For referring physicians
Proximal and long-segment ureteral reconstruction: how I choose the operation
Proximal and mid-ureteral strictures, failed pyeloplasty, multifocal and panureteral disease, the radiated ureter, and the ureter someone has already operated on. These are the questions I ask, in order, with a video for each operation.
Is there a lumen?
The first question is whether a wire crosses the stricture. If it does, the ureter has a lumen and an onlay is on the table: open the narrow segment and patch it with buccal mucosa or appendix, transecting nothing. If nothing crosses, the segment is obliterated, and it gets excised and replaced. An onlay is impossible when the segment is missing rather than narrowed.
If there is a ureteral lumen, try to do an onlay. That is the rule I give fellows, and it is the fork that gets botched most often.
What does bowel cost this patient?
Length is not the whole answer. The second question is how much the patient has to lose by using bowel. In a patient with short gut I will do a lot to avoid bowel, including a buccal graft essentially the full length of a radiated ureter. The lumen decides whether an onlay is possible. The price of bowel decides whether it is taken.
Which side?
The onlay tissue is chosen by side. On the left, buccal mucosa: the appendix does not reach the left ureter. On the right, appendix or buccal, depending on whether the appendix is present, long enough and usable. Side also sets the cost of the fallback. An ileal ureter is harder on the left, because the sigmoid mesentery is in the way, and harder for a proximal defect.
Two strictures?
Multifocal disease does not by itself force replacement. Two separate strictures can each take a non-transecting onlay. What forces replacement is needing to transect the ureter in two places.
After a failed pyeloplasty
Redo pyeloplasty is ruled out by the length of the stricture, not by the prior failure. Ureterocalycostomy and downward nephropexy are on the menu for proximal disease; the proximal location is what puts ureterocalycostomy in play, and neither is a first move. The pyeloplasty operations themselves, primary and redo, have their own page.
The teaching case is a 28-year-old with a 4 cm proximal stricture after a failed pyeloplasty, offered an ileal ureter elsewhere. A wire crosses. He gets an onlay: buccal on the left, appendix or buccal on the right. The ileal ureter is too much surgery for a ureter that can be rebuilt in place, it is the harder operation on the left, and yo-yo voiding and reflux over the decades he has left can cost him the kidney the operation was meant to save.
Ileal ureter or autotransplant?
When the ureter has to be replaced, my default is the ileal ureter: less work, and less risk of losing the kidney. I keep it as short as possible and use the textbook renal-function and metabolic thresholds. Bilateral disease gets bilateral ileal ureters; I almost never do a transureteroureterostomy. Radiation pushes me further toward the ileal ureter. It damages the vessels an autotransplant has to be sewn to, and the bowel it damages is redundant.
Autotransplant is for the ureter that has already been replaced and failed, in a patient with recurrent infections or pain. An ileal ureter is the right first operation for proximal disease when there is no ureter at all and the kidney is socked in, so a nephropexy cannot buy the length.
Solitary kidney, short gut
When both replacements are blocked, no bowel for an ileal ureter and iliac vessels that cannot be released for an autotransplant, what is left is native-tract salvage: a Boari flap to the distal ureter plus a buccal graft proximally, in one stage. It needs a narrow ureteral end to graft onto, and it is easiest to justify on the left, where an ileal ureter is hardest. If that is not possible, infections decide the endpoint: chronic stents over a chronic nephrostomy, and a tapered ileal ureter despite the gut only if drainage fails.
Reconstruct or remove?
With a normal kidney on the other side, a kidney below the textbook split-function threshold is better removed than rebuilt, and recurrent urosepsis lowers that bar. When it is a solitary or dominant kidney, the answer is salvage at high risk.
When I stage
Nephrostomy first when the kidney's function is unproven, when the field is hostile, when the system is infected, or when the patient is malnourished. About three weeks, then the definitive reconstruction.
Two tells afterward. An ileal ureter that keeps infecting is draining poorly, even when it looks patent on imaging. After an autotransplant, the transplant ultrasound on day one or two reads the vascular anastomosis.
Videos by operation
Most operative videos are age-restricted on YouTube, so you need to be signed in to watch them.
