Preparing for ureteral stricture treatment

Ureteral strictures can lead to:

• Back (flank) pain
• Abdominal pain or cramping
• Nausea or vomiting
• Blood in the urine (hematuria)
  • It’s possible that you will see blood in your urine in the toilet, but more commonly it will be seen with a microscope in a urine sample that you give during an exam.
• Urinary tract infection (UTI)
• Permanent harm to the kidney from a backup of urine
  • Permanent harm happens if you have had a stricture for a long time. It is usually detected when kidney-specific blood tests show that your creatine levels are getting higher (worse). Normal creatinine levels are less than 1.

Some people do not have any symptoms and only find out about a ureteral stricture after an X-ray or blood test shows signs of a stricture.

A ureteral stricture has many possible causes, including:

Congenital development

Congenital development means you were born with a ureteral stricture. The ureter has a blockage where it exits the kidney (ureteropelvic junction obstruction). This is usually found and treated when you are a child. It is less common to have a congenital defect in the ureter as an adult.

Scar tissue formation

Scar tissue in or around the ureter can make the ureter narrower. Scar tissue may be caused by:

• Abdominal or pelvic surgery, such as:
  • Hysterectomy
  • Colon resection (for diverticulitis or cancer)
  • Surgery for prostate cancer
  • Surgeries on the large arteries (blood vessels) in the abdomen and in the pelvis (aorta, iliac, and femoral arteries)
• Passing a kidney stone or being treated for a kidney stone
• Radiation therapy for cancers of the pelvis
  • As cancer cells die, they turn into scar tissue. The scar can trap the ureter. This leads to obstruction of the ureter.

External compression of the ureter

Sometimes a part of the body becomes large and presses against the ureter, causing an obstruction. External compression can be caused by:

• Pelvic or abdominal tumor or cancer, including these types:
  • Cervical
  • Ovarian
  • Endometrial
  • Lymphoma (Hodgkin’s, non-Hodgkin’s)
  • Rectal/colon
  • Bladder
  • Other cancers that cause large lymph nodes
• Enlargement of arteries
  • Arteries in the pelvis sometimes get big. This is called an aneurysm. An aneurysm can block the nearby ureters.
• Retroperitoneal fibrosis
  • Rarely, people have a condition that causes thickening of the fatty tissue in the back of the abdomen. This is called idiopathic retroperitoneal fibrosis. It is often treated with steroids you take by mouth. Until the mass gets smaller, it can obstruct the ureter.

There are many ways to treat ureteral stricture. Most people have more than one option for treatment. Talk with your doctor about what treatment is best for you.

Options for ureteral stricture treatment include:

• Observation
• Retrograde ureteral stent placement
• Percutaneous nephrostomy tube
• Endoscopic ureteral dilation/incision
• Ureteroplasty/ureteral reconstruction

Read on to learn more about each option.

Observation

In some cases, your doctor may decide not to treat a ureteral stricture and will instead monitor your health and your condition periodically. This is called observation.

If you are not experiencing symptoms, you have normal kidney function, and you do not have any other medical or surgical treatments scheduled that require your ureteral stricture to be treated, your doctor may recommend observation.

Retrograde ureteral stent placement

Retrograde ureteral stent placement is the most common treatment for ureteral stricture and is often the first treatment your doctor will recommend. A silicone tube extending from the kidney to the bladder is placed into the ureter.

Ureteral stents are not permanent. They must be replaced every three to four months to prevent stones from forming and stopping the normal drainage of urine from the kidney.

Your first ureteral stent is often placed in the operating room while you are under anesthesia. Later stents can be placed in the clinic or ambulatory surgery with little or no anesthesia.

Stents may cause some side effects, although they can get better over time as you get used to having them. Side effects may include:

• Frequency and urgency of urination: Stents can irritate the inner lining of the bladder. This gives people the feeling of needing to use the restroom often and urgently. Medicines are prescribed to help with this, most often oxybutynin (Ditropan).
• Blood in the urine: Stents can irritate the inner lining of the bladder wall. This may cause bleeding. Bleeding happens most often after stent placement, after strenuous activity, and in people who take blood thinners such as coumadin or aspirin. The best way to help with blood in the urine is to stay hydrated so that your kidneys can make more urine to flush out the blood.
• Urinary tract infection (UTI): Bacteria can grow on the ureteral stent and cause infection. Because the stent has no blood supply, getting antibiotics to the area of the infection may be difficult. If infections are common, more frequent stent changes will be needed, usually every one to two months. Your doctor may also talk with you about other treatments — most often a percutaneous nephrostomy tube.

