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Balloon Dilation of the Upper Tract

Non-drug-coated balloon dilation is a minimally invasive endourologic technique for managing benign upper urinary tract strictures, including ureteral strictures, ureteropelvic junction (UPJ) obstruction, and ureteroenteric anastomotic strictures. A 2019 meta-analysis of 19 uncontrolled series in benign ureteral strictures reported pooled technical success of about 89% and long-term success of about 54% at 6–12 months.[1] Success was significantly higher for strictures ≤2 cm; onset within 3 months showed a higher success rate that was not statistically significant. Compromised vascular supply predicts failure.[1][2]

For drug-coated (paclitaxel) balloons, see Drug-Coated Balloon Therapy. For sharp endoscopic incision, see Endoureterotomy.

Indications​

ScenarioNotes
Benign ureteral stricturesIatrogenic injury, ureteroscopy, radiation, or inflammatory.[1][3]
UPJ obstructionPrimary or recurrent after failed pyeloplasty.[4][5]
Ureteroenteric anastomotic stricturesAfter radical cystectomy with ileal conduit, neobladder, or continent pouch. If cystectomy was for cancer, evaluate for tumor recurrence before assuming the narrowing is benign; the cited comparative series included urine cytology in that evaluation.[6][7]
Post-surgical anastomotic stricturesAfter pyeloplasty, ureteral reimplantation, or ureteroneocystostomy.[8][3]

Preprocedure Assessment​

Before elective endoscopic dilation, obtain a urine culture.[18] The 2026 EAU Urological Infections guideline recommends screening for and treating asymptomatic bacteriuria before urologic procedures breaching the mucosa .[18]

Technique​

Use retrograde (cystoscopic or ureteroscopic) or antegrade (nephrostomy) access, usually with fluoroscopic contrast guidance. Pass a guidewire across the stricture, center the balloon on the narrowed segment, dilate, and check the result with antegrade or retrograde pyelography before temporary drainage.[6][3][14] A 76-patient retrospective series also described selected ureteroscope-guided dilation without fluoroscopy.[19] Positioning follows the access route: the retrograde approach uses dorsal lithotomy, as for cystoscopy or ureteroscopy, while the antegrade approach uses the prone, prone-oblique, or supine-oblique position needed for percutaneous nephrostomy or nephrostomy-tract access. No dilation-specific VTE recommendation exists; this is a brief endoscopic procedure, so it falls toward the low end of the general urologic-surgery risk framework on the VTE Prophylaxis page, but individual risk factors (age, obesity, prior VTE, malignancy) still apply.

ParameterTypical setting
Balloon typeA 50-infant UPJ series used 5–7 mm semicompliant high-pressure balloons; adult dimensions were not studied.[9]
Inflation pressureOne 20-patient series used 10–20 atm for 5–15 min; pressure and inflation duration are not standardized.[6][1][10]
Post-dilation drainageUreteral stenting for 4–8 weeks in one series; another reported a mean of 2.1 months (range 1–5 months).[3][6]
StandardizationNo consensus on optimal balloon type, pressure, number of inflations, or stent retention time.[1]

Efficacy by Scenario​

Population / studyResultInterpretation
Benign ureteral strictures, retrospective cohort (114 patients total; 81 received balloon dilation; at least 2 years of follow-up)Balloon dilation succeeded in 33/37 (89.2%) short strictures with intact vascular supply, versus 3/8 long strictures and 2/5 short strictures with compromised supplySelected retrospective cohort; the authors favored endoureterotomy for long strictures and compromised supply.[2]
Benign ureteral strictures, 2019 meta-analysis of 19 seriesAbout 60% success at 3 months and 54% at 6–12 monthsHeterogeneous uncontrolled series.[1]
UPJ obstruction shorter than 2 cm, retrospective comparisonBalloon dilation: 78.9% at 12 months and 71.0% at 24 months; laparoscopic pyeloplasty: 95.5% at both timepointsPatient-selected treatment groups; this was not a randomized trial.[4]
Ureteroenteric stricturesA 27-year series reported 60-month patency of 27% after mixed endourologic procedures versus 69% after open revision; a separate meta-analysis reported 35% pooled success after balloon dilationEndoscopic results were more favorable for strictures ≤1 cm, but the balloon studies and follow-up were heterogeneous.[7][15]

Success estimates are setting-specific across pediatric UPJ, benign native-ureter and ureteroenteric studies.