Buccal mucosa graft onlay ureteroplasty
- SP robotic retroperitoneal dorsal onlay buccal ureteroplasty
- Oral mucosa graft ureteroplasty, SP retroperitoneal, full case uncut, 52 minutes
- SP retroperitoneal buccal ureteroplasty for a 5 cm stricture, full length, 93 minutes
- Buccal ureteroplasty for ureteroscopic injury
- Ureteral injury from spine surgery, repaired with buccal graft
- Buccal graft augmented anastomotic ureteroplasty, transperitoneal
- Augmented anastomotic oral mucosa graft ureteroplasty after prior ureteroureterostomy
- Buccal mucosa graft harvest
- The first robotic buccal ureteroplasty at NYU, 2013
Appendiceal onlay ureteroplasty (right side)
- Appendix onlay ureteroplasty, full length uncut, 100 minutes
- Appendix onlay for a right ureteral stricture after radiotherapy, full length
- Appendiceal onlay after prior ureterolysis
- Bilateral reconstruction: appendiceal flap on the right, buccal graft on the left
- Intravenous ICG to show the appendiceal artery
Ileal ureter
- SP robotic left ileal ureter, full length, 105 minutes
- SP robotic right ileal ureter for radiation obliteration, full length uncut, 127 minutes
- Ileal ureter by an initial retroperitoneal approach, SP robot
- Bilateral ileal ureter for radiation-induced stricture
- Reverse 7 ileal ureter, SP robot
- SP bilateral ileal ureter with bladder augmentation and vesicocutaneous fistula, full length, 170 minutes
Papers
- Robotic ureteral reconstruction using buccal mucosa grafts: a multi-institutional experience. Eur Urol. 2018. PubMed 29239749
- Robotic buccal mucosa graft ureteroplasty: a decade of experience from a multi-institutional cohort. Urology. 2024. PubMed 39622442
- A multi-institutional experience with robotic ureteroplasty with buccal mucosa graft: an updated analysis of intermediate-term outcomes. Urology. 2020. PubMed 32798516
- A multi-institutional experience with robotic appendiceal ureteroplasty. Urology. 2020. PubMed 32681918
- Preoperative predictors of surgical success for robotic ureteral reconstruction of proximal and middle ureteral strictures. Urology. 2023. PubMed 38104667
- Ureteral rest is associated with improved outcomes in patients undergoing robotic ureteral reconstruction of proximal and middle ureteral strictures. Urology. 2021. PubMed 33639184
- Intermediate-term outcomes after robotic ureteral reconstruction for long-segment (4 cm or longer) strictures in the proximal ureter: a multi-institutional experience. Investig Clin Urol. 2020. PubMed 33258325
- Robotic ureteral reconstruction for recurrent strictures after prior failed management. BJUI Compass. 2023. PubMed 37025480
- Role of buccal mucosa graft ureteroplasty in the surgical management of pyeloplasty failure. Asian J Urol. 2024. PubMed 39139522
- Multi-institutional experience comparing outcomes of adult patients undergoing secondary versus primary robotic pyeloplasty. Urology. 2020. PubMed 32687842
- Single-port robotic non-transecting Y-V flap pyeloplasty with stricturoplasty for ureteropelvic junction obstruction: a case series. World J Urol. 2026. PubMed 42303909
- Single-port robotic laparoscopic ureterocalicostomy: surgical technique and clinical outcomes. Can J Urol. 2024. PubMed 39675039
- Reconstruction of a devastated ureter: multi-institutional experience with robotic intracorporeal ileal ureter replacement. Eur Urol. 2026. PubMed 41577584
- Single-port robotic ileal ureter reconstruction: feasibility, technique, and early outcomes. World J Urol. 2026. PubMed 42068369
- Ureteral stricture: current treatment algorithm and key surgical principles in the robotic upper urinary tract reconstruction era. World J Urol. 2026. PubMed 41546831
- Buccal mucosal ureteroplasty for the management of ureteral strictures: patient selection and considerations. Res Rep Urol. 2022. PubMed 35433528
- Robot-assisted ureteral reconstruction using buccal mucosa. Urology. 2015. PubMed 26123519
More
- UPJ obstruction: how I choose the operation
- Distal ureteral stricture
- Ureteroenteric stricture after urinary diversion
- Transplant ureter stricture
- Distal ureter anatomy in 3D: reimplant, psoas hitch and Boari flap overlays
- For patients: What is a ureteral stricture (or UPJ obstruction)? and the patient explanation video