Skip to main content

Ureterocolonic Fistula Repair

This is the surgical-technique atlas for ureterocolonic fistula. For definition, classification (vs ureteroileal, enterovesical, pyeloenteric), full etiology table, pathogenesis, clinical presentation, and diagnostic evaluation, see the clinical-conditions page: Ureterocolonic Fistula. This page focuses on the staged management framework, surgical repair options, and outcomes.

Three core repair principles:

  • The colonic pathology drives the operation — resection of the diseased colon (diverticulitis, malignancy, Crohn's) with primary anastomosis is the workhorse; the ureter typically heals after diversion alone
  • Conservative management (PCN + antegrade stent ± fecal diversion) achieves closure in selected cases — particularly iatrogenic fistulas detected early
  • Nephroureterectomy when the ipsilateral kidney is destroyed by chronic obstruction / infection; distal ureteral reimplantation with optional psoas hitch / Boari flap when the kidney is preserved

Staged Management Framework​

Stage 1 — Acute stabilization​

  • Sepsis control — broad-spectrum antibiotics; drain abscesses
  • Urinary tract diversion — PCN ± ureteral stenting to decompress the collecting system and divert urine from the fistula[1][2]
  • GI tract diversion — proximal diverting colostomy when needed to control fecal contamination[3]
  • Nutritional optimization — TPN or enteral nutrition as appropriate[4]

Stage 2 — Conservative management (may be definitive)​

For select cases — particularly iatrogenic fistulas detected early:

  • PCN + antegrade ureteral stenting — successfully closes ureterocolonic fistulas of both calculous and iatrogenic origin. Lang 1981: 15 patients with ureteral fistulae — PCN + antegrade stent provided an excellent conservative alternative to surgery[1][2]
  • Fecal stream diversion (proximal colostomy) — Krishna 1977 classic case: diverting colostomy alone led to spontaneous closure of a diverticulitis-related ureterocolonic fistula, confirmed on follow-up retrograde pyelography[5]
  • Endoscopic + percutaneous combined approach — Tramontano 2025 post-surgical (anterior resection for sigmoid cancer) ureterocolonic fistula resolved with combined endoscopic urological procedures and percutaneous drainage, avoiding open surgery entirely[6]

Stage 3 — Definitive surgical repair​

When conservative measures fail or the underlying pathology requires resection.

Repair Options​

1. Colonic resection + primary anastomosis (workhorse for colonic-origin disease)​

When the fistula originates from diseased colon (diverticulitis, malignancy):[3][7]

  • Surgery is directed at the colonic pathology; manipulation of the urinary system is generally unnecessary unless the kidney is non-functioning or injured
  • Cirocco 1994 largest review of diverticular ureterocolonic fistula: 100% cure with only one unrelated long-term mortality[7]
  • The ureteral defect typically heals after the diseased bowel is resected and the tract is excised, particularly if a ureteral stent is placed
  • Consider omental interposition between the colonic and ureteral suture lines to reduce recurrence

2. Nephroureterectomy (kidney destroyed)​

When the ipsilateral kidney is destroyed by chronic obstruction / infection (XGP, pyonephrosis):[8][9][10]

  • Indication: severely diminished differential renal function on nuclear renal scan
  • Combined with closure of the colonic defect (primary repair or resection depending on pathology)
  • Omar 2023 pediatric iatrogenic ureterocolonic fistula with decreased renal function — required open nephroureterectomy[8]

3. Ureteral repair / reconstruction (kidney preserved)​

Technique depends on injury location:[11][12]

Defect locationReconstructionSuccess
Distal ureter (most common — sigmoid proximity)Ureteroneocystostomy (reimplantation)91–98%[11]
Distal with insufficient reach+ Psoas hitch — bladder mobilized and fixed to ipsilateral psoas tendon; adds 3–5 cmUp to 97%[11]
Mid-to-distal, 8–12 cm gap+ Boari flap — full-thickness bladder flap tubularized and swung cephaladHigh patency[11][12]
Mid-ureter, both ends viableUreteroureterostomy — primary end-to-end over a stentVariable[11][12]
Extensive / multifocal injuryTransureteroureterostomy (TUU) — injured ureter to contralateral healthy ureter end-to-sideSecond-line; risk to contralateral system[12]
Long defect, no bladder reach, kidney salvageableRenal autotransplantation — kidney reimplanted in pelvis with iliac anastomosisLast resort before nephrectomy[12]
Long defect, ileal substitutionIleal ureteral substitutionLong-segment replacement option

Principles of ureteral reconstruction (ACS / WSES):[11]

  1. Debridement of all devitalized tissue
  2. Spatulation of ureteral ends
  3. Tension-free, watertight, mucosa-to-mucosa anastomosis with absorbable suture
  4. Double-J ureteral stent
  5. Minimal devascularization — preserve periureteral adventitia and blood supply
  6. Retroperitoneal drainage
  7. Tissue interposition (omentum or peritoneum) to separate the repair from the colonic suture line

