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Ureteric stricture (ureteral stricture) is the pathological narrowing of the ureter which may lead to serious complications such as kidney failure.
Several conditions have been identified to cause strictures such as impacted ureteric stones, iatrogenic injuries, tumours and radiotherapy.
Endoscopic urological procedures are common with the advancement of medical technology which allows endoscopic procedures to be among the main operative modalities in urology. However, complications can occur, and iatrogenic injury is disruption of healthy tissue which might lead to local inflammation in the process of healing and scarring which can result in ureteric stricture.
Non-endoscopic open surgical procedures such as colon surgery where the operation field is very close to the adjacent retroperitoneal ureter is a well-known procedure where ureters can be injured, especially when surgical plans are distorted in conditions such as tethered colon cancer or advanced inflammatory bowel disease. In the same way gynaecological operations near the ureters can lead to their injury, one of the common conditions where surgical plans are not clear is the presence of advanced endometriosis.
Radiotherapy had been identified as a cause of ureteric strictures formation. Damage occur as a result of both direct and indirect insults such as direct injury to cell proteins and DNA or mutation of the DNA which leads to future insults respectively. [1] This is not surprising as in the same way radiotherapy is expected to treat cancer and hence collateral damage can occur hence it can be challenging to treat as blood supply and vascularity are believed to be affected when stricture repair is intended. [2] For instance, Radiotherapy of cervical cancer can cause ureteric stricture in 2.2% of patients at 10 years. [3]
Radiotherapy had been identified as a modality of treatment of several cancers in the pelvis and the abdomen which may lead to ureteric stricture formation among other urological adverse effects too such as radiation induced cystitis. Among those cancers are; /colon and Anorectal cancer, cervical cancer, endometrial cancer and prostate cancer.
Kidney stones are becoming more common with time, and their incidence is believed to increase recently due to unhealthy diet habits. The passage of kidney stones into ureters might lead to their impaction and the development of local inflammatory process around the stone in addition to the obstruction of the ipsilateral kidney and build up of pressure manifested as hydronephrosis. Several studies were conducted to find stricture rates which varies from one to another but it seems that modern technology and treatment approaches are minimising the chances for stricture development post impacted stone treatment.
The symptoms of ureteric stricture varies from one patient to another, onset; acute or chronic, mode of injury or concurrent complications play a significant role as most other conditions. It can be associated with ipsilateral (same side) kidney obstruction and hydronephrosis, hence loin pain resulting from hydronephrosis and building up of pressure in the renal pelvis from obstructed urine flow which leads to its statics and pain.
Other symptoms related to ureteric strictures can be those related to complications such as recurrent UTI.
Ureteric strictures can be diagnosed using both imaging modalities and under direct vision through endoscopic procedures such as Ureteroscopy.
Several radiological studies can be used to detect such a stricture. Ultrasound Scans can show signs of obstruction such as hydronephrosis, while a CT scans can show the same and can locate the stricture or narrowing especially if used with contrast (CT Urogram), it can delineate other pathologies that might contribute to stricture such as Tumours or impacted stones.
Nuclear imaging plays a significant role to diagnose difficult cases and to evaluate the ipsilateral kidney function, such as MAG3 studies. Dynamic imaging are well known to play an essential diagnostic rule too such as Whitaker test. Overall, national and local guidelines, surgeon preferences and availability of the diagnostic modality plays a rule in choosing the diagnostic modalities used.
Treatment of ureteric strictures varies from one patient to another depending on the level, cause and extent of stricture in addition to patient factors such as comorbidities and preferences. Treatment options include minimally invasive palliative procedures such as Nephrostomy tube insertion or ureteric stents insertion or ureteral balloon catheter dilatation.
