Lee C. Zhao, MD

For referring physicians

Distal ureteral stricture: how I choose the operation

Distal ureteral strictures after hysterectomy, ureteroscopy, radiation, endometriosis or a failed reimplant, and the ureter injured during someone else's operation. The questions I ask, in order, with a 3D model and a video for each operation. Strictures after a urinary diversion and after kidney transplant have their own pages.

Does the bladder reach?

Most distal strictures in my practice get a reimplant, and I usually do it side to side without transecting the ureter. A psoas hitch or a Boari flap is for the gap the bladder can be pulled up to meet. When the bladder cannot reach, the next question is the same one that governs the proximal ureter: is there a lumen? If a wire crosses, the segment can be opened and patched with a buccal graft. If it is obliterated and the bladder will not reach, the ureter is replaced.

See the distal ureter in 3D: reimplant, non-refluxing tunnel, psoas hitch and Boari flap overlays

Which route?

Transperitoneal or retroperitoneal, multiport or single-port, the anastomosis is the same. The retroperitoneal single-port route stays out of the peritoneal cavity. In women, a distal reimplant can be done through the vagina with the single-port robot, retroperitoneally, without entering the abdomen at all.

After a failed reimplant

A reimplant that has strictured is reconstructed on the same rules, and the salvage can be done without mobilizing the ureter off the iliac vessels.

Videos by operation

Most operative videos are age-restricted on YouTube, so you need to be signed in to watch them.

Side-to-side reimplantation, transperitoneal or retroperitoneal

Transecting reimplantation and distal ureterectomy

Transvaginal single-port reimplantation

Boari flap

Ureteroureterostomy and the injured ureter

Papers

  1. Lee M, Zhao K, Chao B, et al. Preoperative factors for success of robotic ureteral reconstruction for distal ureteral strictures. J Endourol. 2024. PubMed 39432479
  2. Slawin J, Patel NH, Lee Z, et al. Ureteral reimplantation via robotic nontransecting side-to-side anastomosis for distal ureteral stricture. J Endourol. 2020. PubMed 32233674
  3. Corse TD, Dayan L, Cheng N, et al. A multi-institutional experience utilizing Boari flap in robotic urinary reconstruction. J Endourol. 2023. PubMed 37128188
  4. Chao BW, Zhao K, Lee M, et al. Patient-reported symptoms suggestive of vesicoureteral reflux after robotic ureteral reimplantation in adults. J Robot Surg. 2025. PubMed 40232636
  5. Bourillon A, Freton L, Verhoest G, et al. Robotic vs. open ureteral reimplantation: a retrospective comparative single-centre series. BJUI Compass. 2025. PubMed 41250765
  6. Zhao LC and colleagues. Single-port robotic-assisted transvaginal retroperitoneal ureteral reimplantation: early experience. J Urol, AUA 2026 abstract. 2026.
  7. Lee M, Lee Z, Houston N, et al. Robotic ureteral reconstruction for recurrent strictures after prior failed management. BJUI Compass. 2023. PubMed 37025480
  8. Bourillon A, Peyronnet B, McGuire BB, et al. Ureteral stricture: current treatment algorithm and key surgical principles in the robotic upper urinary tract reconstruction era. World J Urol. 2026. PubMed 41546831
  9. Marien T, Bjurlin MA, Wynia B, et al. Outcomes of robotic-assisted laparoscopic upper urinary tract reconstruction: 250 consecutive patients. BJU Int. 2015. PubMed 25682696

All my ureteral reconstruction papers

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