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Endoureterotomy

Endoureterotomy is an endoscopic treatment for ureteral stricture in which the narrowed ureter is incised full-thickness from within the lumen and then stented while the ureter heals in an expanded configuration. It is an endoscopic option for selected benign strictures; balloon dilation is another, and a 2026 expert algorithm favors balloon dilation as the initial endoscopic treatment for many simple strictures. Endoscopic durability is most favorable for short, nonocclusive, well-vascularized lesions; long, obliterative, ischemic, radiation-related, or recurrent strictures generally favor reconstruction.[1][2][3][4][40]

For reconstructive alternatives, see Ureteroureterostomy, Ureteral Reimplantation, Buccal Mucosa Graft Ureteroplasty, and Upper Tract Reconstruction Principles. Endoscopic paclitaxel dilation is covered separately under Drug-Coated Balloon Therapy.

Core Principle​

The operation releases the scar ring by making a longitudinal full-thickness incision through mucosa, muscularis, and adventitia until periureteral fat is seen.[5][6][7] A ureteral stent then splints the incised segment for roughly 4-8 weeks, allowing the lumen to re-epithelialize open rather than recontracting immediately.

The analogy is direct visual internal urethrotomy: both procedures are attractive because they are low morbidity, and both are vulnerable to recurrence when the stricture is long, ischemic, dense, or repeatedly treated.

Endopyelotomy is the same concept applied at the ureteropelvic junction (UPJ). It has a narrower role now that minimally invasive pyeloplasty is widely available.

Historical Development​

EraDevelopmentRelevance
Davis intubated ureterotomyOpen intubated ureterotomy conceptEstablished the principle that an incised ureter can heal over a splint
1980sAntegrade percutaneous endopyelotomyMoved UPJ incision into the endoscopic era
1992Meretyk, Clayman, and colleagues reported a dedicated endoureterotomy seriesEarly 62% success and the beginning of stricture-specific endoscopic series[5]
1993Acucise cutting balloon introducedFluoroscopy-guided incision without direct visualization[8]
1997Ho:YAG laser endoureterotomy series reportedHelped establish laser incision as the dominant modern technique[9]
Modern eraLaser incision plus selective balloon dilation, steroid injection, dual stents, or metallic stentsAttempts to improve an operation whose core limitation is restenosis biology[10][11][12][13]

Approaches​

ApproachHow It Is DoneBest FitLimitations
Retrograde ureteroscopicSemirigid or flexible ureteroscope passed from bladder to stricture; incision under direct visionMost native ureteral strictures; outpatient endoscopic workflowCan be difficult across tight, proximal, or ureteroenteric strictures
Antegrade percutaneousNephrostomy access with antegrade ureteroscope/nephroscopeProximal ureter, UPJ, transplant, or ureteroenteric strictures where retrograde access is poorRequires percutaneous access and its morbidity
Combined antegrade-retrogradeRendezvous access from both endsNear-obliterative strictures where a wire cannot be passed safelyMore complex; often a signal that reconstruction may be more durable
Acucise cutting balloonFluoroscopic balloon with electrocautery wire incises while inflatedHistorical option for UPJ or ureteral stricturesNo direct visualization, no biopsy, less control of incision depth; now largely replaced by laser[8][14][15]

Energy Sources​

Energy SourceMechanismAdvantagesDrawbacks
Ho:YAG laserPulsed photothermal incision at 2100 nmPrecise, hemostatic, works through small flexible scopes; the energy source most often reported in contemporary seriesRequires direct vision and endoscopic access[6][9]
Electrocautery / hot wireElectrical tissue incisionWidely available; historical experienceThermal spread and less precise control than laser
Cold knifeMechanical incisionNo thermal injuryHarder to use in small tortuous ureteral lumens
AcuciseBalloon-mounted electrocautery wireFast and fluoroscopy-guidedBlind incision, bleeding risk, no biopsy, largely historical[8][14]
Thulium fiber laserEmerging photothermal laser platformPotentially precise cuttingLimited ureteral endoureterotomy outcomes data