Various surgical techniques are employed to restore urine flow or repair damaged ureters when conservative treatments are insufficient. These reconstructive procedures address issues such as obstructions, trauma, surgical injury, or diseases that compromise the integrity of the urinary tract. The choice of technique depends on the nature and extent of the damage, the location of the ureteral defect, and the patient’s overall condition. [4] Procedures such as Rendez-vous and reconstructive surgeries such as flaps or using ileum [5] to reconstruct ureters are used and had various success rates. Ureter reimplantation, for example, repositions the ureters to correct flow abnormalities. Surgical techniques such as the psoas hitch procedure involve mobilizing the bladder to bridge a gap in the ureter by securing it to the psoas muscle for added stability. [6] The Boari flap technique reshapes part of the bladder wall into a tube to replace a damaged ureter segment, while appendiceal ureter interposition uses the appendix as a substitute for the ureter. For more extensive reconstruction, the ileal ureter approach repurposes a segment of the small intestine (ileum) to create a new channel for urine flow, often draining into an external pouch.
Technology is driving more hope finding more treatment options, laparoscopic assisted robotic techniques are developing and been reported while tissue engineering for reconstruction is not developed yet as it is in other urological reconstruction topics. [7]
Urology, also known as genitourinary surgery, is the branch of medicine that focuses on surgical and medical diseases of the urinary system and the reproductive organs. Organs under the domain of urology include the kidneys, adrenal glands, ureters, urinary bladder, urethra, and the male reproductive organs.
The ureters are tubes composed of smooth muscle that transport urine from the kidneys to the urinary bladder. In an adult human, the ureters typically measure 20 to 30 centimeters in length and about 3 to 4 millimeters in diameter. They are lined with urothelial cells, a form of transitional epithelium, and feature an extra layer of smooth muscle in the lower third to aid in peristalsis. The ureters can be affected by a number of diseases, including urinary tract infections and kidney stone. Stenosis is when a ureter is narrowed, due to for example chronic inflammation. Congenital abnormalities that affect the ureters can include the development of two ureters on the same side or abnormally placed ureters. Additionally, reflux of urine from the bladder back up the ureters is a condition commonly seen in children.
A urethral stricture is a narrowing of the urethra, the tube connected to the bladder that allows urination. The narrowing reduces the flow of urine and makes it more difficult or even painful to empty the bladder.
A ureterosigmoidostomy is a surgical procedure wherein the ureters, which carry urine from the kidneys, are diverted into the sigmoid colon. It is performed as a secondary treatment in bladder cancer patients who have undergone cystectomy. Rarely, the cancer can present in children between the ages of 2 & 10 years old as an aggressive rhabdomyosarcoma, although there have been diagnoses of children as young as 3 months old. The procedure was also used several decades ago as a correctional procedure for patients born with bladder exstrophy. In the case of some bladder exstrophy patients, occasional bowel incontinence at night is one uncontrollable consequence.
A ureterocele is a congenital abnormality found in the ureter. In this condition the distal ureter balloons at its opening into the bladder, forming a sac-like pouch. It is most often associated with a duplicated collection system, where two ureters drain their respective kidney instead of one. Simple ureterocele, where the condition involves only a single ureter, represents only twenty percent of cases.
Urinary retention is an inability to completely empty the bladder. Onset can be sudden or gradual. When of sudden onset, symptoms include an inability to urinate and lower abdominal pain. When of gradual onset, symptoms may include loss of bladder control, mild lower abdominal pain, and a weak urine stream. Those with long-term problems are at risk of urinary tract infections.
Hydronephrosis describes hydrostatic dilation of the renal pelvis and calyces as a result of obstruction to urine flow downstream. Alternatively, hydroureter describes the dilation of the ureter, and hydronephroureter describes the dilation of the entire upper urinary tract.
Renal colic, also known as ureteric colic, is a type of abdominal pain commonly caused by obstruction of ureter from dislodged kidney stones. The most frequent site of obstruction is the vesico-ureteric junction (VUJ), the narrowest point of the upper urinary tract. Acute obstruction and the resultant urinary stasis can distend the ureter (hydroureter) and cause a reflexive peristaltic smooth muscle spasm, which leads to a very intense visceral pain transmitted via the ureteric plexus.