Percutaneous nephrostomy tube

Percutaneous nephrostomy is the second most common way to get urine to drain from a blocked kidney. Unlike a ureteral stent, the nephrostomy tube drains urine into a bag, not into the bladder.

Some reasons a person or provider might choose a percutaneous nephrostomy tube instead of a ureteral stent are:

• Failure of the ureteral stent to drain urine: Sometimes urine will continue to back up into the kidney after a stent is placed. This causes pain, infection, and worsening kidney function. This happens most in people whose ureteral stricture is caused by scar tissue.
• Side effects from the ureteral stent: Most people tolerate stents well and have few or no side effects. In some people, a stent can cause them to have severe urgency, frequency, or incontinence (leakage of urine). For these people, a nephrostomy tube may be better.
• Recurrent UTIs: Some people with a ureteral stent get a lot of UTIs. It can be hard to prevent stents from also getting infected, and stent infections are difficult to treat. The stent may then need to be changed more often than is normal — every one to two months.

What to expect when having a percutaneous nephrostomy tube placed

Nephrostomy tubes are not permanent. A tube will need to be replaced every three to six months, depending on how well the tube works.

The first tube is often placed using interventional radiology while you are under anesthesia. You lie on your stomach while the doctor uses fluoroscopy (X-ray) and ultrasound to place the tube. You spend the night in the hospital.

People who are having a tube replaced often do not need anesthesia or to stay in the hospital. This varies from person to person.

After the procedure, you may see blood in the nephrostomy bag for a few weeks.

You may have side effects from having a tube placed. These side effects often get better with time. They can include:

• Pain at the nephrostomy tube site: A small incision (cut) is made in the skin to place the tube. The site of the incision can be painful while it is healing. The pain will go away after the body forms a tract around the tube.
• Blood in the drainage bag: You may notice blood in the bag, especially after you have been active. You can help the kidneys drain the blood by staying hydrated.
• UTI: The site can become infected, so it is important to keep the area clean and as dry as possible. To prevent infection, some people may need to flush their nephrostomy tubes daily with saline (saltwater), which keeps the tube free from bacteria and helps to prevent stone formation.

Endoscopic ureteral dilation/incision

If the stricture is on the inside of the ureter, your doctor may use endoscopic ureteral dilation/incision. This procedure stretches or cuts the ureter to help make it larger so that urine can drain from the kidney. In many cases, this procedure will also fix or cure the stricture.

Endoscopic ureteral dilation/incision is often needed if the stricture was caused by kidney stones or kidney stone procedures.

This procedure is done in the operating room while you are under anesthesia. You should not need to stay in the hospital. You will only stay if your doctor thinks you may get a post-surgery infection or fever or if you have have bleeding or pain that needs closer monitoring.

A stent is often placed (or replaced) after the procedure. The stent helps the ureter heal in an open fashion. It is often left in place for one month.

Your doctor will monitor you closely after the stent is removed. Often ultrasound or CT scan is used to watch for hydronephrosis (large kidney). If the kidney is large, that means the stricture formed again. If so, a temporary ureteral stent or percutaneous nephrostomy tube is often placed until a more permanent surgical repair can be done.

Ureteroplasty/ureteral reconstruction

If you and your doctor want a permanent fix, you may need reconstructive surgery. This is often only done after ureteral stents, percutaneous nephrostomy tubes, or ureteral dilation/incision have not worked.

There are many different surgeries used to repair a ureteral stricture. You and your doctor will discuss which one is the right one for your stricture.

For some people who have ureteral stents placed because of obstruction from tumors, treatment of the tumor with surgery, radiation, or chemotherapy can make the tumor shrink, and this often relieves the obstruction.

