Management of Ureteral Stricture
For a patient with ureteral stricture, the appropriate management depends critically on whether the patient is symptomatic with acute obstruction versus stable disease, with percutaneous nephrostomy (PCN) being the preferred initial intervention for infected or symptomatic obstruction, followed by definitive surgical reconstruction for recurrent or complex strictures rather than repeated endoscopic procedures. 1
Initial Diagnostic Assessment
Before any intervention, you must determine stricture length and location, as this fundamentally dictates your treatment options 1. Use MR urography with IV contrast or MAG3 renal scan as your primary imaging modality to identify the underlying cause and assess functional significance 1. For symptomatic hydronephrosis, ultrasound with color Doppler, MRU with contrast, MAG3 renal scan, or CT urography are all appropriate initial studies 1.
Critical pitfall: Patients with complicated ureteroscopies or severely impacted calculi (median size 1.15 cm in one series) warrant close follow-up with imaging after stone treatment due to the possibility of rapid renal deterioration from stricture formation 2. Sixty percent of ureteral strictures in one study were caused by impacted stones, with 20% of those patients experiencing ureteric complications during stone treatment including perforation, urinoma, or guidewire fracture 2.
Acute/Urgent Management Algorithm
For Infected Obstructed Systems or Symptomatic Obstruction
Percutaneous nephrostomy is your first-line intervention when the patient is septic, hypotensive, or has failed retrograde access 1. PCN is superior to retrograde ureteral stenting in these scenarios because it provides immediate decompression and access for definitive treatment while decreasing reoperation rates and morbidity 1.
If PCN fails or when definitive treatment is planned soon, suprapubic cystostomy should be considered 1.
For Post-Surgical Ureteral Injuries
PCN decompression as primary management decreases reoperation rates and morbidity compared to immediate surgical repair 1. This approach provides access for definitive treatment and may obviate the need for repeated surgery 1. If retrograde stenting fails, interval PCN placement allows for secondary attempts at antegrade stenting across the injury 1.
Definitive Treatment Based on Stricture Characteristics
Short Strictures (<2 cm)
For short bulbar ureteral strictures, either urethral dilation or direct visual internal urethrotomy (DVIU) may be performed as first-line treatment, with success rates ranging from 35-70% 3. However, endoscopic management of benign ureteral strictures via balloon dilation and laser endoureterotomy is an excellent choice in properly selected patients, with opportunity for subsequent salvage treatments if needed 2.
Recurrent or Complex Strictures
Urethroplasty should be offered instead of repeated endoscopic management for recurrent strictures, as repeated endoscopic treatments have >80% failure rate 3. Various surgical reconstruction techniques are available including:
- Simple stricture excision with end-to-end anastomosis 4
- Ureterolysis with omental wrapping 4
- Ureteroneoimplantation 4
- Renal autotransplantation 4
- Ureter-ileum replacement 4
These surgical options can lead to long-term success rates of more than 90% with a rate of significant complications <5% 4.
Radiation-Induced Strictures
Radiation-induced strictures are particularly difficult to manage and may require subsequent urinary diversion 2. For strictures due to lichen sclerosus, non-genital tissue grafts (buccal mucosa preferred) should be used 3.
Postoperative Care Protocol
Place a urinary catheter following intervention to divert urine and prevent extravasation 3. A catheterization period of 24-72 hours is typically sufficient after dilation or DVIU 3. For open urethral reconstruction, perform retrograde urethrography or voiding cystourethrography at 2-3 weeks post-operatively to assess complete urethral healing before catheter removal 3.
Surveillance Schedule
Monitor patients at 3,6,9, and 12 months with symptom assessment, uroflowmetry, post-void residual measurement, and consider flexible cystoscopy if non-invasive parameters are concerning 3. Success is defined as no further need for surgical intervention or instrumentation rather than complete anatomic resolution 3.
Critical pitfall: Do not rely solely on patient symptoms—asymptomatic patients may have significant residual stricture or elevated post-void residual 3.
Complications to Monitor
- Stricture recurrence is the most common complication, typically developing within the first year 3
- Erectile dysfunction may occur transiently after urethroplasty, with resolution typically within six months 3
- Ejaculatory dysfunction (pooling of semen, decreased force, discomfort) reported in up to 21% of men following bulbar urethroplasty 3
- Urinary incontinence is rare and generally related to the original injury rather than treatment 3
Assess sexual function at 6-month and 12-month visits using validated questionnaires, and proactively counsel patients that most erectile dysfunction resolves by 6 months 3.