A damaged ureter can almost always be repaired, though the method depends on where the injury is, how much tissue is involved, and how quickly it gets diagnosed. Surgeons have a broad toolkit ranging from a simple internal stent placed through a scope to full reconstruction using tissue from the patient’s own intestine. The outcomes are generally good: most repairs hold up over years, and kidney function is typically preserved or even improved after successful reconstruction.
How Ureters Get Damaged in the First Place
The ureters are a pair of narrow tubes that carry urine from the kidneys down to the bladder. They run deep in the abdomen and pelvis, and their location makes them vulnerable during surgery on nearby organs. About half of all ureteral injuries happen during gynecologic and obstetric procedures, largely because the lower portions of the ureters sit so close to the uterus, cervix, and ovaries.1PubMed Central. A Review on the Etiology, Prevention, and Management of Ureteral Injuries During Obstetric and Gynecologic Surgeries Colorectal, vascular, and urologic surgeries account for most of the rest.
Risk factors include previous pelvic surgery, endometriosis, pelvic adhesions, large fibroids, adnexal masses, and surgeries for pelvic cancers, where the baseline risk of ureteral injury can reach 5% to 8%.2PubMed Central. Ureteral Injury in Laparoscopic Gynecologic Surgery Obesity and intraoperative bleeding that obscures the surgeon’s view also raise the risk.3PubMed Central. Ureteric Injury During Gynaecological Surgery – Lessons from 20 Cases in Canada Worth noting: roughly half of all patients who sustain a ureteral injury during surgery had none of these risk factors.2PubMed Central. Ureteral Injury in Laparoscopic Gynecologic Surgery
Beyond surgical mishaps, ureters can also be damaged by external trauma like stab wounds or gunshot injuries, by kidney stone procedures that cause scarring, or by radiation therapy for pelvic cancers. Ureteral strictures after stone treatment with a ureteroscope are a recognized late complication, though the exact rate is not well-established and the scarring mechanism is still not fully understood.4PubMed Central. Prevention strategies for ureteral stricture following ureteroscopic lithotripsy Radiation-induced strictures deserve special attention because the tissue damage is diffuse and progressive, making these injuries harder to manage than a clean surgical nick.
Why Catching the Injury Early Changes Everything
The single biggest factor in how well a ureteral repair goes is when the injury gets recognized. If the surgeon notices the problem during the original operation, the repair can often happen right then and there, with considerably better odds. Patients whose injuries are caught later develop complications roughly four times as often, around 40% versus about 10% for immediate diagnosis.5PubMed Central. Delayed Diagnosis of Ureteral Injury Following Penetrating Abdominal Trauma: A Case Report and Review of the Literature
Those delayed complications are serious: infected urine collections, kidney swelling, abnormal connections between the ureter and other structures (fistulae), strictures, and in rare cases kidney failure. A 2024 study found that patients diagnosed late averaged three hospital admissions compared to less than one for those caught during surgery, with hospital stays about five times as long.6Scientific Reports. A delayed diagnosis of iatrogenic ureteral injury results in increased morbidity They also needed roughly three times as many procedures to get the problem fully sorted out.
In the delayed-diagnosis group from another tertiary-center study, more than half required a second procedure and about a fifth needed a third, compared with far lower rates when the injury was found right away.7PubMed. Does Timing of Diagnosis and Management of Iatrogenic Ureter Injuries Affect Outcomes? Experience From a Tertiary Center The kidney-loss rate was also higher with delayed diagnosis, though in that study the difference did not reach statistical significance. The takeaway is clear: early detection dramatically simplifies treatment and improves results.
How the Injury Gets Diagnosed
When a ureteral injury is suspected after surgery, the first-line imaging tool is CT urography, which has largely replaced older methods as the primary way to evaluate the ureters. The scan is done after injecting contrast dye, and the radiologist looks for leaking dye outside the ureter, blockage, or swelling of the kidney above the injury. For a more definitive picture, retrograde pyelography, performed by threading a small scope up through the bladder, is considered the most accurate method for pinpointing the exact location and extent of damage, though it requires the patient to be stable enough for the procedure.8Insights Imaging. Ureteral trauma: MDCT findings, common misses and misinterpretations, and implications on patient management
Symptoms that suggest a missed ureteral injury in the days or weeks after surgery include persistent flank pain, fever, decreasing urine output, or urine leaking from the surgical wound or vagina. If any of these appear, imaging should be done promptly rather than waiting to see if they resolve.
Stenting and Other Minimally Invasive First Steps
For minor injuries, partial tears, or small ureteral fistulae, the simplest intervention is placing a ureteral stent. This thin, flexible tube threads through the ureter from bladder to kidney, holding the channel open while the tissue heals around it. It can often be placed without any incision at all, through a cystoscope inserted via the bladder.