Predictors of Outcome​

Favorable factors:[1][3][2]

  • Stricture length ≤2 cm.
  • Onset within 3 months (a higher success rate in the meta-analysis, not statistically significant).
  • Intact vascular supply (no prior radiation, no devascularizing dissection).
  • Primary rather than recurrent stricture.

Failure risk factors:[10][2]

  • Multiple strictures (independent predictor on multivariate analysis).
  • Compromised vascular supply (post-radiation, ischemic).
  • Long strictures.
  • Prior failed repair.
  • Larger balloon circumference was associated with failure in one retrospective cohort.[10]

Complications​

Guidewire passage may fail; in one mixed-treatment series, 13/59 attempts required invasive surgery because the wire could not traverse the stricture.[14] Hematuria, mucosal injury, and ureteral perforation are recognized procedural harms.[20] In a selected 42-patient benign lower-ureter series using balloon dilation with internal-external drainage, hematuria in the drainage bag cleared in 1–4 days and no perforations were reported.[20]

Comparison With Surgical Reconstruction​

Reconstruction generally offers greater durability at the cost of a larger intervention. Operative time, admission and cost depend on the specific repair, era and local pathway. For ureteroenteric strictures, a 2026 review of seven comparative cohorts (368 renal units) found higher primary patency after open revision than after mixed endoscopic management (RR 2.31, 95% CI 1.54–3.47), with more minor complications after open repair; success definitions varied.[16] Use the population-specific outcomes above for counseling.[4][7][11]

Adjunctive Techniques​

  • Balloon dilation and endoureterotomy. One retrospective lower-ureter cohort reported 1-year success of 87% with combined treatment (30 patients) versus 78% with dilation alone (37 patients); the groups differed in age and stricture length.[10]
  • Laser incision and triamcinolone injection followed by balloon dilation. 20 of 24 ureteroenteric strictures (83.3%; 21 patients) had no recurrence at a median 30 months in a retrospective series.[12]
  • Acucise balloon catheter. Combined electrocautery incision and dilation was reported successful in eight patients among 11 patients with 12 treated strictures at median 16 months; reported subgroup success was 83% for ureterovesical and 50% for uretero-ileal strictures.[13]

Clinical Role​

Balloon dilation is used as a first-line minimally invasive option for selected patients (short, primary strictures with intact vascularity) and as a temporizing or alternative approach in patients unfit for open reconstruction. For recurrent UPJ obstruction after pyeloplasty, a 2026 review of 12 mixed-age comparative studies (549 patients) found higher odds of success after redo pyeloplasty than after pooled endoscopic treatments, including balloon dilation and endopyelotomy (OR 6.32, 95% CI 3.25–12.32); risk of bias was high to serious.[17] Re-dilation remains feasible for selected recurrent ureteral strictures. In a retrospective mixed-treatment cohort, 43/59 attempted patients were analyzed after 13 required invasive surgery for failed guidewire access and three were followed elsewhere; 32 received balloon dilation, 10 catheter dilation, and one laser incision.[14] Among 34 initially successful patients, six recurred within 36 months (four within 12 months), all after malignancy treatment. Three were re-dilated; two met success criteria at 36 months and one died earlier of progressive malignancy.[14] The authors advise long-term follow-up.[7][14]

Follow-Up​

Follow-up after stent removal assesses symptoms, renal function, and upper-tract drainage.[14] One retrospective mixed-treatment cohort checked drainage two weeks after stent removal; stent- and nephrostomy-free patients then had CT urography or MAG3 scintigraphy plus creatinine/eGFR at 3, 6, 12, 24, and 36 months.[14]

See Also​

References​

1. Lu C, Zhang W, Peng Y, et al. Endoscopic balloon dilatation in the treatment of benign ureteral strictures: a meta-analysis and systematic review. J Endourol. 2019;33(4):255–262. doi:10.1089/end.2018.0797

2. Richter F, Irwin RJ, Watson RA, Lang EK. Endourologic management of benign ureteral strictures with and without compromised vascular supply. Urology. 2000;55(5):652–657. doi:10.1016/s0090-4295(00)00484-2

3. Beckmann CF, Roth RA, Bihrle W. Dilation of benign ureteral strictures. Radiology. 1989;172(2):437–441. doi:10.1148/radiology.172.2.2748824

