Augmented Anastomotic Ureteroureterostomy
Augmented anastomotic ureteroplasty is a hybrid ureteral reconstruction that combines primary ureteral reanastomosis on one wall with oral mucosal graft augmentation on the opposite wall. It is also called augmented anastomotic ureteroureterostomy because the operation borrows the logic of end-to-end ureteroureterostomy but avoids the circumferential tension that would occur if the entire stricture were excised and rejoined.[1][2][3]
A related appendiceal augmented-roof variant preserves the ureteral backing while reapproximating the posterior mucosa and does not involve full ureteral transection.[7] For short-segment primary repair, see Ureteroureterostomy. For non-transecting graft onlay, see Buccal Mucosa Graft Onlay (Ureter). For long-segment substitution, see Ileal Ureter Substitution.
Concept
Standard ureteroureterostomy is limited by gap length after debridement. Once the diseased segment exceeds roughly 2-3 cm, complete excision and end-to-end repair can become ischemic or tight. Pure oral mucosa onlay works best when the lumen remains patent enough to open longitudinally without transecting the ureter. Augmented anastomotic ureteroplasty is intermediate between those two operations.[1][2][4]
The core maneuver:
- excise the most obliterated or worst-scarred portion of the stricture,
- reapproximate healthy ureter on one wall, usually posterior or dorsal,
- bridge the ventral defect with buccal or lingual mucosa; the related appendiceal augmented-roof variant preserves the ureteral backing and uses a pedicled flap.[7]
- wrap or support the repair with omentum when possible.
This converts a longer partially obliterated stricture into a shorter primary anastomosis plus a patch-augmented lumen. In contemporary mixed onlay and augmented-anastomotic oral-graft series, treated strictures span about 2-8 cm; graft reconstruction can avoid bowel substitution or renal autotransplantation in appropriately selected patients.[1][2][6][11]
Indications
Augmented anastomotic ureteroplasty is best for complex proximal or mid-ureteral strictures that are unsuitable for tension-free primary ureteroureterostomy but with sufficient viable native ureter and vascular support for graft augmentation.[1][2][5][12]
| Indication | Why the Hybrid Repair Fits |
|---|---|
| Long proximal or mid-ureteral stricture, usually 2-8 cm | Primary UU would be tight; onlay alone may not address an obliterated segment |
| Partially obliterated stricture | The obliterated segment is excised, while the remaining narrowed segment is graft-augmented |
| Failed pyeloplasty or failed endoscopic management | Avoids repeatedly incising dense scar while preserving native ureter |
| Periureteral fibrosis limiting mobilization | Reduces the amount of ureter that must be excised and mobilized |
| Viable plate and a short obliterated core | May permit augmentation while avoiding bowel substitution or autotransplantation |
| Right-sided stricture with usable appendix | Allows appendiceal onlay or interposition in selected anatomy[7][10] |
If the ureter reaches without tension after debridement, standard ureteroureterostomy remains simpler. If the stricture is pan-ureteral, ischemic over a long segment, or embedded in hostile tissue without a graft bed, ileal ureter, transureteroureterostomy, renal autotransplantation, or nephrectomy may be more realistic.
Preoperative Planning
Preoperative planning defines stricture length and location, renal salvageability, graft strategy, and whether ureteral rest is appropriate. In Zhou et al.'s protocol, ureteral rest involved stent removal, nephrostomy drainage, and repeat antegrade and retrograde imaging after four weeks.[15] In a propensity-matched retrospective ureteral reconstruction cohort, rest was associated with higher surgical success (79/82 versus 71/82).[16]
| Question | Planning Tool |
|---|---|
| Where are the proximal and distal limits? | CT urogram, MR urogram, antegrade/retrograde pyelography |
| Is the segment obliterated or merely narrowed? | Retrograde pyelogram, antegrade study, diagnostic ureteroscopy |
| Is the kidney worth reconstructing? | MAG3/DTPA renography, serum creatinine, cortical thickness, symptoms |
| Is infection controlled? | Zhou et al. cultured urethral and nephrostomy urine and treated infection until cultures were negative before surgery.[15] |
| Is the oral cavity suitable? | Prior graft harvest history, oral disease, mouth opening, patient preference |
| Is an omental wrap available? | Prior abdominal surgery, side of repair, transperitoneal access |
| Is appendix an option? | Right-sided stricture, healthy appendix, adequate length and mesentery |
Concurrent intraoperative ureteroscopy can locate the distal stricture margin by transillumination; after grafting, it can confirm luminal patency.[8] Intravenous ICG can aid perfusion assessment; intraluminal ICG outlines the ureter without assessing blood supply. If both routes are planned, assess perfusion before opening a dye-filled ureter: spilled intraluminal ICG can obscure subsequent vascular fluorescence.[1] Neither replaces assessment of tissue quality.