Stenting works best for injuries that are recognized early and involve partial rather than complete disruption of the ureter. In a case series of ureterovaginal fistulae, stenting alone resolved the problem in about 71% of patients who were candidates for it.9PubMed. Ureterovaginal fistula: a case series However, a systematic review looking at a larger pool of fistulae found a much more modest pooled success rate for endoscopic stenting of around 32%, with surgery ultimately needed for the majority.10PubMed. Management strategies and outcome of ureterovaginal fistulae: A systematic review and meta-analysis Success rates vary widely depending on injury severity, which explains the discrepancy. The same review showed that when fistulae did go to surgery, the success rate was essentially 100% regardless of whether the operation happened early or late.
When a stent cannot be placed from below, or when the kidney needs immediate drainage, a percutaneous nephrostomy tube can be inserted through the skin directly into the kidney. This buys time and protects the kidney while the team plans a definitive repair.
Direct Surgical Repairs
When stenting is not enough, the choice of surgical repair depends heavily on where along the ureter the damage is and how much tissue needs to be removed or bypassed. Surgeons generally divide the ureter into three zones: upper (near the kidney), middle, and lower (near the bladder). Each zone lends itself to different techniques.
Reconnecting the Two Ends
For injuries in the upper or middle ureter where only a short segment is damaged, the most straightforward repair is ureteroureterostomy: cutting out the damaged section and stitching the two healthy ends back together. The key requirement is that the reconnection must be free of tension, because a tight join is far more likely to scar shut. In one surgeon’s experience with robotic-assisted ureteroureterostomy, tension-free connections were achieved in all twelve patients, even when the excised segment measured up to 4.5 centimeters. To gain extra length when needed, the kidney can be freed from its attachments and shifted downward.11PubMed. Single surgeon experience with robot-assisted ureteroureterostomy for pathologies at the proximal, middle, and distal ureter in adults
Reimplanting Into the Bladder
Injuries to the lower ureter, near the bladder, are typically handled by reimplanting the ureter into the bladder wall. This procedure, called ureteroneocystostomy, is one of the most commonly performed ureteral reconstructions. When the gap between the cut end of the ureter and the bladder is too large for a simple reimplant, surgeons can mobilize the bladder upward to meet the ureter. In a psoas hitch, the bladder is lifted and stitched to the psoas muscle in the pelvis. For even longer gaps, a Boari flap creates a tongue of bladder tissue that is rolled into a tube to bridge the distance.
A large single-institution review of 100 ureteral reimplantations spanning more than 25 years, including primary reimplants, psoas hitches, and Boari flaps, found excellent functional outcomes without significant complications across all three techniques.12PubMed. Outcomes of distal ureteral reconstruction through reimplantation with psoas hitch, Boari flap, or ureteroneocystostomy for benign or malignant ureteral obstruction or injury
Repairs for Longer or More Complex Damage
When large stretches of ureter are destroyed or scarred, the simpler techniques run out of reach. Surgeons then turn to more involved reconstructive strategies.
Borrowing From the Other Ureter
Transureteroureterostomy connects the damaged ureter to the healthy one on the opposite side, routing urine across the midline so both kidneys drain through a single ureter. This sounds dramatic, and there has long been concern about putting the good side at risk. In practice, the results have been reassuring. A long-term study of 63 patients found the connection stayed open in over 96% of cases, and kidney function actually improved compared to preoperative levels.13PubMed. Transureteroureterostomy revisited: long-term surgical outcomes Complications were more common when the procedure was done for cancer-related problems than for benign conditions. The technique has also been used successfully in children, though patients with neurogenic bladders require close long-term monitoring.14PubMed. Successful use of transureteroureterostomy in children: a clinical study
Using a Segment of Intestine
When a very long segment of ureter is missing or scarred beyond salvage, surgeons can harvest a piece of small intestine (ileum) and use it as a substitute ureter. This is a major operation, but it can rescue kidneys that would otherwise be lost. At one high-volume center, 46 out of 188 ureteral reconstructions over 16 years required ileal interposition. At an average follow-up of about four and a half years, the overall success rate was 83%.15PubMed. Long-term Follow Up of Ileal Ureteral Replacement for Complex Ureteral Strictures: Single Institution Study About a quarter of patients experienced a major complication, and a small number eventually needed a kidney removed, underscoring that this is a salvage procedure for situations where less invasive options have failed.
