Background

A narrowing of the ureteral lumen that results in functional blockage is known as a ureteral stricture. 

The most prevalent type of ureteral stricture is ureteropelvic junction (UPJ) blockage, which is a constriction at the level of the UPJ that can be acquired or congenital. 

Radiation treatment, gynecologic, urologic, and visceral surgical procedures can induce iatrogenic harm in addition to congenital abnormalities. 

The muscular tube that connects the renal pelvis to the bladder in the retroperitoneum is called the ureter and it is lined by transitional epithelium. 

Depending on the height of the individual, the ureter’s length ranges from 20 to 30 cm. As per on where it located, the lumen’s diameter ranges from 4 to 10 mm. 

The ureterovesical junction (UVJ), the UPJ, and the flyover by the ureter as it goes over the bifurcation of the iliac arteries are the narrowest places. 

The ureter crosses the common iliac artery and vein, passes anterior to the iliopsoas muscles and posterior to the gonadal arteries, and enters the pelvis inferiorly in both men and women. 

The ureter enters the bladder after the vas deferens loops anteriorly in males. The ureter in women passes near the uterine cervix and posterior to the uterine arteries before arriving to the intramural bladder. 

Epidemiology

Iatrogenic ureteral stricture is more common because of the extensive use of upper tract endoscopy. 

Patients having ureteroscopy for calculus treatment had ureteral stricture rates ranging from 3% to 11%, according to early ureteroscopy research. 

Postoperative stricture development can occur in as many as 24% of individuals having ureteroscopy for impacted ureteral stones. 

Between 3% and 5% of urine diversion cases involve uretero-intestinal anastomotic strictures. 

Up to 38% of individuals get secondary ureteral strictures that need to be treated after ureteral repair. 

Anatomy

Pathophysiology

A stricture is classified as ischemia by Wolf and colleagues if it occurs after open surgery or radiation therapy, and as nonischemic if it results from spontaneous stone passage or a congenital defect. 

Pathologic examination of the strictures shows fibrosis, abnormal collagen deposition, and variable degrees of inflammation, depending on the etiology and time after the causal trauma. 

Mild ureteral obstruction only results in proximal ureteral dilatation and hydronephrosis, while severe obstruction results in total blockage and consequent loss of kidney function. 

In other cases, severe blockage is quiet or asymptomatic and the degree of symptoms does not correspond well with the degree of obstruction. 

Etiology

The cause of ureteral stricture is as follows: 

Congenital Causes 

Acquired Causes 

It is classified as follows: 

Benign or malignant 

Extrinsic or intrinsic 

Iatrogenic or non-iatrogenic 

Genetics

Prognostic Factors

With a mean of around 55%, balloon dilation has a success rate of 48%-88%. 

Endoureterotomy has a 78% success rate when performed to treat benign strictures. At three years, 32% of endoureterotomy procedures performed to treat ureteroenteric strictures are successful.  

Results from right ureteroenteric strictures are often better than those from left ureteroenteric strictures. 

When used to treat ureteral strictures following kidney transplantation, balloon dilatation has a success rate of 45% to 79%. 

The success percentage of an antegrade or retrograde cold-knife incision at 26 months is 82%. 

Clinical History

Clinical History: 

Collect details including presenting complaint, past medical and surgical history of patients. 

Physical Examination

Abdominal Examination 

Genitourinary Examination 

Systemic Examination 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Acute symptoms are: 

Severe flank pain, Gross hematuria, Fever, chills, rigors 

Chronic symptoms are: 

Dull flank pain, Recurrent UTIs, Microscopic hematuria, Progressive hydronephrosis 

Differential Diagnoses

Ureteric Calculus 

Sloughed renal papilla 

Blood clot in ureter 

Genitourinary tuberculosis  

Schistosomiasis 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Treatment Paradigm: 

The results of open surgery are increasingly being replicated by laparoscopic and robot-assisted laparoscopic procedures. 

These methods tend to decrease blood loss and length of hospital stay, but they also need longer operating hours and may be more expensive. 

There is a great chance of failure with balloon dilation and endoureterotomy if the damaged kidney functions less than 25%. 

After the blockage is removed, some individuals who have impaired kidney function because of it may have a considerable improvement in their kidney function. 

CT scanning with delayed contrasted views and retrograde pyelography are frequently the most effective methods for evaluating the stricture’s anatomical features. 

In people who have had cancer in the past, think about taking a biopsy sample from the stricture. 

A sterile urine culture should be performed on the patient before surgery or endoscopic procedures to reduce the risk of perioperative infection. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

use-of-non-pharmacological-approach-for-ureteral-stricture

Antibiotics are used perioperatively and may be continued for 24 hours or until drains are removed. 

The drains are left in place until the output is very low (less than 30 mL/d) or the drainage is determined to be serum by measuring the drain creatinine level. 

For four to six weeks, stents are kept in place in patients who have had an endoureterotomy. 

Stents in patients who have anastomotic repairs are kept in place for ten to twenty-one days. 

Appointments with urologist and preventing recurrence of disorder is an ongoing life-long effort. 

Use of Antibiotics

Ciprofloxacin: 

It inhibits relaxation of DNA to promote breakage of double-stranded DNA. 

Doxycycline: 

It inhibits protein synthesis and that causes RNA-dependent protein synthesis to arrest. 

Use of Antineoplastics Agents

Paclitaxel: 

Natural taxane inhibits the production of DNA, RNA, and proteins by preventing the depolymerization of cellular microtubules. 

use-of-intervention-with-a-procedure-in-treating-ureteral-stricture

Balloon dilatation is the most popular first treatment for benign ureteral strictures, which is followed by 4-6 weeks of stent implantation. 

Endoureterotomy has a greater success rate than balloon dilatation and is frequently used for benign strictures. 

All open treatments have a higher risk of morbidity, and a longer hospital stay than endoscopic procedures. 

use-of-phases-in-managing-ureteral-stricture

Early follow-up imaging tests, such as renal scintigraphy, IVP, or renal ultrasonography, are usually carried out two to four weeks following stent removal. 

For the first two years, imaging is done at 3-month intervals and thereafter at 6-month intervals if the patient remains asymptomatic. 

Most stricture recurrences are discovered during the first year following surgery. 

In supportive care and management phase, patients should receive required attention such as lifestyle modification and surgical interventional procedures. 

The regular follow-up visits with the urologist are scheduled to check the improvement of patients along with treatment response. 

Medication

Future Trends

Media Gallary

References

Urethral Strictures – StatPearls – NCBI Bookshelf