Indications for treatment

• Preservation of renal function
• Relief of symptoms (pain, infection, urolithiasis)

Anatomy

• Narrowest parts: UPJ, UVJ, and where ureter crosses over iliac vessels
• Ureter is posterior to gonadal vessels, vas deferens, uterine artery (water under the bridge)
• In women, near uterine arteries, ovarian vessels, and cervix - can be injured

Etiology

• Most common - congenital UPJ obstruction 
• Extrinsic - mass, fibrosis, malignancy, crossing vessel at UPJ
• Intrinsic - scar from radiation, impacted stone, surgery

Ipsilateral flank pain/tenderness, renal colic, may be more intense during diuresis
Hematuria, UTI

Work-up:

• UA/UCx
• BUN, Cr, BMP
• Renal ultrasound
• Hydronephrosis != clinically significant stricture - partial obstruction can cause hydro without symptoms/renal deterioration
• CT urogram - best test for stricture
• Renal scan to quantify obstruction/kidney function
• Recurrent or suspicious stricture - consider biopsy

Acutely: stent or perc tube to relieve obstruction

Indwelling stents - can be collapsed/obstructed (esp if 2/2 malignancy). Metal coil stents, larger stents, or 2 stents can help. If stents fail, should place nephrostomy tube
Balloon dilation

• 12F-30F, rapid or slow dilation, x 30s-10m, cycle 1-10x, place 6F-16F stent x 2-6 weeks postop
• Follow up with pyelogram, US, or renal scan 1 mo after stent removal, then q6-12 mo

Endoureterotomy - higher success rate than balloon dilation

• Full thickness incision of ureter, 2-10 mm past stricture (confirm with extravasation of contrast)
• Antegrade (percutaneous) - for mid/proximal ureteral strictures
• Retrograde (through bladder)
• UPJ/abdominal ureter - incise lateral (great vessels are medial, renal vessels anterior/posterior). UPJ is incised into renal pelvis
• Near common iliac/pelvic ureter - incise anterior
• UVJ - incise at 12 o'clock to avoid inferior vesical artery (lateral). Incise through UO
• Leave stent x 4-6 weeks; f/u as above

Surgical repair

• Ureteral reimplant
• Usual method for injury below iliac vessels to avoid interrupting blood flow to distal ureter with mobilization
• Psoas hitch - contralateral superior vascular pedicle of bladder is divided -> mobilize towards ureter. Bladder dome is sutured cephalad to ipsi psoas tendon (avoid genitofemoral nerve). Ureter is reimplanted into bladder dome. Contraindicated if bladder is too small, e.g. contracted
• Boari flap - Flap of bladder is rotated cephalad and tubularized; ureter is reimplanted into flap (often done with Psoas hitch)
• Ureteroureterostomy (UU) - primary anatomosis for short defects; preferred for abdominal ureter. Can perform nephropexy to mobilize kidney up to 8 cm inferiorly; suture to RP muscles
• Transureteroureterostomy (TUU) - bring injured ureter through mesenteric window superior to IMA (avoid kinking) and anastomose to contralateral ureter
• Ileal ureter - interpose with segment of ileum (useful for long segment of damaged ureter)
• UPJ: pyeloplasty (flap vs. dismembered; dismembered allows repositioning of ureter if there is a crossing vessel)
• If not enough pelvis to sew to - ureterocalycostomy
• Vascular hitch option for crossing vessel
• Follow up
• Urethral cathether x 24 hrs (7-10 days if bladder was incised, cysto before removal)
• RP drain is removed at least 24 hrs after urethral catheter to avoid urinoma
• Remove stent in 4-6 weeks
• CT urogram or renal scan 4-8 weeks after stent removal

Nephrectomy if kidney is poorly functioning