What Is a Ureterectomy? Surgery, Recovery, and Risks

A ureterectomy is the surgical removal of part or all of a ureter, the narrow tube that carries urine from a kidney down to the bladder. The most common reason for the procedure is cancer of the upper urinary tract, though strictures, traumatic injuries, and certain congenital abnormalities can also require it. What makes ureterectomy particularly interesting from a surgical standpoint is that removing a section of ureter is only half the challenge; the surgeon then has to restore a working path for urine to travel, and the techniques for doing that vary widely depending on how much ureter is taken out.

Why a Ureterectomy Is Performed

The most frequent indication is upper tract urothelial carcinoma, a cancer that arises in the lining of the ureter or the renal pelvis (the funnel-shaped collecting area inside the kidney). This cancer accounts for only about 5 to 10 percent of all urothelial cancers, with the vast majority occurring in the bladder, but when it does appear in the ureter, surgery is the primary treatment. Depending on the tumor’s location, size, and grade, a surgeon may remove just the affected segment of ureter or take the entire ureter along with the kidney on that side.

Beyond cancer, ureterectomy can be necessary for long-segment ureteral strictures, where scar tissue narrows or blocks the ureter to the point that stents or endoscopic treatments no longer work. Radiation therapy to the pelvis, prior surgery, and chronic inflammation can all produce these kinds of extensive strictures. Traumatic injury during pelvic or gynecologic surgery is another scenario. In children, congenital duplications of the urinary system sometimes require partial ureterectomy when one branch of a duplicated ureter causes obstruction or reflux that cannot be managed conservatively.

Segmental Ureterectomy vs. Radical Nephroureterectomy

When cancer is the reason for surgery, the central decision is whether to perform a segmental ureterectomy or a radical nephroureterectomy. In a segmental ureterectomy, the surgeon removes only the diseased portion of the ureter and then reconnects the remaining healthy ends or reimplants the ureter into the bladder. In a radical nephroureterectomy, the entire kidney, the full length of the ureter, and a small cuff of bladder tissue around the ureteral opening are all removed in one piece.

For decades, radical nephroureterectomy was considered the default for nearly all upper tract urothelial cancers. The logic was straightforward: take everything to minimize the chance of leaving cancer behind. But that approach sacrifices a functioning kidney, which matters enormously for patients who already have reduced kidney function, a solitary kidney, or other medical conditions that make preserving renal tissue important. Research over the past decade has increasingly supported the idea that segmental ureterectomy can be oncologically equivalent for appropriately selected patients. A large population-based study found no significant difference in overall survival between the two approaches for localized ureteral tumors, with segmental ureterectomy shown to be non-inferior to radical nephroureterectomy in adjusted analyses.¹ Similarly, a comparative study of the two procedures found no statistically significant differences in cancer-specific survival, progression-free survival, or intravesical recurrence-free survival at three years.²

The decision between the two procedures still depends on tumor characteristics. Low-grade, small, and non-invasive tumors in the distal or mid-ureter are the best candidates for segmental ureterectomy. High-grade or multifocal disease, tumors in the renal pelvis, or cancers that have invaded deeply into the ureteral wall generally push the decision toward radical nephroureterectomy. Surgeon preference and the patient’s overall health also play a role, and the choice is typically made after thorough discussion about the tradeoffs.

How the Urinary Tract Gets Reconnected

Removing a segment of ureter creates a gap that has to be bridged so urine can still flow from the kidney to the bladder. The reconstruction technique depends on where in the ureter the gap is and how long it is.

Ureteral reimplantation: For tumors in the lower third of the ureter, the surgeon removes the diseased segment along with a cuff of bladder wall, then sews the remaining healthy ureter directly into the bladder. This is the most straightforward reconstruction.
Psoas hitch: When the gap is too long for a simple reimplantation, the bladder can be mobilized and stitched to the psoas muscle in the pelvis, pulling it upward to meet the shortened ureter. Combined with kidney mobilization, this technique can bridge a substantial distance.³
Boari flap: A tongue-shaped flap is cut from the bladder wall and fashioned into a tube that reaches up to meet the remaining ureter. This is often combined with a psoas hitch and can cover mid-ureteral defects that a simple hitch cannot reach.⁴
End-to-end anastomosis: If the gap is short and the remaining ureter has enough length, the two healthy ends can simply be sewn together. This works best for mid-ureteral defects where there is plenty of healthy ureter on both sides.
Ileal ureter: For very long defects where none of the above techniques can bridge the gap, a segment of small intestine (ileum) can be harvested and used as a substitute ureter. This is a more complex operation reserved for situations where conventional reconstruction is not feasible.⁵

