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.
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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.
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.
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