Retrograde Laser Technique​

  1. Cystoscopy and retrograde pyelography define stricture location, length, severity, and upstream dilation.
  2. Safety wire placement across the stricture is attempted. A completely impassable segment should prompt antegrade access, rendezvous strategy, or reconstruction rather than blind force.
  3. Ureteroscopy confirms the stricture endoscopically. Suspicious lesions should be biopsied before incision; malignant strictures are not endoureterotomy disease.
  4. Incision planning uses the ureteral level, cross-sectional vascular anatomy and endoscopic orientation to select a line away from adjacent vessels and bowel. The incision line varies with ureteral level and nearby vessels and bowel.
  5. Laser incision is made with a small Ho:YAG fiber, commonly 200-365 microns, through the full scar thickness until periureteral fat is visible.[9][16]
  6. Balloon dilation may be added after incision, typically to open the released scar ring and confirm full expansion.[11][16]
  7. Adjunctive triamcinolone has been used off-label in selected protocols. Its incremental benefit and optimal dose are not established by the uncontrolled combination-treatment series; it is not a routine requirement.[2][12]
  8. Stenting splints the incision. Standard double-J stents are common; larger-caliber endoureterotomy stents or dual ipsilateral stents have been used to increase luminal scaffolding.[2][13][17]
  9. Drainage and follow-up depend on approach and extravasation. Stents are usually removed after 4-8 weeks.

Incision Direction​

At the UPJ, Sampaio and Favorito's vascular anatomy work supports avoiding deep anterior incision because prominent anterior vessels were common, while the posterior surface was often vessel-free only within a limited segment. For UPJ endopyelotomy, Sampaio and Favorito advise a lateral deep incision on anatomic grounds.[18]

For upper ureteral strictures, a posterolateral incision is commonly described; for distal strictures, an anteromedial line is described to avoid nearby vessels. At the iliac crossing, in a transplant, after diversion or after prior reconstruction, establish the actual vascular and bowel relationships before a full-thickness incision.[32] One anatomic teaching rule, based on the ureter's segmental arterial supply running medially in the proximal ureter, posteriorly in the mid-ureter and laterally in the distal ureter, pairs each level with an incision on the opposite side of the vessel course: lateral proximally, anterior in the mid-ureter, and medial distally.[35]

Patient Selection​

Endoureterotomy is a selection-sensitive treatment.

FeatureFavors EndoureterotomyFavors Reconstruction
LengthUsually <2 cm and nonocclusive; individualize near the boundary[40]≥2 cm, especially >3 cm; weigh anatomy and stricture biology
EtiologyNonischemic, stone-related, short iatrogenic narrowingRadiation, devascularization, ureteroenteric ischemia, dense fibrosis
LumenPartial stricture; wire can passObliterated or near-obliterated segment
Renal functionAdequate function and potentially recoverable drainagePoor function warrants individualized assessment of reconstruction, drainage or nephrectomy
Prior treatmentFirst endoscopic attemptFailed prior endoureterotomy or repeated dilation
HydronephrosisMild or moderateSevere chronic dilation
Patient priorityLowest morbidity and accepts recurrence riskMaximal durable patency

Classic series repeatedly found worse outcomes with long strictures, ischemic strictures, compromised ipsilateral renal function, and ureteroenteric strictures.[1][2][3][4]

The classic prognostic-factor framework for endopyelotomy names stricture length, hydronephrosis grade, ipsilateral renal function and a crossing vessel (especially combined with a higher hydronephrosis grade) as the recognized predictors of outcome; teaching materials have proposed specific numeric cutoffs for candidacy (for example, function above roughly 25-30% and a stricture under about 1.5-2 cm) that vary between sources and are not a single agreed threshold.[33]

