Ureteral stricture

The ureters are paired organs that drain urine from the two kidneys into the bladder. They are muscular organs that actively transport urine from the renal pelvis into the bladder. From the bladder, the urine then flows out via the urethra.

As the ureter is naturally a very narrow organ, even small changes can cause a narrowing. If urine can no longer drain from the kidney, the dreaded backflow of urine into the renal pelvis can occur. A number of diseases can be considered as causes, for example congenital causes, infections, ureteral tumours or space-occupying lesions in the abdominal cavity. Scarred narrowings can also develop after the passage of urinary stones, radiotherapy or surgical procedures. A ureteral stricture can also occur in connection with endometriosis.

If the ureter is sufficiently narrowed, urinary retention occurs, medically known as "hydronephrosis". If urinary retention occurs acutely, the patient feels a severe, colicky pain in the flank. Such acute urinary retention is an absolute medical emergency and must be treated in hospital immediately. Slowly developing, chronic urinary retention, on the other hand, can go completely unnoticed. If left untreated, it can lead to kidney failure and infections, up to and including life-threatening blood poisoning.

A ureteral stricture is diagnosed during a urological examination. If the ureteral stricture causes urinary retention, this is usually first treated by inserting a thin ureteral catheter, a ureteral stent, a so-called double-J stent (DJ). This only serves to drain the urine safely as an immediate measure, as it does not eliminate the cause.

To better assess the narrowing, ureterorenoscopy (URS) is usually performed under general anaesthesia. Access is via a very thin and long instrument. This is inserted into the bladder via the urethra. There, either the right or left ureteral orifice is located and the instrument is then advanced through the ureter to the narrowing or into the kidney. In this way, access is achieved elegantly via the natural route. In the case of relevant narrowings, a ureteral stent is inserted again during this ureteroscopy.

Patients are admitted for robot-assisted da Vinci ureteral reimplantation on the day before the operation. The operation takes place under general anaesthesia. To treat the ureteral stricture, the robot's minimally invasive instruments are inserted into the abdominal cavity using keyhole surgery. Under three-dimensional vision, the surgeon carefully exposes the narrowed ureter and the bladder and detaches them from the surrounding tissue. The narrowing is removed and the healthy end is sutured into a new opening in the bladder. The robot-assisted surgical technique provides the best support for this demanding procedure. Postoperative care takes place in the recovery room before the patient is transferred to the normal ward. The entire inpatient stay lasts approx. 7 days. The ureteral stent, which serves to protect the suture, must later be removed by means of a short cystoscopy under local anaesthesia.

The be-all and end-all of the operation is to suture the junction tension-free, as this is the only way to achieve good healing. If the healthy end of the ureter is too far away from the bladder, a workaround is needed. In this case, the bladder is pulled upwards and attached to a muscle (psoas hitch technique). If even more length is required, a flap from the bladder is formed into a tunnel and extended upwards (Boari flap).

Thanks to 10x magnification, the anatomical structures can be visualised much better than with conventional laparoscopy. Compared with conventional (open) surgical techniques, this results in a better outcome, less blood loss and a shorter hospital stay. In addition, there is less pain after a robot-assisted operation.

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In addition to the general risks of any operation, such as bleeding or fever, there are special risks. During the procedure, the ureter is implanted, modelled on nature, in such a way that urine is prevented from flowing back to the kidney when the bladder is full. Nevertheless, this valve mechanism can fail and lead to kidney damage over a longer period of time. A ureteral stenosis can recur over time and cause urinary retention again. All possible risks of the surgical procedure for a ureteral stricture are discussed in a detailed consultation before the operation.

As a rule, professional activities such as office work are possible again 3–4 weeks after the operation. Sporting activities can be resumed after 3 months.

Ureteral reimplantation is performed under general anaesthesia. Due to the small incisions, hardly any pain is to be expected after the operation.