Upper Tract Reconstruction
Upper tract reconstruction is the set of operations used to restore unobstructed drainage from the renal pelvis to the bladder while preserving renal function. In practice, the key variables are location, defect length, ischemic burden, etiology, and the salvageability of the ipsilateral renal unit. Short healthy defects tolerate direct repair; long or hostile segments require grafts, bowel, contralateral drainage, or renal relocation.
General Principles
- Principles of Upper Tract ReconstructionAnatomic staging, renal functional assessment, preservation of ureteral blood supply, tension-free spatulated repair, location-based technique selection, graft support, and escalation from pyeloplasty or ureteroureterostomy to substitution and salvage.
14 of 14 techniques
| Technique | Domain | Notes |
|---|---|---|
| Endoureterotomy | Endoscopic / Minimally Invasive | Retrograde or antegrade full-thickness endoscopic incision of a short, non-ischemic, non-irradiated ureteral stricture, stented across the defect for re-epithelialization. Best as a low-morbidity salvage or bridge, not a substitute for formal reconstruction. |
| Drug-Coated Balloon Therapy | Endoscopic / Minimally Invasive | Paclitaxel-coated balloon therapy. Urethral Optilume is approved for selected strictures; ureteral DCB evidence is limited to off-label Lutonix data and remains investigational. |
| Pyeloplasty | UPJ / Proximal | Gold-standard reconstruction for ureteropelvic junction obstruction. Anderson-Hynes dismembered pyeloplasty remains the default because it excises the diseased junction, permits dependent funnel-shaped reconfiguration, and handles crossing vessels cleanly. |
| Ureterocalicostomy | UPJ / Proximal | Salvage proximal reconstruction for failed pyeloplasty, dense UPJ fibrosis, or an intrarenal pelvis when a durable new UPJ cannot be fashioned. |
| Ureteroureterostomy | Segmental Primary Repair | Best for short, well-vascularized proximal or mid-ureteral defects after complete excision back to healthy tissue. Succeeds only when the repair is truly tension-free. |
| Augmented Anastomotic Ureteroureterostomy | Segmental Primary Repair | Bridges the gap between simple ureteroureterostomy and full substitution by combining partial reanastomosis with graft augmentation when the defect is just too long for direct repair. |
| BMG Onlay | Graft / Onlay Reconstruction | Workhorse graft option for longer proximal or mid-ureteral strictures when circumferential replacement would be excessive. Uses the same graft-bed logic as urethral reconstruction and is usually wrapped with omentum. |
| Appendiceal Onlay / Interposition | Graft / Onlay Reconstruction | Useful right-sided tissue-preserving option when appendix length, caliber, and mesentery are favorable. Can function as either an onlay or a short interposition segment. |
| Ureteral Reimplantation | Distal Reimplantation | Default distal reconstruction when the ureter reaches the bladder without tension. Appropriate for benign distal strictures, iatrogenic injury, and distal ureterectomy defects. |
| Non-Transecting Reimplantation | Distal Reimplantation | Distal reimplant variant that preserves a strip of periureteral adventitia and blood supply when full transection seems unnecessarily ischemic. |
| Boari Flap with Psoas Hitch | Distal Reimplantation | Escalation step for longer mid-to-distal defects when direct reimplantation is too short. Mobilizes the bladder to meet the ureter rather than sacrificing upper-tract tissue. |
| Trans Ureteroureterostomy (TUU) | Substitution / Salvage | Second-line option when ipsilateral tissue planes are hostile but the contralateral ureter is healthy and safely reachable without tension. |
| Ileal Ureter Substitution | Substitution / Salvage | Standard bowel substitute for long-segment or pan-ureteral loss when native-tissue options are exhausted and renal function merits salvage. |
| Renal Autotransplantation | Substitution / Salvage | Last major salvage step for complex proximal or multi-segment disease when other reconstructions are not feasible or would be more morbid. |