Outcomes: Endoscopic Ureteral Stricture and UPJ Series​

SeriesNTechniqueSuccessKey Lesson
Meretyk et al.13Endoureterotomy62%Early dedicated series; steroid injection appeared promising[5]
Singal et al.22 treated (21 assessed; mixed native and ureteroenteric strictures)Ho:YAG laser16/21 (76%) clinically well without recurrenceLength and etiology drove results; three patients had only 3–6 months of follow-up[9]
Wolf et al.38 benign strictures with ipsilateral function ≥25%Mixed endoureterotomy80% 3-year successNone of 9 procedures with ipsilateral function <25% succeeded; ureteroenteric strictures performed worse[2]
Richter et al.19 strictures with compromised vascular supplyPooled endopyelotomy/ureterotomy with stenting17/19 (89.5%) for the pooled subgroupNative-ureter-only success was not reported separately. Balloon dilation succeeded in 33/37 (89.2%) short strictures with intact vascularity, with poorer results in long or poorly vascularized strictures.[19]
Razdan et al.50 patients (mixed benign and malignant; native and ureteroenteric)Ureteroscopic endoureterotomy74% overall in the mixed cohortAll seven strictures >2 cm failed; dual stenting succeeded in 8/10 recurrent cases.[3]
Gnessin et al.35Ho:YAG laserSymptom-free 29/35 (82%); radiographically unobstructed 26/33 (78.7%) at median 27 monthsNonischemic success 100% versus 64.7% for ischemic strictures[1]
Corcoran et al.34Balloon dilation and/or Ho:YAG endoureterotomy85% (29/34)Mean stricture length 1.6 cm; mean 1.7 procedures per patient[4]
Ou et al.95 patients receiving endourologic treatmentMixed endoscopic51.6% with symptomatic improvement and radiographic blockage alleviation95.7% by the same success definition in a separate 47-patient reconstruction group[10]

In a retrospective series of 35 benign strictures, 29/35 (82%) were symptom-free and 26/33 (78.7%) were free of radiographic obstruction at median 27 months; outcomes were better for nonischemic than ischemic strictures.[1] Broader cohorts report lower success when long, complex, ischemic, or recurrent strictures are included.

Ureteroenteric Anastomotic Strictures​

Ureteroenteric anastomotic strictures are harder endoscopic targets because ischemia, scarring, prior diversion, and altered anatomy are common. For a short, accessible ureteroenteric stricture, an endoscopic first attempt may be considered after counseling about recurrence and repeat intervention. In a 2026 systematic review, open revision had higher primary patency than endoscopic treatment in seven nonrandomized comparative cohorts (368 renal units; RR 2.31, 95% CI 1.54–3.47), while endoscopic laser results were better for strictures <1 cm; definitions and cohorts varied.[38]

SeriesTechniqueSuccessNote
Wolf et al.Mixed endoureterotomy32% 3-year successMarkedly worse than benign native strictures[2]
Lin et al.Acucise30% (3/10 benign strictures after excluding malignancy; patent at 18 and 30 months)Limited durability for ureteroenteric disease[20]
Touiti et al.Acucise50% ureteroileal; 83% ureterovesicalSite-specific results in six strictures per group; median follow-up 16 months[15]
Laven et al.Endoureterotomy vs open revision8/16 renal units (50%) vs 12/15 (80%); median follow-up 35 vs 34 monthsHigher reported success after open revision in this cohort; success meant radiologic improvement or full activity without pain, infection, stent, or nephrostomy[21]
Gomez et al.First-line endourologic management20/28 strictures (71.4%); median follow-up 25 monthsAmong 27 patients, three grade II and five grade III complications were reported; selection and risk require counseling[22]
Katims et al.Laser incision, triamcinolone, balloon dilation, then parallel stents or upside-down nephrostomy tubes20/24 strictures (83.3%) in 21 patients; median follow-up 30 monthsUncontrolled combination protocol[12]

Transplant and UPJ Settings​

Transplant Ureteral Strictures​

Transplant strictures are anatomically and biologically distinct. Gdor et al.’s 12-patient transplant-kidney cohort included nine ureterovesical anastomotic strictures and three UPJ obstructions; among eight lesions ≤10 mm across these sites, success (stable creatinine without hydronephrosis) occurred in 5/5 after combined balloon dilation and laser endoureterotomy versus 1/3 after balloon dilation alone (mean follow-up 52 months for the eight).[23] These are small numbers, but they are consistent with the general pattern that very short strictures are the best endoscopic candidates.

