The ureters are two thin tubes — one from each kidney — that carry urine down to the bladder. A ureteral stricture is a narrowing or blockage in one of these tubes, causing urine to back up, the kidney to swell, and — if untreated — permanent kidney damage.
Unlike urethral strictures, ureteral strictures affect both men and women. They occur most commonly at the upper end of the ureter (where it joins the kidney, called the ureteropelvic junction or UPJ), or at the lower end where it enters the bladder. Middle ureteral strictures are less common and are usually caused by external compression or injury.
The urgency of treatment depends on whether one or both kidneys are affected, how severe the blockage is, and whether there’s any sign of infection (which — with obstruction — is a medical emergency).
Ureteral injury or inadvertent ligation (tying off) during abdominal or pelvic surgery — particularly gynecological surgery, colorectal surgery, or vascular surgery — is one of the most common causes. The ureter lies close to many pelvic structures and can be accidentally cut or sutured during other procedures.
Radiation to the pelvis for prostate, cervical, endometrial, rectal, or bladder cancer can cause progressive fibrosis of the ureter in the radiation field, leading to strictures that develop months to years after treatment. These can be very difficult to treat because the surrounding tissue has poor healing capacity.
A stone stuck in the ureter for a prolonged period can cause local inflammation and scarring that persists even after the stone passes or is removed. Repeated stone episodes at the same location significantly increase this risk.
Ureteropelvic junction (UPJ) obstruction is a narrowing at the point where the kidney's collecting system meets the ureter. It can be congenital (present from birth) or develop due to crossing blood vessels, scar tissue, or kinking. It's one of the most common causes of hydronephrosis (kidney swelling) in both children and adults.
Repeated ureteroscopy for kidney stones, or difficult procedures involving balloon dilation or laser at the UPJ, can cause scarring that leads to a secondary stricture. This is one of the more common post-procedure complications in patients who have had multiple stone procedures.
Retroperitoneal fibrosis — an inflammatory condition that encases the structures at the back of the abdomen — can squeeze and obstruct one or both ureters. Cancer, enlarged lymph nodes, or aortic aneurysms can also externally compress the ureter without actually invading it.
Ureteral strictures don’t always cause obvious symptoms — especially when they develop slowly. Some are discovered only on routine imaging done for another reason. When symptoms occur, they typically reflect kidney obstruction or infection.
A dull, persistent ache on one side of the back or flank — the kidney being under pressure from backed-up urine. Can be worsened by drinking fluids. Sometimes mistaken for musculoskeletal back pain.
Stagnant urine in a dilated (swollen) kidney collecting system is prone to infection. Repeated pyelonephritis (kidney infections) with no other obvious cause should raise suspicion for obstruction.
Can occur due to the dilated, inflamed kidney or associated kidney stones. May be visible (red/pink urine) or only detectable on a urine test.
Swelling of the kidney collecting system seen on ultrasound, CT, or MRI — often found incidentally. Hydronephrosis always requires investigation to determine whether there's an underlying obstruction that needs treatment.
Prolonged obstruction gradually reduces the function of the affected kidney. Discovered through blood tests showing rising creatinine, or through a nuclear medicine scan (MAG3 or DTPA) that compares function between the two kidneys.
Many ureteral strictures are silent — found only because imaging was done for another reason. A "silent" obstruction can still damage the kidney over time, which is why it still needs evaluation even without symptoms.
The treatment approach depends on the cause, location, length, severity of the blockage, and the function remaining in the affected kidney. Options range from temporary drainage (to protect the kidney while the situation is evaluated) through to definitive surgical reconstruction.
When there is a blocked kidney — especially if infected — the immediate priority is to drain it. Two options are available:
Both are temporary measures. Once the kidney is drained and any infection treated, the plan for definitive management of the stricture can be made without time pressure.
A balloon catheter is passed up the ureter (either through the existing nephrostomy tube from above, or via ureteroscopy from below) to the stricture, then inflated to dilate it. A stent is left in place afterward to maintain the opened area while it heals.
Balloon dilation is simplest and most effective for short (<1–2 cm), benign strictures that are not caused by radiation. Success rates are modest (40–60%) and many strictures recur — but it is a reasonable initial approach for appropriate strictures, particularly as an adjunct to long-term stenting.
A ureteroscope is passed to the stricture and a laser or cold knife makes a longitudinal incision through the scar tissue, allowing the ureteral wall to spring open. A stent is placed for 4–6 weeks afterward. Success rates are similar to balloon dilation — best for short, non-radiation strictures. For longer or radiation-induced strictures, endoscopic treatment is generally not durable and surgical reconstruction is preferred.
Pyeloplasty is the standard surgical repair for ureteropelvic junction (UPJ) obstruction — the most common ureteral stricture location. The narrowed or poorly functioning segment at the junction of the kidney and ureter is excised and the healthy tissue is reconstructed into a wide, funnel-shaped connection. Dr. Bansal performs pyeloplasty robotically — through small port sites with no large incision — with success rates of 90–95%.
Robotic pyeloplasty has essentially replaced open pyeloplasty in experienced hands. It offers equivalent success rates with shorter hospital stay (usually 1–2 nights), less pain, and faster return to normal activity. A ureteral stent is left in place for 4–6 weeks after surgery and is removed in the office.
In about 25–40% of UPJ obstructions, an aberrant blood vessel crosses directly over the UPJ and compresses it. A robotic pyeloplasty allows the junction to be reconstructed above or around the vessel — permanently relieving the obstruction.
For strictures in the lower ureter — particularly those caused by prior surgery, radiation, or injury — the damaged segment can be excised and the healthy ureter reimplanted into the bladder in a new location. Various techniques allow the bladder to be mobilized or the ureter to be lengthened to bridge any gap:X
For short lower ureteral strictures with adequate healthy ureter length — the stricture is removed and the ureter re-attached to the bladder.
The bladder is moved upward and anchored to a muscle in the pelvis (psoas muscle) to bring it closer to the healthy ureter, bridging longer gaps.
A tube of bladder tissue is created and used to bridge even longer gaps between the bladder and the remaining healthy ureter. Useful for mid-ureteral strictures.
For very long ureteral defects where normal ureteral tissue cannot bridge the gap, a segment of small intestine (ileum) is used to replace the ureteral segment. A complex but durable solution for extreme cases.
If a kidney has been obstructed for so long that less than 10–15% of function remains — assessed by a nuclear medicine kidney scan — it may no longer be worth reconstructing. In this case, removal of the damaged kidney (nephrectomy) is sometimes the better option to eliminate a source of recurrent infections. Dr. Bansal will discuss this honestly and thoroughly before any treatment decision is made.