4. Combined colonic resection + ureteral repair​

Often both pathologies require simultaneous attention:

  • Resection of diseased colon + ureteral reimplantation or repair
  • Omental interposition between colonic and ureteral suture lines to reduce recurrence
  • Consider diverting ostomy if there is concern about the integrity of the colonic anastomosis

Etiology-Specific Considerations​

Crohn's disease​

  • Preoperative optimization (nutritional support, anti-TNF) resolves urinary symptoms in ~ 57%, reducing the need for urinary-tract repair (Chen 2023)[13]
  • Anti-TNF therapy — sustained remission without surgery in 45% of entero-urinary fistula patients in a multicenter study (HR 0.23 for avoiding surgery; Taxonera 2016)[14]
  • ACG 2025 — infliximab ± immunomodulator as initial therapy before surgery for fistulizing CD[15]
  • AGA conditionally recommends infliximab or adalimumab (± thiopurine); anti-TNF + ciprofloxacin × 12 wk is significantly more effective than biologic monotherapy[16]
  • When surgery is required, resect diseased bowel; non-inflamed bowel or urinary organs can often be primarily repaired or left to heal by secondary intention[17]
  • Surgical management achieves 96–99% sustained remission with ~ 4% recurrence[13][14]

Diverticular disease​

  • Elective colonic resection for complicated diverticulitis with associated fistula[18]
  • Resection with primary anastomosis is typically curative; ureteral manipulation usually unnecessary[7]

Iatrogenic (post-surgical)​

  • Early recognition is critical — immediate repair 78% success vs 61% delayed[19]
  • Initial management with retrograde or antegrade ureteral stenting; operative repair if stenting fails[20]
  • WSES — ureteral closure + nephrostomy + delayed reconstructive surgery is a useful damage-control strategy in the acute setting[12]

Malignancy​

  • Radical resection of involved colon + ureter; prognosis depends on cancer stage[21]

Minimally Invasive / Endoscopic Options​

For poor surgical candidates or small fistulas:

  • Retrograde endoscopic fibrin glue injection — Sharma 2005: 75% success (6/8) for various urinary-tract fistulas at mean 11.75 mo; no complications[22]
  • Endoscopic clip closure (through-the-scope, OTS) from the colonic side[23][24]
  • Endoscopic suturing and tissue sealants[24]
  • Ureteral stenting alone — may be sufficient for small, early fistulas, particularly iatrogenic[2][6]

Outcomes​

  • Colonic resection for diverticular ureterocolonic fistula — 100% cure (Cirocco)[7]
  • Crohn's-related entero-urinary surgical management — 96–99% sustained remission[13][14]
  • Ureteral reimplantation (± psoas hitch / Boari flap) — 91–98% success[11]
  • Conservative management (stenting ± nephrostomy) — closure in selected cases, especially iatrogenic fistulas detected early[1][2][6]
  • Delayed diagnosis — increased morbidity, including loss of renal function necessitating nephrectomy[8][11]

Key Takeaways​

  • The colonic pathology drives the operation — resection of diseased colon with primary anastomosis is the workhorse for diverticulitis, malignancy, and Crohn's; the ureter typically heals with a stent.
  • Nephroureterectomy when the ipsilateral kidney is destroyed by chronic obstruction / infection.
  • Ureteral reconstruction (reimplant ± psoas hitch / Boari, UU, TUU, autotransplant, ileal substitution) when the kidney is preserved but the ureteral defect requires direct repair.
  • Conservative PCN + stent can be definitive for iatrogenic fistulas detected early (Krishna spontaneous closure case, Tramontano combined endoscopic + percutaneous).
  • Crohn's — anti-TNF + ciprofloxacin × 12 wk for medical therapy; surgical resection achieves 96–99% sustained remission when needed.

References​

1. Lang EK. "Diagnosis and management of ureteral fistulas by percutaneous nephrostomy and antegrade stent catheter." Radiology. 1981;138(2):311–317. doi:10.1148/radiology.138.2.7455109

2. Hausegger KA, Portugaller HR. "Percutaneous nephrostomy and antegrade ureteral stenting: technique–indications–complications." Eur Radiol. 2006;16(9):2016–2030. doi:10.1007/s00330-005-0136-7

3. Brown RF, Lopez K, Smith CB, Charles A. "Diverticulitis." JAMA. 2025. doi:10.1001/jama.2025.10234

4. Gill HS. "Diagnosis and surgical management of uroenteric fistula." Surg Clin North Am. 2016;96(3):583–592. doi:10.1016/j.suc.2016.02.012

5. Krishna AV, Dhar N, Pletman RJ, Hernandez I. "Spontaneous closure of ureterocolic fistula secondary to diverticulitis." J Urol. 1977;118(3):476–477. doi:10.1016/s0022-5347(17)58070-2

6. Tramontano S, Iacone B, Parrella V, et al. "Case report: unusual presentation and atypical course of a case of ureterocolic fistula after anterior resection for sigmoid cancer." Front Oncol. 2025;15:1549485. doi:10.3389/fonc.2025.1549485

7. Cirocco WC, Priolo SR, Golub RW. "Spontaneous ureterocolic fistula: a rare complication of colonic diverticular disease." Am Surg. 1994;60(11):832–835.

