrotic tissue.
  • Intraperitoneal transposition of the mobilized ureter.
  • Omental wrapping to prevent re-entrapment.
  • Routine intraoperative biopsy of the retroperitoneal tissue to exclude malignancy.[9]

Approaches — Open vs Laparoscopic vs Robotic​

Different operative cohorts vary in selection, prior treatment and outcome definitions. Their percentages should not be read as a ranking of open, laparoscopic and robotic success.

Open Ureterolysis​

The traditional approach. In a prospective series of 50 patients, 96% were stent-free at 3 months and 94% at 12 months. Median hospital stay 8 days, median blood loss 390 mL, serious complications (Clavien III–IV) in 12%.[8] A separate 100-patient NSQIP analysis of ureterolysis found 12% 30-day complications, predominantly grades I–II. These are not long-term patency outcomes or an open-only comparison.[10]

Laparoscopic Ureterolysis​

Comparable success rates (87.5–93.8%) with significantly shorter hospital stay (mean 2.1 vs 5.9 days for open, P = .004) and reduced transfusion requirements in idiopathic RPF (3.7% vs 13.7%, P = .007).[11][12] In a tertiary-center comparison, success rates were 92% open vs 91% laparoscopic, with no significant difference in complications but shorter hospitalization and faster return to normal activities with laparoscopy.[13]

Robot-Assisted Ureterolysis​

In a series of 17 patients and 21 renal units, no unit remained obstructed at mean 20.5 months, but 3 patients required secondary procedures and one enterocutaneous fistula required bowel resection. This is eventual resolution, not 100% primary success without morbidity. An earlier pilot series demonstrated robotic biopsy and omental wrapping; these small cohorts do not establish superiority to open or laparoscopic surgery.[9][14]

Key Considerations​

  • Additional procedures were reported in 11/50 patients (22%) in the open series. The NSQIP study instead recorded 6 concomitant reconstructive procedures; these are different endpoints, not a pooled reintervention rate.[8][10]
  • Empiric contralateral ureterolysis may not be necessary — in one series, none of 13 patients who underwent unilateral ureterolysis developed contralateral disease progression.[9]
  • Tissue diagnosis is important when malignancy is possible. Frozen section may guide the operation, but equivocal findings require adequate permanent pathology and, when appropriate, immunophenotyping; frozen section alone cannot reliably exclude every lymphoma.[9]

Decision Framework — Medical + Stenting vs Ureterolysis​

The decision between prolonged medical management with stenting versus ureterolysis in RPF-related ureteral obstruction lacks formal consensus, but the available evidence provides a practical framework.[3][1]

Initial Approach — Medical Therapy + Temporary Stenting​

The current standard of care favors a conservative-first strategy: temporary ureteral stenting (or PCN) combined with glucocorticoid-based immunosuppressive therapy, reserving ureterolysis for refractory cases.[2][1] The rationale: medical therapy addresses the underlying immune-mediated process, whereas surgery only addresses the mechanical obstruction without preventing disease progression, recurrence, or systemic manifestations.[2]

In the largest reported series (Santiago 2021, n = 52), 69% achieved resolution of ureteral obstruction with medical management and temporary stenting alone, at a median stent duration of 16 months. Only 15% ultimately required ureterolysis (at median 2.2 years); medication side effects were uncommon (12%).[7] Recurrent obstruction after a stent-free period occurred in 18%.[7]

Timing Considerations​

  • Assess response to medical therapy with repeated renal function and imaging. There is no universal minimum 3–6-month trial that overrides failed drainage, renal deterioration or intolerable treatment.[2][3]
  • In the Santiago series, patients who ultimately required ureterolysis underwent the procedure at median 2.2 years after diagnosis — suggesting prolonged conservative management is often attempted before surgical escalation.[7]
  • Some authors argue ureterolysis should be considered earlier — particularly with stent failure or declining renal function — rather than as "last resort". O'Brien and Fernando reported median GFR changes of +25% in the stent-failure group and −10% in 5 nephrostomy-dependent patients. These selected indication groups do not demonstrate that delayed surgery caused worse recovery; the latter change was not statistically significant.[8]

