The ureter is a muscular tube that transports urine from the kidney, where it is produced, down to the bladder for storage. Most adults have two ureters. When a ureter becomes obstructed, damaged, or severely narrowed, the flow of urine can back up, potentially leading to swelling of the kidney, infection, or long-term loss of kidney function.
Ureter reconstruction is a specialized surgical field focused on repairing or replacing a compromised segment of this tube to restore unrestricted urine flow. The procedure aims to re-establish a healthy connection between the kidney and the bladder, preventing complications and preserving the function of the upper urinary tract. Successful reconstruction depends heavily on selecting the appropriate technique tailored to the location and extent of the damage.
Causes of Ureteral Damage
The most frequent reason for needing ureteral reconstruction is the development of a ureteral stricture, a segment of narrowing typically caused by scar tissue following prior procedures like endoscopic surgery for kidney stones, chronic inflammation, or stone impaction.
Another common source of injury is iatrogenic trauma, meaning damage accidentally inflicted during other abdominal or pelvic operations. Ureteral injury most often occurs during complex procedures like gynecological or colorectal surgeries, where the ureter lies close to the operative field. While overall rates are low, the injury can involve crushing, ligation, or transection of the tube.
Injury can also arise from previous radiation therapy directed at pelvic malignancies. This radiation causes ischemic injury, which leads to significant tissue fibrosis and the formation of long, challenging strictures. These radiation-induced strictures may develop many years after the initial cancer treatment. Less frequently, reconstruction is necessary for defects present from birth or following severe blunt or penetrating trauma to the abdomen.
Surgical Access Methods
The surgeon must first gain access to the damaged ureteral segment before any repair can take place. Minimally invasive techniques are frequently preferred today due to their benefits for patient recovery, including standard laparoscopy or the increasingly common robotic-assisted surgery.
Robotic-assisted surgery uses small incisions to insert specialized instruments and a camera, providing the surgeon with a magnified, three-dimensional view of the surgical field. The robotic platform enhances the surgeon’s dexterity, offering a greater range of motion and precision. This minimally invasive access often translates to less blood loss, reduced post-operative pain, and a shorter hospital stay compared to traditional open surgery.
However, traditional open surgery remains a necessary option in certain situations. This approach may be required for highly complex cases, such as those involving extensive scar tissue, significant inflammation from previous infection, or when managing certain types of cancer. The choice of access method is ultimately based on the location and length of the ureteral damage, the patient’s overall health, and the specific expertise of the surgical team.
Core Reconstruction Techniques
Once the damaged segment is exposed, the technique used to restore continuity depends on the length and location of the defect. For a short stricture, particularly in the upper or middle ureter, a ureteroureterostomy involves removing the diseased section and connecting the two healthy ends together, ensuring the repair is completed without tension.
When the damage is closer to the bladder, two primary techniques are used to bridge the gap. The psoas hitch involves mobilizing the bladder and suturing it to the psoas muscle in the pelvis, effectively pulling the bladder upward to shorten the distance to the ureter. This maneuver can typically bridge defects up to four inches long.
For longer defects near the bladder, up to six inches, the surgeon may perform a Boari flap. This technique involves creating a tubular flap of tissue from the bladder wall, which is then rotated and sutured to the healthy end of the ureter. By using the bladder wall, the surgeon can span a greater distance without the risk of tension on the connection.
In cases of extensive damage or loss of the ureter that cannot be bridged by mobilizing the bladder, a segment of the patient’s own small intestine (ileum) may be used for replacement. This procedure is reserved for the most complex reconstructions. For rare injuries involving the entire ureter, the kidney can sometimes be surgically detached and moved to a lower position in the body, a specialized procedure called kidney auto-transplantation, which significantly shortens the required length of the ureter.
Recovery and Long-Term Monitoring
The recovery period following ureter reconstruction varies based on the method of surgical access, with minimally invasive approaches allowing a quicker return to normal activities. Pain management is handled with oral medications, and patients are encouraged to begin walking shortly after the operation.
A temporary tube, known as a ureteral stent, is placed across the repair site to facilitate healing and ensure the free flow of urine. The stent prevents the reconstructed area from swelling or leaking during recovery. Stents remain in place for a few weeks to several months and are removed once the surgeon confirms the repair is stable.
Patients should anticipate some common symptoms while the stent is in place, including an increased frequency of urination, mild flank pain, and occasional blood in the urine. For approximately six weeks following surgery, patients are instructed to avoid strenuous activity or heavy lifting to prevent strain on the abdominal incisions and the internal repair.
Long-term success relies on ongoing follow-up to ensure the reconstructed ureter remains open and functional. Monitoring involves periodic imaging studies to check for any sign of recurrent narrowing or obstruction. There is a small risk of complications, including infection, leakage, or the recurrence of a stricture over time.