Endopyelotomy for UPJ Obstruction​

Endopyelotomy has lower durability than pyeloplasty. A comparative effectiveness study found higher failure after endopyelotomy than open pyeloplasty, while minimally invasive pyeloplasty was more durable than endopyelotomy.[24] Contemporary review data place retrograde endopyelotomy success below pyeloplasty, with best results in short stenoses, modest hydronephrosis, preserved renal function, and no major crossing-vessel concern.[25][26]

Endopyelotomy is now a selective option for favorable adult UPJ obstruction, failed patients who cannot tolerate reconstruction, or those prioritizing the lowest morbidity after counseling. Pyeloplasty remains the durability standard. For recurrent UPJ obstruction, a 2026 meta-analysis of 12 comparative studies (549 adults and children) associated redo pyeloplasty with higher study-defined success than endopyelotomy or balloon dilation (OR 6.32, 95% CI 3.25–12.32); variable outcomes and high-to-serious risk of bias limit certainty.[42]

Endoluminal ultrasonography, using a small probe (approximately 6 Fr)[43] passed over a guidewire and oriented against the wire and fluoroscopic catheter position, has been described to map a crossing vessel and the length and position of a high-insertion septum before incision, with visible pulsation through the ureteroscope alone considered an unreliable way to localize a crossing vessel; CT angiography can aid preoperative planning when the probe is unavailable, but a small 1999 prospective comparison found fewer crossing vessels with CT than with endoluminal ultrasonography.[41] In one series using this technique, sonographic findings excluded 5 of 37 patients from the procedure, and among the 32 who were treated, 87.5% (28/32) had pain-free resolution of obstruction on diuretic renal scan at a mean 10-month follow-up.[36]

A Cleveland Clinic variant of the antegrade approach places the stent before incising the UPJ, then incises over the stent with a Bugbee electrode; proponents describe the pre-placed stent as marking the intended incision line and guiding marsupialization into the pelvis, and argue that it avoids passing a larger tapered endopyelotomy stent through a freshly incised UPJ, which they believe may reduce avulsion risk. A tapered stent and nephrostomy tube follow. No comparative outcome data show this sequence is safer or more effective than incising first and stenting afterward.[37]

Adjunctive Measures​

AdjunctRationaleEvidence Signal
Balloon dilation after incisionExpands the released scar ring and confirms lumen caliberOften combined with Ho:YAG incision; a 19-series meta-analysis of balloon dilation reported 54% ± 14% success (mean ± standard error) at 6–12 months, without establishing later durability.[11][27]
Triamcinolone injectionReduces fibroblast proliferation and collagen deposition in the incised bedOff-label; observational association and a small combination-treatment series[2][12]
Larger stentsSplint the incision more aggressivelyWolf et al. associated >=12F stenting with better results in strictures >1 cm[2]
Dual ipsilateral stentsIncrease scaffold diameter without a custom endoureterotomy stentIn a randomized bilharzial-stricture study, two 7F stents achieved 83.9% success versus 53.1% with one 7F stent among 63 patients completing follow-up longer than 18 months; generalizability to other etiologies is uncertain.[13]
Covered metallic stentsLonger-term internal scaffold for patients unfit for reconstruction or after endoscopic releaseAllium and other covered stents show improving but still selective evidence[28][29][30]

Metal stents are maintenance or salvage tools. The 2025 meta-analysis pooled different devices and cohorts. A prospective Allium series of 310 patients with 330 ureteral strictures reported declining surgical success over 3 years.[28][30]

Complications​

ComplicationComment
Extravasation / urinomaExpected risk after full-thickness incision; usually managed with stenting, drainage, or nephrostomy if needed
BleedingHemorrhage risk varies by technique. Conlin and Bagley reported no significant hemorrhage in 21 ureteroscopic UPJ incisions.[34] In a 52-procedure balloon-cautery endopyelotomy series, Schwartz and Stoller reported four vascular injuries, including three renal-artery injuries treated with embolization; one presented 12 days later.[39]
UTI / feverTreat with culture-directed antibiotics and ensure drainage. Infectious complications are likely underreported; one series recorded them in about 5% of patients. Follow standard antimicrobial-prophylaxis guidance for the procedure.[34]
Ureteral perforationUsually stented; risk rises with tight strictures and difficult access
Vascular injuryIn a historical 52-procedure retrograde balloon-cautery endopyelotomy series, four vascular injuries (7.7%) occurred, including an ovarian-vein laceration requiring nephrectomy and vein ligation.[39]
Recurrent strictureMain long-term failure mode; recurrence risk depends on selection
Need for secondary procedureRepeat endoscopy, chronic stent, nephrostomy, or definitive reconstruction may be required; covered metal stents can also fail through migration, occlusion, encrustation, or infection.[30]