Most of these reconstructions can now be performed with robotic assistance, which has become increasingly common in ureteral surgery. The robotic platform offers magnified three-dimensional visualization and fine instrument control, which matters when you are sewing together structures only a few millimeters in diameter. Early reports have shown that robotic-assisted ureteral reimplantation with Boari flap and psoas hitch is both safe and reproducible, though long-term comparative data against open surgery remain limited.⁶

The Diagnostic Difficulty That Complicates Planning

One of the trickiest aspects of ureterectomy for cancer is that surgeons often have imperfect information about the tumor before they operate. The standard diagnostic tool is a ureteroscopic biopsy, where a tiny scope is passed up through the bladder and into the ureter to sample the tumor. The problem is that these biopsies tend to underestimate how advanced the cancer actually is. A systematic review and meta-analysis found that biopsy understaging occurred in roughly 46 percent of cases, and undergrading in about 32 percent.⁷ A more recent single-center analysis confirmed similar patterns, with correct staging in only about 55 percent of tumors and pathological upstaging in 39 percent of cases.⁸

This matters because the choice between segmental ureterectomy and radical nephroureterectomy hinges partly on tumor grade and stage. If a biopsy suggests low-grade, superficial disease, a patient and surgeon might choose the kidney-sparing approach, only to discover after surgery that the tumor was more aggressive than expected. Complementary tools like CT urography and urine cytology help but have their own blind spots, detecting invasive disease or high-grade tumors in only a minority of cases where they are present.⁸ The upshot is that treatment decisions for upper tract urothelial carcinoma carry more uncertainty than many patients realize, and close follow-up after surgery is partly a response to that diagnostic imprecision.

Recovery and What to Expect

Recovery after ureterectomy depends heavily on the scope of the operation and whether it was performed open or with robotic or laparoscopic assistance. For a robotic or laparoscopic segmental ureterectomy, hospital stays of two to three days are typical. Open procedures generally require longer hospitalization. Enhanced recovery protocols, which emphasize early mobilization, reduced opioid use, and structured pain management, have shortened stays and improved comfort across urological surgery more broadly. One study of enhanced recovery in kidney surgery found that median hospital stays dropped from five days to two days for open procedures, with significant reductions in opioid consumption.⁹

Nearly every patient who undergoes ureterectomy with reconstruction will wake up with a ureteral stent, a thin flexible tube threaded through the repaired ureter to keep it open while the surgical site heals. The stent typically stays in place for several weeks. It is, by most accounts, the most bothersome part of recovery. Over 80 percent of patients with a ureteral stent report associated symptoms including flank pain, urinary urgency, frequency, and sometimes blood in the urine.¹⁰ These symptoms vary widely from person to person and tend to be worst in the first couple of days after surgery, though they persist at a lower level for as long as the stent remains.¹¹

The good news is that symptoms improve substantially once the stent is removed. Research comparing stent removal at three days versus seven days (in the context of other urological procedures) found that earlier removal was associated with better urinary symptoms, less pain, and better general health scores.¹² After ureterectomy specifically, stents usually need to stay longer than that to protect the reconstructed anastomosis, but the principle holds: the sooner the stent can safely come out, the better you will feel. Medications that relax the bladder can help with stent-related discomfort in the meantime.¹³

Most patients can return to light daily activities within two to four weeks and more strenuous activities within six to eight weeks, depending on how the surgery was performed and how the healing progresses. Driving is usually off-limits for the first couple of weeks or while you are taking prescription pain medications.

Risks and Complications

Ureterectomy shares the general risks of any abdominal surgery: bleeding, infection, blood clots, and reactions to anesthesia. Beyond those, ureteral reconstruction carries a set of specific risks tied to the fact that you are creating a new junction in a system designed to carry urine continuously.

Urine leak is the signature concern. When the surgical connection between the ureter and bladder (or between two ureteral ends) does not seal completely, urine can escape into the surrounding tissues. Reported rates of urinary extravasation after ureteral reconstruction range from under 1 percent to around 9 percent depending on the specific procedure, with reimplantation carrying rates of roughly 0.6 to 4 percent.¹⁴ Most small leaks resolve with continued drainage through the stent, but larger leaks can lead to abscess formation or sepsis and may require additional procedures.

