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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​

Relief of ureteral obstruction is the first priority when hydronephrosis is present.[3] Both ureteral stenting and percutaneous nephrostomy (PCN) are effective initial options with comparable complication rates (21% vs 18%).[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 hydronephrosis despite adequate stenting (most common indication; ~ 40% of ureterolysis cases in one series).[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​

ApproachSuccess rateHospital stayBlood lossSerious complications
Open87.5–96%5.9–8 days390 mL (median)12% (Clavien III–IV)
Laparoscopic91–93.8%2.1–3.4 daysLower vs openSimilar to open
Robotic~ 100% (small series)2.8 days33 mL (mean)Low

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 multi-center NSQIP analysis of 100 patients found an overall complication rate of 12%, with 92% of complications being Clavien grade I–II (wound or urinary infections).[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​

The emerging approach. In a series of 17 patients (21 renal units), all remained free of obstruction at mean 20.5 months. Compared with pure laparoscopy, robotic assistance offers lower estimated blood loss (mean 33 mL vs 362 mL for open) and shorter hospital stays (mean 2.8 days). Robotic ureterolysis also facilitates the technically demanding omental wrap, which can be performed entirely robotically.[9][14]

Key Considerations​

  • ~ 15–22% of patients require additional procedures after ureterolysis (nephrectomy, uretero-ureterostomy, Boari flap, ureteric reimplant).[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]
  • Frozen-section biopsy during surgery is integral to ruling out lymphoma or other malignancies before proceeding.[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​

  • A trial of medical therapy for at least 3–6 months is generally recommended before concluding obstruction is refractory.[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 demonstrated that patients undergoing ureterolysis for stent failure had the greatest GFR improvement at 1 year (+ 25%), whereas those operated on for nephrostomy dependence (later in disease course) actually experienced a decline in GFR (− 10%) — suggesting delayed surgery may miss the window for renal recovery.[8]

Comparative Outcomes​

StrategySuccessStent durationRenal functionComplications
Medical + stenting69% stent-freeMedian 16 monthsPreserved in most12% med side effects; 18% recurrent obstruction
Ureterolysis (open)94–96% 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 with hydronephrosis — Place ureteral stent (or PCN if stenting fails) and initiate glucocorticoid therapy ± immunosuppressant.[2][15]
  2. At 3–6 months — Reassess with imaging and renal function. 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 — Medical therapy must continue regardless, as surgery does not prevent disease recurrence or systemic progression.[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 develops around an aneurysmal aorta (inflammatory abdominal aortic aneurysm, IAAA), vascular repair is indicated when the aortic diameter exceeds 4.5–5 cm, using the same criteria as for non-inflammatory aneurysms.[2][17] IAAAs occur in 5–10% of all AAA patients.[18]

  • The Society for Vascular Surgery recommends a retroperitoneal approach for open surgical repair (OSR) of inflammatory aneurysms; recent guidelines favor EVAR as first-line when anatomy is suitable.[18][17]
  • Both OSR and EVAR reduce perianeurysmal fibrosis in most patients, but hydronephrosis resolution is more reliably achieved with open repair (69% vs 38% with EVAR).[19]
  • Perianeurysmal inflammation does not fully resolve postoperatively in many cases and may even progress — raising the question of whether postoperative glucocorticoid therapy is beneficial. Ongoing imaging surveillance is essential, as 47% of patients with inflammatory aortitis develop new vascular lesions requiring surgery.[2][17]
  • Surgical intervention should ideally occur outside the window of active inflammation to reduce the risk of restenosis and postoperative complications.[17]

Surgical Biopsy​

Beyond its therapeutic role, surgery serves an important diagnostic function. Laparoscopic or open biopsy is preferred over needle biopsy for diagnostic accuracy, particularly in atypical cases where malignancy must be excluded.[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