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Etiology and Management of Benign Ureteral Strictures in a Contemporary Series
Spencer Kozinn, MD, Kamal Nagpal, MD, PhD, Niall Harty, MD, David Canes, MD, Andrea Sorcini, MD, Ali Moinzadeh, MD.
Lahey Clinic, Burlington, MA, USA.

Introduction: The need for ureteral reconstruction can arise from a variety of clinical scenarios. We examine the etiology and management of benign strictures at our institution.
Methods: We identified all patients with benign ureteral strictures who underwent surgical reconstruction from 2003-2011 by using CPT code analysis. Demographic data was recorded on all patients. We identified the etiology of the stricture, imaging work up carried out pre-operatively, presence of ureteral stent or nephrostomy tube pre-operatively, any attempts at endoscopic repair, surgical approach, perioperative outcomes, and complications.
Results: A total of 53 patients, 21 males and 32 females, underwent surgical repair of a benign ureteral stricture in our study period. The mean age was 49.7 years (range 18-73), body mass index (BMI) was 28.1, and Charlson Comorbidity Index (CCI) score was 1.5. Pain was the most common presenting symptom (n=30, 56.6%), with infection (n=11, 20.8%) and hydronephrosis (n=7,13.2%) the next most prevalent. Thirty-five (66%)of the lesions were due to iatrogenic injury at the time of surgery, 11 (20.8%) related to stone disease and its endoscopic management, and the remainder were due to external beam radiation therapy or congenital abnormalities. Of the surgical injuries, 15 injuries occurred during a gynecologic procedure, most commonly hysterectomy, 9 were associated with colonic resections, and 3 had undergone prior ureteral surgery. All of the injuries associated with laparoscopic and robotic surgery occurred from 2007 and forward. Thirty of the strictures involved the left ureter, 20 the right ureter, and 3 patients had bilateral injuries. Forty-one (77%) patients had stricture of the distal ureter, 5 the mid and distal segments, 2 the mid segment alone, 1 the proximal segment alone, and 4 had pan-ureteral structuring. 17 patients underwent robotic assisted laparoscopoic ureteroneocystostomy, 9 with psoas hitch and one with Boari flap reconstruction. 30 patients underwent open ureterneocystostomy, 18 with psoas hitch and 3 with Boari flap. Less common procedures included ureteroureterostomy in 2 patients, ileal ureters in 2, one autotransplantation, one nephrectomy, and one ileal conduit urinary diversion.
Conclusion: Ureteral strictures requiring operative repair are most commonly due to iatrogenic injury at the time of surgery, with gynecologic procedures being most common. The majority are distal and can be managed with some form of ureteral reimplantation.


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