Operative Strategy
Most contemporary reports are robotic, but the same reconstruction can be performed open or laparoscopically in experienced hands.[1][2][6]
Exposure and stricture definition
- Expose the ureter transperitoneally or retroperitoneally depending on location and prior surgery.
- Preserve periureteral adventitia and blood supply wherever possible.
- Identify the stricture by visual inspection, ureteroscopy, stent palpation, fluorescence, and/or ureterotomy.
- Mobilize only enough ureter for a tension-free posterior anastomosis.
Excision of the obliterated segment
The most severely diseased portion is excised. Only the non-reconstructable core is removed, and narrowed but viable ureter is preserved for graft augmentation.[2][3]
Principles:
- debride to bleeding, viable mucosa,
- avoid stripping the remaining ureteral plate,
- keep the residual defect short enough for a stable graft bed,
- confirm the proximal and distal lumens pass a guidewire or stent.
Primary wall anastomosis
The proximal and distal ureteral ends are spatulated ventrally into healthy tissue before the dorsal wall is reapproximated without tension using interrupted or running absorbable sutures, usually 4-0 or 5-0.[3][15] This recreates one side of the ureter from native ureteral tissue and shortens the remaining defect.[2][3]
The posteriorly augmented lingual mucosa technique emphasizes this sequence: first anastomose the posterior ureteral wall, then leave the ventral defect open for graft onlay.[3]
Graft harvest
| Graft | Role | Practical Notes |
|---|---|---|
| Buccal mucosa graft | Most established free graft | Familiar urethroplasty harvest; usually enough length for 6-8 cm repairs[1][5] |
| Lingual mucosa graft | Alternative oral mucosa graft | Useful when buccal harvest is undesirable or exhausted; reported with low oral morbidity and success of 87-100% at median follow-up of 11-35 months in the series below[2][3][6] |
| Appendiceal flap | Related right-sided, nontransecting augmented-roof variant | The reported pedicled flap preserved the ureteral backing and avoids reliance on free-graft take; use requires a healthy appendix, favorable mesentery, and adequate reach.[7][10] |
For free oral mucosa grafts, the graft is defatted and tailored to be slightly longer and wider than the ureteral defect. The epithelial surface faces the lumen.
Ventral or anterior onlay
The graft is sutured to the ureteral edges to complete the circumference. The repair should be wide, watertight, and not strangulated. A double-J stent is placed across the reconstruction before closure is completed.[1][2][5]
Technical rules:
- use a broad graft; do not create a narrow patch,
- keep the graft flat and untwisted,
- avoid tension at both graft apices,
- make the native posterior anastomosis carry alignment, not tension,
- ensure the stent crosses both ends of the repair; when distal curl position is uncertain after antegrade placement, confirm its position in the bladder cystoscopically, as in Zhao et al.'s protocol.[1]
Omental wrap and drainage
Omentum is commonly wrapped around the reconstructed segment to provide vascular support and physical coverage. In the lingual mucosa 41-case series, omental wrap was used in 90% of patients; in robotic BMG series, omental support is also a routine technical principle.[1][2]
Drain placement and Foley duration depend on leak risk, operative field, and institutional practice. Stent dwell time varies; in the posteriorly augmented lingual series the double-J stent was removed at a median of 3.5 months (range 2–7).[3] Zhou et al. scheduled stent removal at 6–8 weeks, then ultrasound and antegrade urography 1–2 weeks later. At 7–9 weeks, they removed the nephrostomy if the patient was asymptomatic and antegrade urography or a Whitaker test showed no obstruction. Visits were scheduled at 3, 6, 12, 18, and 24 months and annually thereafter.[15]
Augmented Anastomotic vs Non-Transecting Onlay
| Feature | Augmented Anastomotic | Non-Transecting Onlay |
|---|---|---|
| Best stricture | Partially obliterated or mixed obliterated+narrowed stricture | Narrowed but patent lumen |
| Ureteral transection | Yes in the transecting repair; 16/61 Zhou repairs used a nontransecting fold variant that preserved dorsal adventitia[15] | No, ureter is opened longitudinally |
| Native ureter repair | One wall is reanastomosed end-to-end | Native ureteral plate remains continuous |
| Graft role | Completes the opposite wall and augments circumference | Widens the incised strictured lumen |
| Main advantage | Handles an obliterated core while avoiding full substitution | Maximizes blood supply by avoiding transection |
| Main risk | Transection can jeopardize blood supply if overdone | Inadequate if lumen is obliterated or scar plate is poor |
