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Ureteral Stricture: Etiology, Diagnosis and Treatment

Review literature: (Hafez and Wolf, 2003 ).

Definition of Ureteral Stricture

Ureteral stricture is the narrowing of the ureter, caused by various diseases and leads to upper urinary tract obstruction upper urinary tract obstruction.

Etiology of Ureteral Stricture

Diseases of the ureter (intrinsic causes):

• Ureteral stones
• Infections (e.g., urogenital tuberculosis and schistosomiasis)
• Upper tract (ureteral) carcinoma
• Idiopathic or congenital diseases

Iatrogenic causes:

Iatrogenic ureteral injury is caused by radiation or intra-operative injury (e.g., ureteroscopy, rectal surgery, hysterectomy, or vascular surgery).

Extraureteral diseases (extrinsic causes):

Various diseases may lead to obstruction of the ureter by compression or infiltration; please see the differential diagnosis of hydronephrosis.

Signs and Symptoms of Ureteral Stricture

Ureteral stricture may develop unnoticed. A slowly progressive ureteral stricture is often asymptomatic. Flank pain, fever, and hematuria occur depending on the underlying disease or infectious complications.

Diagnostic Workup

Imaging of Ureteral stricture:

• Renal ultrasound: grade of hydronephrosis?
• Intravenous urography or abdominal CT scan: etiology of ureteral stricture?
• Renal scintigraphy: renal function? Significant obstruction?

Endoscopy:

Perform retrograde pyelography and ureterorenoscopy to confirm the diagnosis and to assess the length of the stricture. Biopsy of the stricture is necessary in case of an unclear etiology.

Treatment of Ureteral Stricture

Ureteral Stenting:

Ureteral stenting is the initial treatment of symptomatic hydronephrosis after endoscopic diagnosis (see above). In conditions with possible spontaneous healing and resolution of the ureteral stricture, the ureteral stent can be removed after a few weeks (e.g., infections).

Endoscopic Balloon Dilatation:

A balloon dilatator is introduced after retrograde (or antegrade) pyelography and the insertion of a guide wire. Dilatation is done to a diameter of 4–6 mm, and a ureteral stent (DJ) is placed for 2–4 weeks. The success rate is 50–75%. Balloon dilatation is especially suitable for short segment strictures of less than 2 cm and for strictures after lithotripsy of ureteral stones.

Endoscopic Ureterotomy:

The stricture is incised under endoscopic vision after retrograde (or antegrade) pyelography and insertion of a guide wire. A full-thickness cut through the ureteral wall is done until the periureteral fat is seen. Visualization is possible with retrograde (URS) or antegrade (nephroscope) techniques. Ureterotomy is possible with a cold knife (without cauterization) and laser fibers (holmium or Neodym:YAG).

Care has to be given to vessels near the ureter. Proximal strictures (above the iliac vessels) should be cut latero-dorsally. Strictures near the iliac vessels and below should be cut anterior-medially. After the ureterotomy, a thick ureteral stent is placed for 8–10 weeks. The success rate is slightly higher than balloon dilatation, especially after strictures of ureteral anastomosis. The length of the stricture is the most important prognostic factor.

Ureteroureterostomy:

Ureteroureterostomy is a simple operation for treating short segment strictures (< 3 cm) of the proximal and mid ureter.For details see section ureteroureterostomy.

Ureteral Reimplantation:

Ureteral reimplantation is suitable for the treatment of distal ureteral strictures up to 4–5 cm of length [see section ureteroneocystostomy]. With the help of the psoas hitch technique, 6–10 cm of the ureter can be replaced. With the Boari-flap technique and depending on bladder capacity, 12–15 cm of the ureter can be replaced. An additional distance of 6 cm can be bridged by mobilization of the kidney and fixation of the lower pole to the psoas muscle.

Transureteroureterostomy:

Strictures of the mid ureter in combination with a low bladder capacity may be treated with transureteroureterostomy. A short donor ureter (proximal stricture) and a diseased ureter on the opposite side are contraindications. Furthermore, transureteroureterostomy is unsuitable for Ormond disease, after retroperitoneal radiation, upper tract urothelial carcinoma, and in patients with recurrent nephrolithiasis.

Renal Autotransplantation:

Explantation of the kidney and anastomosis with the iliac vessels is possible if the renal pelvis with a short proximal ureter can be anastomosed with the bladder.

Use of Buccal Mucosa Grafts:

A longitudinal incision of the strictured ureter segment and onlay grafting with buccal mucosa is used for multifocal ureteral strictures or after failed pyeloplasty.

Use of Ileum in Ureteral Reconstruction:

Reconstruction of long-segment ureteral strictures is possible with ileum (as a last resort). An appropriate segment of the ileum is delivered to the retroperitoneum and is anastomosed with full-thickness watertight sutures to the renal pelvis and bladder in an isoperistaltic fashion for adequate urine transport. Contraindications for ileal ureteral substitution are significant chronic kidney disease, bladder dysfunction, inflammatory bowel disease, or radiation injury of the bowel. Modified techniques to reduce complications (mucus obstruction, metabolic changes, and stone formation) and the length of used bowel include tapering the bowel graft, using a reconfigured ileal ureter (Yang-Monti), and combining it with a Boari flap (Xiong et al., 2020).

References

Hafez und Wolf 2003 HAFEZ, K. S. ; WOLF, Jr.: Update on minimally invasive management of ureteral strictures.
In: J Endourol
17 (2003), Nr. 7, S. 453–64

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