Stricture, where scar tissue narrows the reconstructed segment and partially or fully blocks urine flow, is the other major long-term risk. If a stricture develops, it may need to be treated with a balloon dilation, laser incision, or in some cases a revision surgery. The stent left in place after surgery is specifically designed to minimize this risk by keeping the healing tissues propped open.

For patients undergoing radical nephroureterectomy rather than segmental ureterectomy, the additional risk is the loss of kidney function that comes with removing an entire kidney. The remaining kidney compensates to a degree, but studies show that patients who keep both kidneys through segmental ureterectomy have significantly better kidney function at one month and one year after surgery compared with those who undergo the radical procedure.² Even in older patients, postoperative creatinine levels tend to be lower after segmental ureterectomy than after radical nephroureterectomy.¹⁵ Preserving kidney function is not just an abstract lab value; it affects your eligibility for certain medications, your cardiovascular risk, and your options if the cancer recurs and you need systemic chemotherapy, which is filtered through the kidneys.

Bladder Recurrence and How to Reduce It

One of the more counterintuitive risks after any upper tract urothelial cancer surgery is the development of a new tumor in the bladder. The same type of cells that line the ureter also line the bladder, and the cancer can recur there even after the ureteral tumor has been completely removed. Rates of intravesical recurrence are substantial. In one retrospective study, bladder recurrence reached 57 percent in patients who had kidney-sparing surgery and 39 percent in those who had radical nephroureterectomy, with most recurrences in the radical group happening within the first postoperative year.¹⁶

A practical step to reduce this risk is a single dose of chemotherapy instilled directly into the bladder shortly after surgery. A randomized trial found that a single postoperative dose of mitomycin C reduced bladder recurrence in the first year by about 40 percent in relative terms, with the number needed to treat to prevent one bladder tumor being just nine patients.¹⁷ This is a relatively simple intervention that has become part of many postoperative protocols.

The management of the bladder cuff, the small ring of bladder tissue around the ureteral opening, also influences recurrence. A systematic review and meta-analysis found that the technique used to excise the bladder cuff matters, with open intravesical excision associated with better outcomes than extravesical approaches. Endoscopic cuff excision performed comparably to the open intravesical technique in the same analysis.¹⁸

Long-term Surveillance After Ureterectomy

After ureterectomy for cancer, you are not simply done. Follow-up involves regular cystoscopies (looking inside the bladder with a camera) to watch for bladder recurrence, periodic imaging to check the remaining upper urinary tract, and blood work to monitor kidney function. The surveillance schedule is typically intensive in the first year, since that is when most recurrences appear, and then gradually spaces out if things look clear.

If you had a segmental ureterectomy and still have a kidney on the operated side, your remaining ureter and renal pelvis also need monitoring, since the same lining that produced the original cancer remains at risk. This means your surveillance schedule may be somewhat more involved than for someone who had the whole kidney and ureter removed. CT urography and ureteroscopy are the main tools used for upper tract follow-up, each with the diagnostic limitations discussed earlier. The tradeoff is worth it for most patients: a more demanding follow-up schedule in exchange for keeping a functioning kidney.

When Children Need Ureteral Surgery

Ureterectomy in children is almost never about cancer. The most common pediatric indication involves duplex kidneys, a congenital condition where one kidney has two separate collecting systems, each with its own ureter. When one branch of the duplicated system causes problems like a ureterocele (a balloon-like swelling where the ureter enters the bladder), vesicoureteral reflux, or obstruction, that branch may need to be removed along with the non-functioning portion of kidney it serves. In a ten-year series from a tertiary referral center, ureteroceles were present in about 43 percent of patients with complicated duplex kidneys, and vesicoureteral reflux in about 42 percent. The majority required an invasive surgical approach, most commonly heminephrectomy with partial ureterectomy.¹⁹

The goals in pediatric surgery are somewhat different from adult cancer surgery. Preserving as much functioning kidney tissue as possible is even more critical, since these children will be relying on their kidneys for a lifetime. The surgical principles of reconstruction, including reimplantation and end-to-end anastomosis, are similar to those used in adults, though the smaller scale of pediatric anatomy adds its own technical challenges. Outcomes for children with duplex kidney anomalies are generally good when the surgery is performed at an experienced center, with most children going on to have normal or near-normal renal function on the operated side.