The retrospective 10-year BMG cohort found no independent association between configuration and success. Only 13/163 analyzed patients failed, limiting power.[4]
Outcomes
| Series | Technique Mix | Key Outcomes |
|---|---|---|
| Zhao et al. 2018 | 19 robotic BMG ureteroplasties; onlay 79%, augmented anastomotic 21% | 90% success at median 26 months[1] |
| Lee et al. 2021 | 54 robotic BMG ureteroplasties; expanded cohort overlapping Zhao et al. 2018 | 47/54 (87.0%) without obstructive flank pain or ureteral obstruction on functional imaging at median 27.5 months; major complications 3/54 (5.6%); median length of stay 1 day[1][5] |
| Liang et al. 2022 | 41 LMG ureteroplasties (40 laparoscopic, 1 robotic); augmented anastomotic 41%, onlay 59% | 97.6% success at median 35 months; omental wrap in 90%[2] |
| Fan et al. 2021 | 10 posteriorly augmented anastomotic LMG ureteroplasties | 100% success at median 11 months; median residual defect 3 cm and graft length 4 cm[3] |
| Chao et al. 2025 | 163 analyzed of 169 robotic BMG operations over 10 years | 150/163 (92.0%) free from additional intervention for recurrent stenosis at median 29 months; median time to failure 10.2 months; technique not an independent failure predictor[4] |
| Wang et al. 2026 | 15 robot-assisted LMG reconstructions; augmented anastomotic 47%, onlay 53% | 87% success at median 21 months; estimated 2-year recurrence-free survival 83%[6] |
| Chai et al. 2025 | 76 robotic LMG ureteroplasties at three centers (2021-2023); augmented anastomotic 37%, onlay 63% | 76/76 met a composite clinical and imaging success definition at mean 27 months (range 13-48); omental wrap in 96%[14] |
| Zhou et al. 2026 | 61 posteriorly augmented anastomotic LMG repairs at three centers; 16 included an adventitial-fold variant | The authors classified 61/61 as surgical successes at median 32 months (range 7-98); 26 had follow-up of at least 3 years. One patient had poor antegrade patency but improving ultrasound and no symptoms; cohort overlap with Chai et al. is possible.[15] |
Systematic evidence supports the broader oral mucosal graft ureteroplasty concept. A BMG systematic review reported success in 66/72 procedures (91.6%); grade ≥3 complications occurred in 3/60 cases with complication reporting (5%).[13] A 2023 meta-analysis pooled 23 single-arm studies: oral graft and ileal replacement success estimates were 94.9% and 85.8%, respectively.[12] Strictures were much shorter in graft cohorts (mean 3.73 versus 11.55 cm).[12]
Complications
| Complication | Notes |
|---|---|
| Stricture recurrence | Main failure mode; in the 163-patient BMG cohort, median time to failure was 10.2 months[4] |
| Early obstruction after stent removal | Can reflect edema, leak, collection, or technical narrowing |
| Urinary leak or urinoma | Usually managed with drainage, stent duration, or percutaneous intervention |
| UTI or pyelonephritis | Common low-grade complication across ureteral reconstruction series |
| Clavien-Dindo grade 3 or higher complication | 2/19 (10.5%) in Zhao et al.'s initial mixed BMG series, 3/54 (5.6%) in the overlapping expanded cohort, and 3/60 (5%) among cases with complication reporting in the systematic review[1][5][13] |
| Oral donor-site morbidity | Pain, numbness, tightness, bleeding, or lingual hypoesthesia; usually transient, but donor-site bleeding can require intervention[6][9] |
Failure after oral mucosa ureteroplasty may still be salvageable with repeat grafting, ileal ureter, renal autotransplantation, chronic stenting, nephrostomy, or nephrectomy depending on renal function and stricture biology.
Advantages
- The operation extends the reconstructable range beyond simple ureteroureterostomy.
- With oral grafting, it avoids bowel harvest and the bowel segment’s mucus and metabolic burden; UTI or bacteriuria can still occur.
- It avoids renal autotransplantation in many focal proximal and mid-ureteral strictures.
- It preserves native ureteral tissue and at least one native ureteral wall.
- It suits robotic reconstruction because the operation is suture-intensive rather than bowel-intensive.
- Both augmented and onlay configurations have favorable reported outcomes, but comparative equivalence remains unproven.[4][12]
Limitations
- The repair requires a viable graft bed and adequate periureteral vascularity.
- Evidence for oral-graft repair of strictures longer than 8 cm remains limited, although a selected posteriorly augmented lingual-graft cohort included a stricture up to 9 cm and a mixed onlay/augmented lingual-graft cohort included lengths up to 11.5 cm.[6][12][14][15]
- The evidence is retrospective and mostly from high-volume reconstructive centers.
- Durability beyond 5 years is less well documented than for ileal ureter or classic reimplantation.
- Oral graft harvest adds donor-site morbidity and requires patient counseling.