Outcomes From Separate Cohorts​

StrategySuccessStent durationRenal functionComplications
Medical + stenting69% stent-freeMedian 16 monthsPreserved in most12% med side effects; 18% recurrent obstruction
Ureterolysis (open)94% stent-free at 12 moN/A (stent-free)+6% GFR overall; +25% in stent-failure group12% serious (Clavien III–IV)

Practical Decision Framework​

  1. At diagnosis — Assess renal function, infection and obstruction severity. Secure drainage promptly when indicated, establish the diagnosis and etiology, then coordinate disease-directed medical therapy.[2][15]
  2. During treatment — Reassess renal function and imaging early enough to detect failed drainage; do not wait months when function is threatened. If hydronephrosis is resolving and inflammatory markers are normalizing, continue medical therapy and plan stent-removal trial.[3]
  3. Consider ureterolysis if — Persistent hydronephrosis despite stenting, declining renal function, intolerable stent symptoms, medication intolerance / failure, or need for tissue diagnosis.[8][1]
  4. Do not delay excessively — Prolonged nephrostomy dependence or chronic obstruction may lead to irreversible renal atrophy, reducing the benefit of eventual ureterolysis.[8]
  5. Post-ureterolysis — Continue multidisciplinary assessment of disease activity. Further immunosuppression depends on the cause and activity of RPF and treatment tolerance; surgery does not mandate indefinite medication in every patient.[2][16]

The treatment goal remains freedom from stent / nephrostomy + withdrawal of glucocorticoids + preservation of renal function — a composite endpoint that neither strategy alone reliably achieves in all patients.[3]

Vascular Surgery — Inflammatory Aortic Aneurysm​

When RPF accompanies an inflammatory abdominal aortic aneurysm (IAAA), involve vascular surgery. ESVS 2024 recommendation 147 advises considering repair at diameter ≥55 mm, favoring EVAR when anatomy is suitable (class IIa, level C). Symptoms, rupture risk and the individual vascular anatomy can change management; a universal 4.5–5-cm threshold is inappropriate.[20]

A 2015 Cochrane review found no eligible randomized or controlled clinical trials comparing elective open repair and EVAR for IAAA. It therefore does not establish a trial-proven difference in hydronephrosis resolution.[19] Fibrosis and ureteral obstruction may persist or progress after vascular repair, so renal drainage and vascular surveillance remain necessary. Treatment timing and any ongoing immunosuppression require multidisciplinary decisions.[17][18][20]

Surgical Biopsy​

Beyond its therapeutic role, surgery serves an important diagnostic function. Choose image-guided core biopsy or surgical biopsy according to accessibility, suspicion for malignancy, tissue requirements and any prior nondiagnostic sample. The cited literature does not support a universal preference for open or laparoscopic biopsy in every patient.[6] Robotic-assisted biopsy can be combined with ureterolysis in a single procedure.[9]

See Also​

Videos​

Laparoscopic Left Ureterolysis with Omental Wrap for Retroperitoneal Fibrosis
AINU Surgical Videos (2025)

References​

1. Fenaroli P, Maritati F, Vaglio A. "Into Clinical Practice: Diagnosis and Therapy of Retroperitoneal Fibrosis." Current Rheumatology Reports. 2021;23(3):18. doi:10.1007/s11926-020-00966-9

2. Vaglio A, Salvarani C, Buzio C. "Retroperitoneal Fibrosis." Lancet. 2006;367(9506):241–251. doi:10.1016/S0140-6736(06)68035-5

3. Tanaka T, Masumori N. "Current Approach to Diagnosis and Management of Retroperitoneal Fibrosis." International Journal of Urology. 2020;27(5):387–394. doi:10.1111/iju.14218

4. Mertens S, Zeegers AG, Wertheimer PA, Hendriksz TR, van Bommel EF. "Efficacy and Complications of Urinary Drainage Procedures in Idiopathic Retroperitoneal Fibrosis Complicated by Extrinsic Ureteral Obstruction." International Journal of Urology. 2014;21(3):283–288. doi:10.1111/iju.12234

5. Scheidt MJ, Hohenwalter EJ, Pinchot JW, et al. "ACR Appropriateness Criteria Radiologic Management of Urinary Tract Obstruction." Journal of the American College of Radiology. 2020;17(5S):S281–S292. doi:10.1016/j.jacr.2020.01.039

