What are the definitive reconstructive options for an adult with a radiation‑induced ureteral stricture that has failed repeated stent placements?

Definitive Reconstructive Options for Radiation-Induced Ureteral Stricture with Failed Stenting

For radiation-induced ureteral strictures that have failed repeated stent placements, proceed directly to surgical reconstruction rather than continuing endoscopic attempts, as repeated endoscopic maneuvers increase morbidity and delay definitive treatment. 1

Immediate Temporizing Measure

• Place a percutaneous nephrostomy (PCN) for decompression while planning definitive reconstruction, as this achieves technical success rates approaching 100% and allows time for surgical optimization 1, 2
• PCN is preferred over continued stent attempts when retrograde stenting has failed, particularly in radiation-damaged tissue 3

Definitive Surgical Reconstruction Options (in order of preference)

For Distal Third Ureteral Strictures:

Primary approach: Ureteral reimplantation (ureteroneocystostomy)

• Excise the strictured segment and perform direct reimplantation into the bladder with wide spatulation of the anastomosis 1
• Add psoas hitch technique when the remaining ureter cannot reach the bladder without tension—this involves mobilizing and hitching the bladder to the psoas minor tendon 1
• Use Boari flap if psoas hitch is insufficient for a tension-free anastomosis 1
• Success rates of 64-100% are reported for ureteral reimplantation in similar pathology 1

For Middle Third Ureteral Strictures:

Primary approach: Ureteroureterostomy

• Debride both ureteral ends back to viable, well-vascularized tissue and perform end-to-end anastomosis with running or interrupted sutures 1
• Minimize ureteral devascularization during mobilization, as radiation has already compromised blood supply 1
• Stent the anastomosis and cover with peritoneum or omental wrap to improve vascularity in radiation-damaged tissue 1, 4
• Historical success rates range 76-92% 1

For Extensive or Complex Strictures:

Consider advanced reconstructive techniques:

• Robotic ureteral reconstruction achieves 88.2% clinical and radiological success at median 13-month follow-up in radiation-induced strictures 4
• Appendiceal bypass graft or ileal ureter interposition for strictures >2.5 cm or when primary anastomosis is not feasible 4
• Buccal mucosa graft ureteroplasty for select cases requiring augmentation 4

Last Resort Option:

Transureteroureterostomy (second-line technique)

• Mobilize the contralateral "donor ureter" and transpose it below the sigmoid colon to perform end-to-side anastomosis with the "recipient ureter" 1
• This is restricted to patients with poor prognosis due to risk of injuring the contralateral healthy ureter 1

Critical Technical Considerations for Radiation-Damaged Tissue

• Plan for adjunctive procedures to improve vascularity: omental wrap is frequently necessary due to poor tissue quality from radiation 4
• Expect longer operative times (median 215 minutes) and be prepared for tissue friability 4
• Avoid repeat procedures on radiation-damaged tissue, as this heightens the risk of necrosis and failure 4
• Ensure wide excision of fibrotic tissue back to healthy, bleeding edges before anastomosis 1

Alternative for Non-Surgical Candidates

Extra-anatomic stent (EAS) as salvage procedure

• When surgical reconstruction is contraindicated or not possible, place a percutaneous stent from the kidney tunneled subcutaneously into the bladder to bypass the obstruction entirely 5
• This establishes extra-anatomical urinary drainage without requiring ureteral continuity 5

Common Pitfalls to Avoid

• Do not persist with endoscopic dilation or repeat stenting in radiation strictures—poor long-term patency rates do not justify continued attempts 1
• Do not attempt reconstruction without adequate vascular support—radiation damage requires omental wrapping or other vascularized tissue coverage 4
• Do not underestimate stricture length—obtain CT urography with delayed excretory phase imaging to fully delineate the extent of injury 1
• Perform brush biopsy at the time of intervention to confirm benign stricture and exclude malignancy 1

Timing of Definitive Reconstruction

• Perform reconstruction when the patient is medically optimized and can safely tolerate the procedure, typically 3-6 months after PCN placement 1
• Ensure hemodynamic stability and resolution of any active infection before proceeding 1