Timing of Failure and Follow-Up​

Failure timing varies by cohort. In Gnessin et al., all but one failure occurred before 9 months; Wolf et al. observed no benign-stricture failure after 11 months, with 25 patients still at risk. In a broader mixed endourologic cohort, Ou et al. reported a median recurrence time of 51 months.[1][2][10] Surveillance is close during the first postoperative year and continues thereafter.

Typical follow-up includes:

  • stent removal at 4-8 weeks,
  • renal ultrasound or CT urogram after stent removal,
  • functional drainage study when symptoms, renal function, or imaging are equivocal,
  • low threshold for earlier imaging if flank pain, fever, rising creatinine, or recurrent hydronephrosis develops,
  • continued longer-term surveillance for ureteroenteric, ischemic, transplant, or metal-stent cases.

Endoureterotomy vs Reconstruction​

Endoureterotomy offers shorter operative time, less blood loss, faster recovery, and outpatient feasibility. Its cost is durability. Ou et al. found overall success of 51.6% for endourologic treatment compared with 95.7% for surgical reconstruction in benign ureteral strictures, in a retrospective, predominantly stone-related cohort.[10] Zi et al. similarly found that balloon dilation could approximate reconstructive approaches early but lost ground at 12 and 24 months.[31]

ScenarioUsually Better Choice
Short (<2 cm), benign, partial, nonischemic strictureInitial balloon dilation or endoureterotomy may be considered after discussing recurrence risk; the 2026 expert algorithm favors balloon dilation for many simple strictures.[40]
Long (>2 cm) proximal/mid strictureBMG ureteroplasty, augmented anastomotic repair, appendix, or ileal substitution depending anatomy
Upper/mid complete transection or short excisable strictureUreteroureterostomy
Distal strictureUreteral reimplantation, psoas hitch, Boari flap, or selective non-transecting reimplant
Radiation-induced, ischemic, recurrent, or obliterated strictureReconstruction favored
Ureteroenteric anastomotic strictureEndoscopic attempt is reasonable in selected cases; revision remains the durability standard
Poor operative candidateEndoureterotomy, balloon dilation, chronic stent, nephrostomy, or metallic stent may be pragmatic

Operative Pearls​

  • Confirm benign disease before incision; biopsy suspicious strictures.
  • Do not force a wire through an obliterated segment; use antegrade or rendezvous access or reconstruct.
  • A therapeutic incision releases the full scar thickness, but only along a planned safe line; avoid uncontrolled extension into adjacent structures.
  • Match incision direction to the ureteral level and actual vessels; a lateral or posterolateral rule is unsafe for every distal stricture.
  • Counsel patients that low morbidity is paired with lower durability than reconstruction.
  • Recurrent narrowing after a technically adequate endoureterotomy should usually prompt consideration of definitive reconstruction rather than serial incision, except when endoscopic treatment is palliative.[40]
  • For ureteroenteric strictures, counsel on recurrence and revision options. Steroid-containing combination protocols remain incompletely validated.
  • Preserve future reconstruction options by avoiding devascularizing or traumatic repeated instrumentation.

Summary​

Endoureterotomy is an option for short, benign, partial, nonischemic ureteral strictures with preserved renal function. Ho:YAG laser incision under direct vision is the most commonly reported modern technique, combined with stenting and, selectively, balloon dilation. Steroid injection is an off-label adjunct with uncertain incremental benefit. Wolf et al. reported 80% Kaplan–Meier success at 3 years for 38 benign ureteral-stricture treatments with ipsilateral renal function at least 25%.[2] In Ou et al.'s nonrandomized broader cohort, endourologic success was 51.6% versus 95.7% after reconstruction; the groups were not matched.[10] Its role is selective: endoureterotomy may be considered as an initial endoscopic attempt for selected short, nonocclusive native strictures or ureteroenteric anastomotic strictures, and as a palliative or temporizing option for poor reconstructive candidates.[2][23]

References​

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