Ureteral Strictures (obstruction)

Overview

A ureteral stricture is a narrowing in the tube that carries urine from the kidney to the bladder. When a narrowing in the ureter occurs, (for example, by urinary stones), the kidney cannot function normally and will become damaged over time. Also, dilation of the kidney (called hydronephrosis) will occur.  

If you are experiencing pain or having problems when urinating, talk to us. Our team of urologists at City of Hope are experts who use leading-edge methods to diagnose and treat the various urologic conditions that affect millions of men.

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The physicians in our Division of Urology and Urologic Oncology are leading experts in treating patients with all types of urologic disorders and cancers. Just as no two patients are alike, a ureteral stricture requires a unique treatment plan tailored to each individual to attain the best possible outcomes.
 

NEWS & BREAKTHROUGHS

Male Anatomy - bw (Courtesy: National Cancer Institute)

About the ureter

The ureter is a muscular tube that carries urine from the kidney to the bladder. A ureteral stricture is a narrowing of this tube. When a narrowing in the ureter occurs, the kidney cannot function normally and will be damaged over time. There will also be dilation of the kidney (known as hydronephrosis).

As urine leaves the kidney, it is collected in the renal pelvis, which is usually confined within the kidney. When the renal pelvis meets the ureter, this is called the ureteropelvic junction.

The ureter passes behind the other organs in the abdomen in a space called the retroperitoneum. It goes toward the bladder and runs parallel to the aorta and inferior vena cava (the main vein that brings blood back from the legs).

Once in the pelvis, the ureter meets up with the bladder and enters the bladder at a site called the ureteral office.

Common symptoms of ureteral strictures include:

  • Pain
  • Urinary tract infections
  • Kidney stones

Causes of ureteral strictures

  • Congenital obstruction: If patients are born with an obstruction, it is usually discovered when they are young, but occasionally presents as an adult. The obstruction can occur at either the level of the ureter and the bladder (called the ureteral orifice), or at the junction of the ureter and kidney (called the ureteropelvic junction—UPJ).
  • Stone induced strictures: When a person passes a kidney stone or has surgery for kidney stones, strictures may develop.
  • Iatrogenic: This is an injury caused at the time of another abdominal surgery. Most of the time, operative injury to the ureter is seen immediately at the time of surgery and repaired. In some cases, the injury is missed and the patient develops symptoms that lead to a delayed presentation.
  • Radiation: Treatment with radiation for cancers in the abdomen can lead to narrowing of the ureter.
  • Idiopathic: This means that the cause of a ureteral stricture is unknown.
  • Retroperitoneal fibrosis: In some cases, there may be inflammation around the ureter from an unknown source that causes narrowing of the ureter.
  • Malignant obstruction: Sometimes cancer that is untreatable or in the process of being treated will compress the ureter, causing an obstruction. This is not a true stricture, but the symptoms may be similar.

Common sites of ureteral strictures

  • UPJ obstruction: This is usually a congenital problem that may not present until adulthood. The symptoms include pain in the back, infections and kidney stones.
  • Proximal ureteral stricture: These strictures are generally associated with kidney stones or previous repairs of UPJ obstructions. Proximal means that the stricture is close to the top of the ureter and the kidney.
  • Pan-ureteral strictures: These strictures extend from the kidney to the bladder, or have multiple sites of narrowing throughout the ureter. They are most commonly seen in cases of recurrent kidney stone disease.
  • Distal ureteral stricture: This stricture is close to the bladder or at the level of the ureteral orifice. Injury at the time of other surgeries, stones or radiation to the pelvic organs may cause distal strictures. If the stricture happens at the level of the ureteral orifice, it is usually congenital or happens at the time of treatment for bladder tumors.

 

 
 
 

How we diagnose ureteral strictures

  • Nuclear medicine renal scan: This study indicates how well the kidney is draining. It involves placing a tracer into the blood and following that tracer as it moves through the kidney and into the ureter. It also shows how well the kidney is functioning.
  • Antegrade nephrostogram: This test involves placing a small tube through the skin of the back and into the kidney. Contrast dye is then placed into the kidney as images are taken, allowing us to see where the ureter narrows down and if there is drainage of urine from the kidney.
  • Retrograde pyelogram: For this procedure, a small camera is placed through the urethra and into the bladder. Then a small tube is placed into the ureter while contrast dye is injected as images are taken. This allows doctors to highlight the ureteral anatomy and identify exactly where the narrowing occurs.
  • CT urogram: This special computed tomography (CT) scan produces detailed anatomic information about not only the ureter, but surrounding structures as well.  