8. Omar H, Fulaij AA, Felemban J, et al. "Iatrogenic ureterocolic fistula in pediatric age group: a case report and review of the literature." Urology. 2023;173:e1–e5. doi:10.1016/j.urology.2023.01.005

9. Maeda Y, Nakashima S, Misaki T. "Ureterocolic fistula secondary to colonic diverticulitis." Int J Urol. 1998;5(6):610–612. doi:10.1111/j.1442-2042.1998.tb00422.x

10. Flood HD, Jones B, Grainger R. "Ureterocolic fistula: a unique complication of extracorporeal shock wave lithotripsy." J Urol. 1992;147(1):122–124. doi:10.1016/s0022-5347(17)37154-9

11. Johnsen N, Wessells H, Archer-Arroyo K, et al. Best Practices Guidelines: Management of Genitourinary Injuries. American College of Surgeons; 2025.

12. de'Angelis N, Schena CA, Marchegiani F, et al. "2023 WSES guidelines for the prevention, detection, and management of iatrogenic urinary tract injuries (IUTIs) during emergency digestive surgery." World J Emerg Surg. 2023;18(1):45. doi:10.1186/s13017-023-00513-8

13. Chen Y, Cao L, Qiu J, et al. "Surgical management and outcome of entero-urinary fistula complicating Crohn's disease: a single center study." World J Surg. 2023;47(12):3365–3372. doi:10.1007/s00268-023-07196-x

14. Taxonera C, Barreiro-de-Acosta M, Bastida G, et al. "Outcomes of medical and surgical therapy for entero-urinary fistulas in Crohn's disease." J Crohns Colitis. 2016;10(6):657–662. doi:10.1093/ecco-jcc/jjw016

15. Lichtenstein GR, Loftus EV, Afzali A, et al. "ACG clinical guideline: management of Crohn's disease in adults." Am J Gastroenterol. 2025;120(6):1225–1264. doi:10.14309/ajg.0000000000003465

16. Feuerstein JD, Ho EY, Shmidt E, et al. "AGA clinical practice guidelines on the medical management of moderate to severe luminal and perianal fistulizing Crohn's disease." Gastroenterology. 2021;160(7):2496–2508. doi:10.1053/j.gastro.2021.04.022

17. Lightner AL, Vogel JD, Carmichael JC, et al. "The American Society of Colon and Rectal Surgeons clinical practice guidelines for the surgical management of Crohn's disease." Dis Colon Rectum. 2020;63(8):1028–1052. doi:10.1097/DCR.0000000000001716

18. Hall J, Hardiman K, Lee S, et al. "The American Society of Colon and Rectal Surgeons clinical practice guidelines for the treatment of left-sided colonic diverticulitis." Dis Colon Rectum. 2020;63(6):728–747. doi:10.1097/DCR.0000000000001679

19. Aaron AE, Amabile A, Andolfi C, et al. Gastrointestinal Surgical Emergencies Textbook. American College of Surgeons; 2021.

20. Morey AF, Broghammer JA, Hollowell CMP, McKibben MJ, Souter L. "Urotrauma guideline 2020: AUA guideline." J Urol. 2021;205(1):30–35. doi:10.1097/JU.0000000000001408

21. Karamchandani MC, West CF. "Vesicoenteric fistulas." Am J Surg. 1984;147(5):681–683. doi:10.1016/0002-9610(84)90141-7

22. Sharma SK, Perry KT, Turk TM. "Endoscopic injection of fibrin glue for the treatment of urinary-tract pathology." J Endourol. 2005;19(3):419–423. doi:10.1089/end.2005.19.419

23. Willingham FF, Buscaglia JM. "Endoscopic management of gastrointestinal leaks and fistulae." Clin Gastroenterol Hepatol. 2015;13(10):1714–1721. doi:10.1016/j.cgh.2015.02.010

24. Cereatti F, Grassia R, Drago A, Conti CB, Donatelli G. "Endoscopic management of gastrointestinal leaks and fistulae: what option do we have?" World J Gastroenterol. 2020;26(29):4198–4217. doi:10.3748/wjg.v26.i29.4198