Tests you may need before ureteroplasty/ureteral reconstruction

To decide which of the repair options is best to fix your ureteral stricture, your doctor often needs to conduct a series of tests to determine the length and place of your ureteral stricture and the health of your bladder. These tests may include:

• Exam under anesthesia (EUA): Your doctor takes X-rays of your bladder, kidney, and ureter to decide the length and place of the stricture and to see the size and health of your bladder.
• Urodynamics: This test measures the size and pressure in your bladder. It also shows whether urine that enters your bladder can go backwards into the kidney, also known as vesicoureteral reflux. During the test, the bladder is filled with saline using a small catheter. This is done without anesthesia. You go home the same day.
• MAG-3 renal scan: When a ureteral stricture leads to kidney damage, sometimes the kidney is too damaged to repair the ureter. This scan will show how well the kidney is working. If the scan shows the kidney is providing less than 20% of the needed function, your doctor may suggest the kidney be taken out instead of fixing the ureter.

Your doctor will also need to know more about your overall health. Tests could include:

• Electrocardiogram (ECG/EKG): This is a test of your heart to be sure it is healthy enough for surgery.
• Blood work: Blood tests can tell your doctor whether the supporting organs (kidney, liver, and intestines) are working well enough for surgery, and they are used to check the health, number, and size of your red blood cells (hemoglobin, hematocrit).
• Chest X-ray: This is necessary to see whether your lungs are healthy enough for surgery.
• Medicine review: This is a review of all medications you take to make sure your blood pressure is controlled and to know whether you are taking any medicines that lead to bleeding (coumadin, aspirin, clopidogrel) so that your doctor knows which of them you should stop taking before surgery.
• Urine test for tobacco use: You will need to stop using tobacco (cigarettes, chewing tobacco, vaping products, nicotine gum) before your surgery. A urine test is often done on the day of surgery to be sure you have stopped.

Surgeries used to repair ureteral stricture

There are many types of surgery to repair ureteral stricture. All of them have advantages and disadvantages. Not all options are possible for all strictures. You and your doctor will discuss which option is best for you. Options include:

Ureteral reimplantation: This is the most common type of ureteral reconstruction. The ureter is cut just above the narrowing, then it is sewn into a new place in the bladder.

Ureteral reimplantation with psoas hitch: This is used for ureteral strictures close to the kidney. The muscular part of the bladder is sewn to a tendon in the back of the abdomen. This lessens the tension and helps the ureter heal in its new place in the bladder.

Ureteral reimplantation with Boari flap: Part of the bladder is cut to work like a ureter. Strictures much higher in the pelvis can then be repaired. This can only be done in people with large enough bladders. The bladder often needs to measure more than 400 mL (about 12 ounces). It is not often done in people who have had pelvic radiation.

Ipsilateral uretero-ureterostomy (IUU): This is done only for short (less than 3 cm) ureteral strictures that are higher up in the abdomen. This type of stricture is often caused by trauma, kidney stones, or kidney stone procedures. It is common for your doctor to do the IUU using laparoscopic or robotic help.

Trans-ureteroureterostomy (TUU): This is done for ureteral strictures higher up near the kidney that are too long for an IUU, too high up to use the bladder (Boari flap). This surgery requires one healthy ureter. Strictures caused by stones or cancer are often not treated with TUU. The unhealthy ureter is cut just above the stricture and the healthy end is sewn to the side of the healthy ureter. The ureter often goes under the sigmoid colon.

Buccalmucosa/substitution ureteroplasty: Tissue is moved from one place in the body (often the mouth) and is sewn to the unhealthy part of the ureter. This patches the ureter and makes it larger. This is often done for strictures higher up in the abdomen (near the kidney) when IUU and TUU cannot be done.

Bowel substitution ureteroplasty: A ureteral stricture may be too long for the other techniques, or the bladder may be too small or unhealthy to be used. Part of the bowel can be used to bridge the gap between the kidney and bladder. The small intestine (ileum) or appendix is often used for strictures in the right ureter. This is used when long strictures involve both ureters.

Ureteral clipping: When repair of the ureteral stricture cannot be done but routing of urine from the bladder or pelvis is needed (with vesicovaginal fistulas or severe urinary incontinence), your doctor may permanently clip or suture your ureter. If this is done, a percutaneous nephrostomy tube is needed for life or until you are healthy or stable enough for reconstruction.

Nephrectomy: If ureteral reconstruction might cause more harm than good, or if the MAG-3 renal scan shows the kidney is not working well, you and your doctor may decide that it is best to remove the kidney. The other kidney must be healthy before this is done.

