Dr. med. Dirk Manski



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Ureteral Stricture

Review literature: (Hafez and Wolf, 2003 ).

Definition of Ureteral Stricture

Ureteral stricture is the narrowing of the ureter, caused by various diseases with development of a upper urinary tract obstruction.

Etiology of Ureteral Stricture

Diseases of the ureter (intrinsic causes):

Iatrogenic causes:

Ureteral injury may be caused by radiation or intra-operative injury (e.g. ureteroscopy, rectal surgery, hysterectomy or vascular surgery).

Extraureteral diseases (extrinsic causes):

A variety of diseases may lead to obstruction of the ureter by compression or infiltration, please see 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, hematuria occur depending on the underlying disease or infectious complications.

Diagnostic Work-Up

Imaging of Ureteral stricture:

Endoscopy:

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 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:

After retrograde (or antegrade) pyelography and insertion of a guide wire, a balloon dilatator is introduced. Dilatation is done to a diameter of 4–6 mm. Placement of a ureteral stent (DJ) is done 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:

After retrograde (or antegrade) pyelography and insertion of a guide wire, the stricture is cut under endoscopic vision. A full thickness cut through the ureteral wall is done until the periureteral fat can be seen. Visualization is possible with retrograde (URS) or antegrade (nephroscope) techniques. Different technical solutions exist for the ureterotomy: cold knife (without cauterization), 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 ureterotomy, a thick ureteral stent is placed for 8–10 weeks. The success rate is slightly higher than for 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 the treatment of short segment strictures (< 3 cm) of the proximal and mid ureter.For details see section ureteroureterostomy. Short strictures of the distal ureter are better treated by reimplantation (see below).

Ureteroneocystostomy:

Ureteroneocystostomy 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 ureter can be replaced. With the Boari-flap technique and depending on bladder capacity, 12–15 cm of 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 of the opposite side are contraindications. Furthermore, transureteroureterostomy is unsuitable for Ormond's disease, after retroperitoneal radiation, upper tract transitional cell 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 Ileum in Ureteral Reconstruction:

Reconstruction of long-segment ureteral strictures is possible with ileum (as a last resort). An appropriate segement of the ileum is delivered to the retroperitoneum via a small window in the colonic mesentery. On the right side, caecum and colon mobilization may be sufficient. The ileum 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 renal insufficiency, bladder dysfunction, inflammatory bowel disease or radiation injury of the bowel.







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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


  Deutsche Version: Ureterstriktur