4. Xu N, Chen SH, Xue XY, et al. Comparison of retrograde balloon dilatation and laparoscopic pyeloplasty for treatment of ureteropelvic junction obstruction: results of a 2-year follow-up. PLoS One. 2016;11(3):e0152463. doi:10.1371/journal.pone.0152463

5. Wei C, Wang T, Chen S, Ren X, Chen X. Concomitant management of renal calculi and recurrent ureteropelvic junction obstruction with percutaneous nephrolithotomy and antegrade balloon dilation. J Int Med Res. 2020;48(5):300060520911252. doi:10.1177/0300060520911252

6. Ravery V, de la Taille A, Hoffmann P, et al. Balloon catheter dilatation in the treatment of ureteral and ureteroenteric stricture. J Endourol. 1998;12(4):335–340. doi:10.1089/end.1998.12.335

7. van Son MJ, Lock MTWT, Peters M, van de Putte EEF, Meijer RP. Treating benign ureteroenteric strictures: 27-year experience comparing endourological techniques with open surgical approach. World J Urol. 2019;37(6):1217–1223. doi:10.1007/s00345-018-2475-4

8. Anastasescu R, Merrot T, Chaumoître K, Panuel M, Alessandrini P. Antegrade percutaneous balloon dilation of ureteral strictures after failed pelviureteric or ureterovesical reimplantation in children. Urology. 2011;77(6):1444–1449. doi:10.1016/j.urology.2010.10.052

9. Parente A, Angulo JM, Romero RM, et al. Management of ureteropelvic junction obstruction with high-pressure balloon dilatation: long-term outcome in 50 children under 18 months of age. Urology. 2013;82(5):1138–1143. doi:10.1016/j.urology.2013.04.072

10. Wang B, Gao W, Yang K, et al. Analysis of the efficacy and risk factors for failure of balloon dilation for benign ureteral stricture. J Clin Med. 2023;12(4):1655. doi:10.3390/jcm12041655

11. Zi D, Cao W, Chen F, Zhu L. Management for benign ureteral stricture: comparison of robot-assisted laparoscopy, conventional laparoscopy, and balloon dilation. J Endourol. 2023;37(8):868–875. doi:10.1089/end.2023.0047

12. Katims AB, Edelblute BT, Tam AW, et al. Long-term outcomes of laser incision and triamcinolone injection for the management of ureteroenteric anastomotic strictures. J Endourol. 2021;35(1):21–24. doi:10.1089/end.2020.0593

13. Touiti D, Gelet A, Deligne E, et al. Treatment of uretero-intestinal and ureterovesical strictures by Acucise balloon catheter. Eur Urol. 2002;42(1):49–54; discussion 55. doi:10.1016/s0302-2838(02)00070-2

14. Reus C, Brehmer M. Minimally invasive management of ureteral strictures: a 5-year retrospective study. World J Urol. 2019;37(8):1733–1738. doi:10.1007/s00345-018-2539-5

15. Lu X, Wang Y, Chen Q, Xia D, Zhang H, Chen M. "Endoscopic Procedures in the Treatment of Ureteroenteric Anastomotic Strictures: A Systematic Review and Meta-Analysis." Front Surg. 2021;8:626939. doi:10.3389/fsurg.2021.626939

16. Kendrekar P, Bhatia A, Bakbak H, et al. "Open vs Endoscopic Management of Benign Ureteroenteric Anastomotic Strictures: A Systematic Review and Meta-Analysis." J Endourol. Published online August 6, 2026. doi:10.1177/08927790261472745

17. Chua ME, Wong MM, Gouwtama M, et al. "Challenging recurrent ureteropelvic junction obstructions: endoscopic procedures versus redo-pyeloplasty—a systematic review and meta-analysis." World J Urol. 2026;44(1):256. doi:10.1007/s00345-026-06339-8

18. European Association of Urology. "EAU Guidelines on Urological Infections." EAU Guidelines. 2026. Full guideline.

19. Peng Y, Li X, Li X, et al. "Fluoroscopy-free minimally invasive ureteral stricture balloon dilatation: a retrospective safety and efficacy cohort study." Transl Androl Urol. 2021;10(7):2962–2969. doi:10.21037/tau-21-203

20. Lu H, Zheng C, Liang B, Xiong B. "Analysis of long-term effect of ureteral balloon dilatation combined with internal and external drainage tube in the treatment of benign ureteral stricture." BMC Urol. 2022;22:4. doi:10.1186/s12894-022-00952-6