A nephrostomy or percutaneous nephrostomy is an artificial opening created between the kidney and the skin which allows for the urinary diversion directly from the upper part of the urinary system. It is an interventional radiology/surgical procedure in which the renal pelvis is punctured whilst using imaging as guidance. Images are obtained once an antegrade pyelogram, with a fine needle, has been performed. A nephrostomy tube may then be placed to allow drainage.
An ileal conduit urinary diversion is one of various surgical techniques for urinary diversion. It has sometimes been referred to as the Bricker ileal conduit after its inventor, Eugene M. Bricker. It is a form of incontinent urostomy, and was developed during the 1940s and is still one of the most used techniques for the diversion of urine after a patient has had their bladder removed, due to its low complication rate and high patient satisfaction level. It is usually used in conjunction with radical cystectomy in order to control invasive bladder cancer.
Vesicoureteral reflux (VUR), also known as vesicoureteric reflux, is a condition in which urine flows retrograde, or backward, from the bladder into one or both ureters and then to the renal calyx or kidneys. Urine normally travels in one direction from the kidneys to the bladder via the ureters, with a one-way valve at the vesicoureteral (ureteral-bladder) junction preventing backflow. The valve is formed by oblique tunneling of the distal ureter through the wall of the bladder, creating a short length of ureter (1–2 cm) that can be compressed as the bladder fills. Reflux occurs if the ureter enters the bladder without sufficient tunneling, i.e., too "end-on".
A ureteral stent, or ureteric stent, is a thin tube inserted into the ureter to prevent or treat obstruction of the urine flow from the kidney. The length of the stents used in adult patients varies between 24 and 30 cm. Additionally, stents come in differing diameters or gauges, to fit different size ureters. The stent is usually inserted with the aid of a cystoscope. One or both ends of the stent may be coiled to prevent it from moving out of place; this is called a JJ stent, double J stent or pig-tail stent.
Pyelogram is a form of imaging of the renal pelvis and ureter.
Urinary diversion is a surgical technique used to create a new pathway for urine to exit the body, often following the removal of the bladder as part of treatment for bladder cancer. In addition to bladder cancer, urinary diversion may be necessary in cases of severe trauma, congenital abnormalities, or other conditions that compromise the normal urinary tract, such as infections or chronic inflammation. The procedure can be either temporary or permanent, depending on the patient’s condition and treatment plan.
A ureterostomy is the creation of a stoma for a ureter or kidney.
Urologic diseases or conditions include urinary tract infections, kidney stones, bladder control problems, and prostate problems, among others. Some urologic conditions do not affect a person for that long and some are lifetime conditions. Kidney diseases are normally investigated and treated by nephrologists, while the specialty of urology deals with problems in the other organs. Gynecologists may deal with problems of incontinence in women.
Fraley syndrome is a condition where the superior infundibulum of the upper calyx of the kidney is obstructed by the crossing renal artery branch, causing distension and dilatation of the calyx and presenting clinically as haematuria and nephralgia. Furthermore, when the renal artery obstructs the proximal collecting system, filling defects can occur anywhere in the calyces, pelvis, or ureter.
Ureteral cancer is cancer of the ureters, muscular tubes that propel urine from the kidneys to the urinary bladder. It is also known as ureter cancer, renal pelvic cancer, and rarely ureteric cancer or uretal cancer. Cancer in this location is rare. Ureteral cancer becomes more likely in older adults, usually ages 70–80, who have previously been diagnosed with bladder cancer.
Michael D. Stifelman Michael D. Stifelman, M.D., is Chair of Urology at Hackensack University Medical Center, Director of Robotic Surgery at Hackensack Meridian Health, and Professor and Inaugural Chair of Urology at Hackensack Meridian School of Medicine.
A ureteric balloon catheter is a balloon catheter intended for treating strictures of the ureter. In fact it is a double J stent on which a balloon is mounted. It is connected to a delivery device (pusher) to introduce it from the bladder into the ureter. The system comprises a non-return valve device, and a pusher with a stylet and two ports.
