Ureteric Stricture — Causes, Diagnosis & Procedure Chooser
A ureteric stricture is a fixed narrowing of the ureter that obstructs urine flow and, if unrelieved, silently destroys the kidney above it.
The big picture
A ureteric stricture is a fixed narrowing of the ureter that obstructs urine flow and, if unrelieved, silently destroys the kidney above it. The two questions that decide everything are why (because a malignant cause changes the whole plan) and where and how long the stricture is (because location and length pick the operation). Reconstruction options run from a simple endoscopic incision for a short stricture all the way to replacing the ureter with bowel — and the chooser maps the stricture to the repair.
The framework: causes (mostly iatrogenic/ischaemic) → pathophysiology (ischaemia → fibrosis) → diagnosis (imaging + drainage + exclude malignancy) → a location- and length-based procedure chooser.
Mechanism pathway
Tap any step to see why it happens.
Diagnostic algorithm
Each step answers one question. Tap to expand.
Procedure chooser
Endoscopic — balloon dilation / endoureterotomy
Least invasive (incision + stent or balloon dilation). Lower success than reconstruction; avoid if heavily ischaemic/radiated.
Ureteroneocystostomy (reimplant) ± psoas hitch ± Boari flap
FitsReimplant for a distal stricture; add a psoas hitch to bridge a longer gap to the bladder, or a Boari flap for an even longer distal defect.
Ureteroureterostomy / transureteroureterostomy (TUU)
Excise and re-anastomose (ureteroureterostomy); or anastomose to the contralateral ureter (TUU).
Ureteroureterostomy / ureterocalicostomy
Ureteroureterostomy for a short upper defect; ureterocalicostomy for a scarred UPJ.
Ileal ureter / autotransplantation (± buccal ureteroplasty)
Bowel interposition replacing the ureter, or moving the kidney to the pelvis (autotransplant); buccal mucosa ureteroplasty for selected long strictures.
First exclude malignancy (ureteroscopy + biopsy) — a malignant stricture → oncologic management (e.g. nephroureterectomy for UTUC), not benign reconstruction. A poorly functioning, non-salvageable kidney (or an unfit patient) → nephrectomy, or permanent drainage (chronic stent/nephrostomy). Always preserve ureteric blood supply during any repair.
Board traps
Most ureteric strictures are iatrogenic — hysterectomy is the leading cause (~54%); impacted (especially proximal) stones are another major cause.
The mechanism is ischaemia → fibrosis; protect ureteric blood supply during any repair.
Always exclude malignancy (ureteroscopy + biopsy) before calling a stricture benign.
Chooser by length/location: short → endoscopic; distal → reimplant/psoas hitch/Boari flap; mid → ureteroureterostomy/TUU; proximal → ureteroureterostomy; long/complex → ileal ureter/autotransplant.
Confirm functional significance and split function (MAG3) — a non-salvageable kidney → nephrectomy.