You will be notified of your check-in time by phone. One to three business days before your surgery, you will get a phone call with your check-in time. If you don’t get that call, or if you have questions, call 1-319-384-8008.

Most ureteral reconstruction surgeries last three to five hours. During this time, you will:

1. Get anesthesia
2. Be positioned
3. Have the procedure
4. Wake up and recover

Major complications are rare, but they can include:

Vascular injury: Injuries to the major blood vessels — such as the iliac and femoral arteries and veins and smaller arteries and veins — can cause bleeding. If this happens, you may need a blood transfusion and repair of the vessels. This repair may be done with the help of the vascular surgery doctors.

Bowel injury: Injuries to the small and large intestines can happen when getting to the ureter. This is often found and repaired during the surgery. Then no other care is needed. Larger injuries or those found later, may lead to removal of part of the bowel or bowel diversion (colostomy or ileostomy). This is often done with the general surgery doctors.

Neurologic positioning injury: When positioning people for surgery, doctors and nurses pad pressure points on the body. Arms and legs are placed in a way that does not lead to nerve injury. Neurologic injuries can still happen. Most of them get better in days to weeks after surgery. Some may need rehabilitation. Almost all of them get better with time and rehab. Some are more common with surgeries that last more than six hours.

Infection: Antibiotics are given before surgery. This lowers the risk of surgical-site infection. Infections can happen in the incision or urine. They often happen days after surgery. Signs are fever, chills, and redness around the wound. Most infections get better with antibiotics. Some need the incision to be opened and drained.

Urine leak: When the ureter is reimplanted into the bladder, stitches are used to hold it in place while the body heals. Urine can leak outside of the urinary tract (bladder/ureter) if a stitch does not hold or healing does not happen fast enough. Most leaks will heal on their own over time. Some will need drains be placed. Few will need a second surgery.

Most people stay two nights. People having surgeries that use the bowel or intestine stay four to six days. People often go home after they:

• Eat solid food
• Pass gas and have a bowel movement
• Walk without help (if they do not need help to walk before surgery)
• Have pain controlled with medicines taken by mouth and their epidural is removed

Most people have one vertical incision, about 6 to 8 cm long, below their belly button. There are three to five smaller incisions if a robotic or laparoscopic surgery is done.

You will have three tubes:

• Foley catheter: This drains your bladder. It will stay in place for one week. Most people return to the clinic to have it removed.
• Jackson-Pratt (JP) drain: This drains any fluid or blood that built up around the repair site after surgery. It will also show any urine leak. Most JP drains are removed before going home.
• Ureteral stent: All repairs are done over a ureteral stent. A stent lets the new connection heal and lowers the chance of a urine leak outside of the repair. Stents are often removed one month after surgery. This is done in the clinic using a cystoscope, which is a camera that goes into the bladder.

You will get:

• Pain medicines: Most people need only a few days of narcotic medicines.
• Stool softeners: Anesthesia, pain, and pain medicines all lead to a slowing of the intestinal tract. Stool softeners help people to have regular bowel movements. These are likely needed while taking pain medicines.
• Antibiotics: Most people only need antibiotics at the time of surgery. People with a UTI at the time of surgery or who had a segment of intestine used may need to go home with antibiotics. This will be specific to each person.

First visit: You will likely need to see your doctor one week after you go home if you have a Foley catheter. You will have a cystogram (X-ray of the bladder) to make sure the bladder has healed. If your incision was closed with staples, these are often removed at this visit too.

Second visit: You will have a cystoscopy and the stent removed about one month after surgery. A small camera is placed through the urethra into your bladder. The camera has a grasper that can remove the stent.

Third visit: About three months after surgery, you will have an ultrasound of your kidneys to make sure the repair worked well. The ultrasound will be used to look for hydronephrosis (dilation of the kidney). Any concerns found will be addressed with your doctor at this time.

You will have some discomfort. Call 1-800-322-8442 or get help right away if you:

• Have abdominal, flank, or back pain that gets worse after you go home
• Have a fever
• Cannot drink fluids or are vomiting
• Have UTIs
• Have other new symptoms

If you have a nephrostomy tube or indwelling ureteral stent, it might need to be changed.

Your doctor will see you in the months after your surgery. If you had ureteral stent or percutaneous nephrostomy tube, these are changed every three to four months. If you had a surgical repair, your doctor will have a good idea in the first year if it was a success.