6. Loricera J, Secada-Gómez C, Martín-Gutiérrez A, Blanco R, González-Vela C. "Clinical Features, Diagnosis, and Management of Retroperitoneal Fibrosis in a University Referral Hospital and Literature Review." Internal and Emergency Medicine. 2026. doi:10.1007/s11739-026-04298-x

7. Santiago J, Swartz R, Marder W, et al. "Including Medical Management in the Urologic Approach to Idiopathic Retroperitoneal Fibrosis." Urology. 2021;152:167–172. doi:10.1016/j.urology.2021.03.002

8. O'Brien T, Fernando A. "Contemporary Role of Ureterolysis in Retroperitoneal Fibrosis: Treatment of Last Resort or First Intent? An Analysis of 50 Cases." BJU International. 2017;120(4):556–561. doi:10.1111/bju.13915

9. Keehn AY, Mufarrij PW, Stifelman MD. "Robotic Ureterolysis for Relief of Ureteral Obstruction From Retroperitoneal Fibrosis." Urology. 2011;77(6):1370–1374. doi:10.1016/j.urology.2010.11.025

10. Ross J, Morcos M, Rowe NE. "Safety Analysis of Ureterolysis for Ureteric Obstruction Secondary to Retroperitoneal Fibrosis." World Journal of Urology. 2025;43(1):189. doi:10.1007/s00345-025-05576-7

11. Styn NR, Frauman S, Faerber GJ, Wolf JS. "University of Michigan Surgical Experience With Ureterolysis for Retroperitoneal Fibrosis: A Comparison of Laparoscopic and Open Surgical Approaches." Urology. 2011;77(2):339–343. doi:10.1016/j.urology.2010.03.036

12. Srinivasan AK, Richstone L, Permpongkosol S, Kavoussi LR. "Comparison of Laparoscopic With Open Approach for Ureterolysis in Patients With Retroperitoneal Fibrosis." The Journal of Urology. 2008;179(5):1875–1878. doi:10.1016/j.juro.2008.01.030

13. Ilki FY, Bulbul E, Gultekin MH, et al. "Comparison of Laparoscopic and Open Ureterolysis for Retroperitoneal Fibrosis: Results From a Tertiary Referral Center." Journal of Endourology. 2022;36(11):1425–1430. doi:10.1089/end.2022.0135

14. Mufarrij PW, Lipkin ME, Stifelman MD. "Robot-Assisted Ureterolysis, Retroperitoneal Biopsy, and Omental Wrap: Pilot Series for the Treatment of Idiopathic Retroperitoneal Fibrosis." Journal of Endourology. 2008;22(8):1669–1675. doi:10.1089/end.2008.0034

15. Zhang W, Stone JH. "Management of IgG4-related Disease." The Lancet Rheumatology. 2019;1(1):e55–e65. doi:10.1016/S2665-9913(19)30017-7

16. Raglianti V, Rossi GM, Vaglio A. "Idiopathic Retroperitoneal Fibrosis: An Update for Nephrologists." Nephrology, Dialysis, Transplantation. 2021;36(10):1773–1781. doi:10.1093/ndt/gfaa083

17. Kadian-Dodov D, Seo P, Robson PM, Fayad ZA, Olin JW. "Inflammatory Diseases of the Aorta: JACC Focus Seminar, Part 2." Journal of the American College of Cardiology. 2022;80(8):832–844. doi:10.1016/j.jacc.2022.05.046

18. Chaikof EL, Dalman RL, Eskandari MK, et al. "The Society for Vascular Surgery Practice Guidelines on the Care of Patients With an Abdominal Aortic Aneurysm." Journal of Vascular Surgery. 2018;67(1):2–77.e2. doi:10.1016/j.jvs.2017.10.044

19. Capoccia L, Riambau V. "Endovascular Repair Versus Open Repair for Inflammatory Abdominal Aortic Aneurysms." Cochrane Database of Systematic Reviews. 2015;(4):CD010313. doi:10.1002/14651858.CD010313.pub2

20. Wanhainen A, et al. European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Recommendation 147. Eur J Vasc Endovasc Surg. 2024. Guideline.