How we treat ureteral strictures

Patients with a ureteral stricture have several options for repair. The ideal type of repair depends on the location of the stricture, the cause of the stricture and any prior surgery.

The majority of ureteral strictures we see are treated through a robotic approach, or a robot and open-assisted approach where part of the operation is performed robotically and part is performed through a small incision.

Pyeloplasty: Pyeloplasty is the ideal treatment for congenital ureteral obstruction at the level of the UPJ. The ureter is divided at the point of the stricture and reinserted into the renal pelvis.

Buccal mucosal ureteroplasty: This repair involves using mucosa from the lining on the inside of the mouth to patch the strictured region. This procedure is performed robotically through a minimally invasive approach. This has added versatility to repairing strictures that would have otherwise required significant operations with bowel interpositions or major bladder reconstruction.

Ureteroureterostomy: For short strictures in the mid to upper ureter, the strictured segment can be removed and the healthy ureter reattached.

Boari flap: When the ureter has a long stricture anywhere from the mid to lower ureter, sometimes the bladder has to be reshaped to reach above the site of obstruction. Occasionally, the kidney has to be mobilized in a downward direction to help bridge the gap.

Ureteral reimplant with psoas hitch: For strictures that are low and close to the bladder, the bladder can be minimally mobilized and attached to the psoas muscle in the back of the abdomen. This stabilizes the bladder for the ureter to be reimplanted directly into the bladder.   

Ileal ureter: Historically, ureteral strictures spanning the entire ureter were treated with indwelling stents that had to be changed every four to six months. Now, there are more options to correct these strictures surgically.

The use of buccal mucosal graft has been promising for long segment strictures. However, there are some cases where the best management is to replace the ureter with a small portion of the bowel. In particular, this procedure is highly successful in patients who form kidney stones and have ureteral strictures from passing multiple stones.

It can be a curative therapy as the stones can easily pass into the bladder. This procedure can be used for bilateral strictures.

Ureterolysis:  When someone develops retroperitoneal fibrosis, the ureter can become compressed by the inflammation. Initial treatment for this issue includes a course of steroids with stenting. The steroids can reduce inflammation to relieve the obstruction of the kidney. When the steroids do not work, the ureter may have to be dissected free from the retroperitoneum. This process is called ureterolysis.

Stent placement:  In some cases the best management is to place a plastic or metal tube into the ureter to allow the urine to bypass the stricture site. These are called ureteral stents.  

When a patient first develops a narrowing of the ureter, these stents are often the first option. They do not cure the stricture but they do allow urine to pass into the bladder. Ureteral stents must be changed at regular intervals (usually every four to six months).  

Though the stents may be uncomfortable at first, patients become accustomed to them after some time. The choice between using stents over an operation is based on the patient’s health status and preferences.

City of Hope brings expert urologic care to treating any urologic condition.

Urologic Surgeons - Duarte

Clayton S. Lau, M.D.

Clinical Specialties

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  • Urology
Kevin G. Chan, M.D.

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Laura Crocitto, M.D., M.H.A.

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  • Urology
Jonathan Lim Yamzon, M.D.

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  • Urology
Bertram Yuh, M.D., M.S.H.C.P.M., M.I.S.M.

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  • Urology

Urologic Surgeons - Community

Clayton S. Lau, M.D.

Clinical Specialties

  • Urologic Oncology
  • Urology
Seth A. Cohen, M.D.

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  • Female Pelvic Medicine and Reconstructive Surgery
Donald Hannoun, M.D.

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  • Urology and Urologic Oncology
Roger W. Satterthwaite, M.D., M.P.H.

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  • Urology
Jonathan N. Warner, M.D.

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  • Urology and Urologic Oncology
  • Reconstructive Urology
Kristina Wittig, M.D.

Clinical Specialties

  • Urology and Urologic Oncology
Jonathan Lim Yamzon, M.D.

Clinical Specialties

  • Urologic Oncology
  • Urology
Benjamin J. Yuh, M.D.

Clinical Specialties

  • Urologic Oncology
  • Urology
Bertram Yuh, M.D., M.S.H.C.P.M., M.I.S.M.

Clinical Specialties

  • Urologic Oncology
  • Urology
Ali Zhumkhawala, M.D.

Clinical Specialties

  • Urologic Oncology
  • Urology

Urologists - Community

Edward L. Davis, M.D.

Clinical Specialties

  • Urology and Urologic Oncology
Philip G. Pearson, M.D.

Clinical Specialties

  • Urology and Urologic Oncology
David W. Rhodes, M.D.

Clinical Specialties

  • Urology and Urologic Oncology

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