Ileal replacement can be done on both sides simultaneously when bilateral strictures are present, and it can even be combined with bladder enlargement when the bladder itself has been damaged, for instance by radiation therapy.16PubMed. Ileal ureter replacement and ileocystoplasty for the treatment of bilateral ureteral strictures and bladder contracture: technique and outcomes Kidney function after ileal interposition generally stabilizes or improves over the first year.17PubMed Central. Use of ileum for complex ureteric reconstruction: Assessment of long-term outcome, complications, and impact on renal function
Renal Autotransplantation
In the most extreme cases, where the entire ureter is unusable and bowel interposition is not feasible or desirable, surgeons can disconnect the kidney from its blood supply, move it to the pelvis, and reconnect it directly to the bladder, much like a kidney transplant but using the patient’s own organ. This is called renal autotransplantation. It avoids the metabolic side effects of having intestine in the urinary tract and eliminates the need for ongoing monitoring of a bowel segment. A study with a median follow-up of 11 years found that autotransplant preserved kidney function well and avoided the complications associated with intestinal interposition.18PubMed Central. Renal autotransplant for major ureteric loss: Results from median 11 years of follow-up It remains underutilized, likely because few centers have the combined vascular and transplant expertise needed.
The Robotic Surgery Advantage
Most ureteral reconstruction techniques were originally developed as open surgeries, and many are still done that way. Over the past decade, robotic-assisted versions of these procedures have gained traction, and the evidence suggests meaningful benefits for patients even though the long-term success rates are similar.
A systematic review and meta-analysis comparing robotic to open ureteral reimplantation found that the robotic approach was associated with significantly fewer complications, shorter hospital stays by about five days, and substantially lower blood loss and transfusion needs, all without any difference in stricture recurrence or need for repeat surgery.19PubMed Central. Robotic assisted vs. open ureteral reimplantation in adults: a systematic review and meta-analysis A single-center comparison echoed these findings, with median hospital stays of 3 days for robotic versus 11 days for open, while stricture recurrence rates were nearly identical between the two groups.20PubMed Central. Robotic vs open ureteral reimplantation: A retrospective comparative single‐centre series
A broader systematic review covering all types of robotic ureteral reconstruction, not just reimplantation, confirmed significantly lower blood loss and shorter hospital stays with the robotic approach.21PubMed Central. Robotic ureteral reconstruction for benign ureteral strictures: a systematic review of surgical techniques, complications and outcomes The robotic platform’s magnified 3D view and articulating instruments seem particularly well-suited to the fine suturing these repairs demand. The practical upshot for patients is a faster recovery and a shorter hospital stay, with the same long-term result.
Buccal Mucosa Grafts for Mid-Ureter Strictures
A relatively newer technique borrows an idea from urethral surgery: using a graft of tissue harvested from inside the cheek (buccal mucosa) to patch a narrowed segment of ureter rather than cutting it out entirely. This approach is especially useful for strictures in the upper or middle ureter that are too long for a simple end-to-end reconnection but not long enough to justify using intestine.
The ureter is opened along the scarred segment, and the buccal mucosa patch is sewn in to widen the channel. In one series of 14 patients, the success rate was 93% at a median follow-up of 15 months, and no complications were seen at the cheek donor site.22PubMed Central. Ureteroplasty with buccal mucosa graft without omental wrap: an effective method to treat ureteral strictures Robotic-assisted buccal mucosa ureteroplasty has shown similarly promising early results, with about an 83% success rate in a series of 12 patients.23PubMed. Robotic Ureteroplasty with Buccal Mucosa Graft for the Management of Complex Ureteral Strictures These are small case series, and longer follow-up with more patients is needed, but the technique fills a genuine gap in the surgeon’s toolbox for mid-length strictures.
Intraoperative Tools That Improve Precision
One of the challenges in ureteral surgery is judging whether the tissue you are sewing together has enough blood supply to heal properly. Poor perfusion leads to ischemia, scarring, and stricture recurrence. Indocyanine green (ICG) fluorescence imaging is increasingly used during laparoscopic and robotic ureteral reconstructions to assess this in real time. The dye is injected intravenously, and a near-infrared camera shows which segments of the ureter are glowing brightly (well-perfused) and which are dark (poorly perfused).24PubMed Central. Indocyanine green fluorescence imaging for laparoscopic complex upper urinary tract reconstructions: a comparative study This replaces the traditional method of visually guessing whether tissue looks pink enough, which is subjective and unreliable.25American Journal of Transplantation. Evaluation of Transplant Ureter Perfusion Using Indocyanine Green Fluorescence Imaging: A Single-Center Experience As robotic platforms become more widespread, ICG use during ureteral surgery is becoming routine at experienced centers.
Radiation-Damaged Ureters Are a Special Challenge
Strictures caused by radiation therapy for cervical, bladder, rectal, or prostate cancer deserve their own discussion because they behave differently from surgical injuries. Radiation damage affects the tissue broadly, compromising blood supply across a wide area rather than injuring one discrete point. This makes all forms of repair harder and recurrences more likely.
