For referring physicians
Ureteroenteric stricture after urinary diversion: how I choose the operation
The anastomosis that has failed after an ileal conduit, neobladder or continent pouch, usually radiated, often after endoscopic attempts, in an abdomen that has already been opened. The questions I ask, in order, with a video for each operation.
Endoscopic management, once
One endoscopic attempt, then repair. The first attempt is a real attempt at treatment, and it also tells you whether the narrowing is really the problem. It cures only the stricture under 1 cm. Beyond that the endoscopic result is a bridge, whatever anyone calls it, and every further attempt spends kidney function you will want later: the kidney is damaged by chronic infection, and the eventual repair is harder in a worse kidney. The patient too sick for surgery is the one for whom a chronic stent or nephrostomy is the plan rather than the delay.
When you read that a stent series succeeded, ask what was counted. A metal stent that stays in is a temporization wearing the word success.
Three facts before the incision
The kidney is functional. There really is a stricture. Which side it is on. Cross-sectional imaging that shows the hydronephrosis and the parenchyma usually answers all three; a renal scan adds to it rather than replacing it. I will work with whatever imaging exists, and most of these patients arrive with a nephrostomy, which tells me the side and gives me a route. No fluoroscopy, no on-table imaging. The stent is replaced during the operation, and the type does not matter.
Can the conduit move to the ureter?
That question decides the operation, and usually the answer is yes. Inside it there is a second choice, on the same variable. A short stricture where everything mobilizes, ureter included: cut out the strictured segment and redo the anastomosis where it stands. Needing healthy bowel for a new segment of ureter: relocate the anastomosis to an unscarred part of the conduit you already have. Lengthening the conduit into new bowel is not a third move; that is a separate operation with its own bowel anastomosis and its own risk.
The ileal ureter is what is left when the conduit truly cannot be brought to the ureter. It is not the answer to a radiated field or a redo abdomen. Those persuade people toward the bigger operation, and neither one answers the question that decides the case.
Why the left is the problem
Right-sided strictures are easier to repair. Left-sided strictures are more common. The left ureter runs under the sigmoid and has to be dissected out, which is why reach fails more often on the left. In bilateral disease the left usually will not reach, so the operation ends as a Bricker on each side with the conduit in between. Both sides in one sitting is fine. If it must be staged, operate first on the side with more function and more to lose, not the worse side.
What a kidney is worth
There is no split-function threshold, because split function is the wrong denominator. Fifteen percent function in a patient about to go on dialysis is worth reconstructing. Twenty-five percent that is nearly impossible to reconstruct, in a patient with a GFR of 100, is not. A kidney I am not reconstructing gets a nephrectomy if it keeps getting infected and nothing if it is quiet. I try to avoid chronic tubes.
The hostile abdomen
My first choice in the reoperative abdomen is the single-port robot, used to go around the mesh, the old conduit and the old laparotomy rather than through them. The robot is the wrong tool only when you cannot get into the abdomen at all, and imaging does not show adhesions, so I start robotically and decide from inside. The conversion trigger is a rate, not a finding: no progress, or too long to get in. Say the time limit out loud before the case. On an unfamiliar platform I take the same cases and convert sooner. A stuck, tethered ureter is a dissection to avoid, not a leak to manage: bypass it.
Videos by operation
Most operative videos are age-restricted on YouTube, so you need to be signed in to watch them.
Redo anastomosis and reimplant into the conduit
- SP repair of bilateral ureteroenteric strictures, full length, 70 minutes
- Right ureteroenteric stricture repair after APR, SP robot, with enterotomy and closure
- Ureteral reimplant for ureteroenteric stricture to conduit
- Full-length Toumai repair of a left ureteroileal stricture with right distal ureterectomy
- Semi-live 2026: SP repair of bilateral ureteroenteric stricture (Italian commentary)
Flap and onlay repairs
Ileal ureter when the conduit cannot reach
After neobladder or continent diversion
- Left ureteroenteric stricture, reimplant into neobladder, full length uncut, 33 minutes
- Neobladder with left ureteroenteric stricture, repair using an additional segment of ileum
- Left ureteral reimplant with Boari flap into the Studer limb of a neobladder
- Intracorporeal Indiana pouch with an additional ileal loop for the ureteral anastomosis
Papers
- Robotic ureteroenteric stricture repair: a decade of surgical experience and technique evolution. J Endourol. 2026. PubMed 42544538
- Robotic repair of ureteroenteric stricture following radical cystectomy: a multi-institutional experience. Urology. 2022. PubMed 35007620
- Editorial comment on the definition of benign ureteroenteric anastomotic strictures in ileal conduits after radical cystectomy. Urology. 2024. PubMed 38452942
- 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
- Robotic assisted repair of post-ileal conduit parastomal hernia: technique and outcomes. Urology. 2021. PubMed 34481825
- Robotic ureteral reconstruction for recurrent strictures after prior failed management. BJUI Compass. 2023. PubMed 37025480