- Appendiceal flap options are usually right-sided and anatomy-dependent; left-sided use requires adequate pedicle reach.[7][10]
Operative Pearls
- Do not turn a fully patent stricture into a transected repair unless the obliterated segment demands it.
- The native posterior wall anastomosis should align the ureter; the graft should augment, not rescue tension.
- Measure the defect after debridement and after the posterior wall is reapproximated.
- Harvest a graft slightly longer than the final defect; short grafts create narrow apices.
- Plan vascular graft support; omentum is common, with suitable local vascular tissue as an alternative.
- A healthy appendix with favorable reach is a pedicled alternative, most often on the right; superiority over oral mucosa is unproven.
- If the stricture is long, ischemic, radiated, and poorly vascularized, bowel or autotransplant may be the cleaner operation.
Videos
References
1. Zhao LC, Weinberg AC, Lee Z, et al. Robotic ureteral reconstruction using buccal mucosa grafts: a multi-institutional experience. Eur Urol. 2018;73(3):419-426. doi:10.1016/j.eururo.2017.11.015.
2. Liang C, Wang J, Hai B, et al. Lingual mucosal graft ureteroplasty for long proximal ureteral stricture: 6 years of experience with 41 cases. Eur Urol. 2022;82(2):193-200. doi:10.1016/j.eururo.2022.05.006.
3. Fan S, Yin L, Yang K, et al. Posteriorly augmented anastomotic ureteroplasty with lingual mucosal onlay grafts for long proximal ureteral strictures: 10 cases of experience. J Endourol. 2021;35(2):192-199. doi:10.1089/end.2020.0686.
4. Chao BW, Raver M, Lin JS, et al. Robotic buccal mucosa graft ureteroplasty: a decade of experience from a multi-institutional cohort. Urology. 2025;197:174-179. doi:10.1016/j.urology.2024.11.059.
5. Lee Z, Lee M, Koster H, et al. A multi-institutional experience with robotic ureteroplasty with buccal mucosa graft: an updated analysis of intermediate-term outcomes. Urology. 2021;147:306-310. doi:10.1016/j.urology.2020.08.003.
6. Wang Z, Plamadeala N, Ogalla A, Tailly T, Verla W, Lumen N. Robot-assisted lingual mucosa graft onlay reconstruction for ureteric strictures refractory to endoscopic treatment. J Vis Exp. 2026;(228). doi:10.3791/68627.
7. Gabrielson A, Li O, Cohen AJ. Robotic-assisted augmented roof ureteroplasty with appendiceal onlay flap. Urology. 2023;176:243-245. doi:10.1016/j.urology.2023.02.027.
8. Arora S, Campbell L, Tourojman M, et al. Robotic buccal mucosal graft ureteroplasty for complex ureteral stricture. Urology. 2017;110:257-258. doi:10.1016/j.urology.2017.06.037.
9. Xiong S, Wang J, Zhu W, et al. Onlay repair technique for the management of ureteral strictures: a comprehensive review. Biomed Res Int. 2020;2020:6178286. doi:10.1155/2020/6178286.
10. Zhang B, Chen J, Chen X, et al. Laparoscopic ureteroplasty for the treatment of long ureteral strictures with appendiceal interposition and appendiceal onlay flap: technical description and initial experience. World J Urol. 2025;43(1):678. doi:10.1007/s00345-025-06048-8.
11. Bello D, Van Shufflin M, Hofer MD. Expanding the armamentarium: perspectives on buccal mucosal grafts and appendiceal flaps in ureteral reconstructive surgery. J Clin Med. 2025;14(21):7681. doi:10.3390/jcm14217681.
12. You Y, Gao X, Chai S, et al. Oral mucosal graft ureteroplasty versus ileal ureteric replacement: a meta-analysis. BJU Int. 2023;132(2):122-131. doi:10.1111/bju.15994.
13. Heijkoop B, Kahokehr AA. Buccal mucosal ureteroplasty for the management of ureteric strictures: a systematic review of the literature. Int J Urol. 2021;28(2):189-195. doi:10.1111/iju.14426.
14. Chai S, Zhou Y, Dong M, et al. Robotic ureteroplasty with lingual mucosa graft: a multi-institutional experience. Minerva Urol Nephrol. 2025;77(4):500-507. doi:10.23736/S2724-6051.25.06433-X
15. Zhou Y, Chai S, Xu K, et al. "Posteriorly augmented anastomotic ureteroplasty with lingual mucosal onlay grafts: 8-year multi-institutional experience in 61 cases." Eur Urol Open Sci. 2026;85:9-15. doi:10.1016/j.euros.2026.01.007
16. Zhou Y, Chai S, Xu K, et al. "Effect of ureteral rest on surgical outcomes in adults with ureteral stricture undergoing reconstruction: a propensity score matching study." World J Urol. 2025;43(1):186. doi:10.1007/s00345-025-05577-6