In a multi-institutional review, endourologic treatment (stenting or balloon dilation) was attempted first in about 72% of radiation-induced stricture cases, but only succeeded in 59% at one year. Nearly half of patients ultimately needed open or robotic reconstruction. Strictures longer than 2 centimeters and those in patients who also received chemotherapy were significant predictors of recurrence.26PubMed Central. Management of Ureteral Stricture Disease After Radiation Therapy for Pelvic Malignancies: A Retrospective, Multi-Institutional Analysis When reconstruction is done in irradiated tissue, surgeons often bring in tissue from outside the radiation field, such as an ileal segment or a buccal mucosa graft, to avoid building the repair on compromised ground.
Long-Term Kidney Function After Repair
Patients understandably worry about whether their kidney will still work after ureteral reconstruction, especially if multiple procedures were needed or if one kidney was already struggling. The evidence is mostly reassuring.
A study of ureteral reconstruction in patients with solitary kidneys, where any drop in function carries serious consequences, found that overall kidney filtration rates were unchanged at last follow-up compared to before surgery. Among patients who started with reduced kidney function, filtration actually improved slightly after successful repair.27PubMed Central. Renal function after ureteral reconstruction surgery in patients with solitary kidney A separate study looking specifically at poorly functioning kidneys found that all patients had successful repairs at a median follow-up of about four years, with no return to surgery for revision or kidney removal.28PubMed Central. Ureteral reconstruction is safe and successful in poorly functioning kidneys
There is a caveat: patients who entered surgery with normal kidney function saw a small, statistically significant decline over time.27PubMed Central. Renal function after ureteral reconstruction surgery in patients with solitary kidney Whether this reflects natural aging, the underlying disease process, or the surgery itself is unclear, but the decline was modest and did not push patients into clinical kidney failure. The message for patients is that ureteral reconstruction generally preserves kidney function well, and in cases where the kidney was already being squeezed by obstruction, it can actually improve things.
Living With Temporary Drainage While Awaiting Repair
Many patients end up spending weeks or months with either a ureteral stent or a nephrostomy tube while waiting for definitive surgery or allowing inflamed tissue to settle. Quality of life during this period is a real concern.
Stents and nephrostomy tubes have different downsides. Stent patients tend to report more urinary discomfort: urgency, frequency, and pain with urination. Nephrostomy patients deal more with mobility restrictions and challenges around keeping the external bag clean and secure.29PubMed Central. Ureteric stent versus percutaneous nephrostomy for acute ureteral obstruction – clinical outcome and quality of life: a bi-center prospective study Interestingly, the same study found that nephrostomy patients’ symptoms tended to improve over time while stent-related discomfort remained constant, giving the nephrostomy group a better overall quality-of-life score at the second measurement.
A systematic review and meta-analysis echoed the finding that stenting tends to cause more urinary symptoms than nephrostomy drainage.30Asian Journal of Urology. Percutaneous nephrostomy versus ureteral stent in hydronephrosis secondary to obstructive urolithiasis: A systematic review and meta-analysis Yet when patients who had tried both devices were asked which they preferred, the majority chose the internal stent, likely because it is invisible from the outside and does not involve an external tube and bag.31PubMed. Quality of life with tandem ureteral stents compared to percutaneous nephrostomy for malignant ureteral obstruction The choice often comes down to how long the drainage will be needed and which set of side effects the patient finds more tolerable.
Tissue Engineering and the Future
Given the challenges of borrowing tissue from the intestine or cheek, the idea of growing a replacement ureter in a lab is appealing. Researchers have made real progress in animal models, testing various scaffold materials seeded with stem cells or urothelial cells. Natural grafts and hybrid materials seem to perform better than purely synthetic ones, and seeding scaffolds with cells leads to better function than leaving them bare.32PubMed Central. Bioengineering solutions for ureteric disorders: clinical need, challenges and opportunities Work on porcine-derived ureteral scaffolds treated with specific crosslinking agents has shown promising signs of tissue remodeling and integration in laboratory settings.33Frontiers in Bioengineering and Biotechnology. Tissue Engineering of Ureteral Grafts: Preparation of Biocompatible Crosslinked Ureteral Scaffolds of Porcine Origin
As of the most recent critical review, however, no tissue-engineered ureteral replacement has been tested in a human clinical trial.34Frontiers in Bioengineering and Biotechnology. Tissue engineering in reconstructive urology—The current status and critical insights to set future directions-critical review The ureter presents unique engineering challenges: it needs to conduct urine in one direction via peristalsis, resist reflux, and maintain a watertight lining in a hostile chemical environment. These are hard problems to solve with a scaffold. For now, tissue engineering for the ureter remains a laboratory pursuit, though the pace of progress suggests clinical trials could emerge within the next decade or two.