Non-Transecting Ureteral Reimplantation
Non-transecting ureteral reimplantation is an emerging distal ureteral reconstruction in which the ureter is not divided. Instead, a longitudinal ureterotomy is made in healthy ureter proximal to the stricture and anastomosed side-to-side to the bladder, bypassing the diseased distal segment while aiming to preserve longitudinal periureteral blood supply.[1][2]
The term most specifically refers to the robotic non-transecting side-to-side ureterovesical anastomosis described by Slawin, Lee, and colleagues from the Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS).[1]
For established distal reconstruction, see Ureteral Reimplantation and Boari Flap & Psoas Hitch. For non-transecting proximal or mid-ureter graft logic, see Buccal Mucosa Graft Onlay (Ureter) and Augmented Anastomotic Ureteroureterostomy.
Concept
Standard ureteroneocystostomy transects the ureter at or above the diseased segment, debrides or bypasses the distal ureter, spatulates the healthy proximal ureter, and implants it into the bladder. This is the mature standard operation for most distal ureteral strictures and injuries when the ureter reaches the bladder without tension.[4][5][7] The ACS 2025 guideline recommends reimplantation for injuries distal to the iliac vessels whenever possible; it reports 91–98% success for intravesical and extravesical reimplantation using studies of pediatric reflux and adult distal strictures.[4]
The non-transecting side-to-side concept asks whether some distal strictures can be bypassed without dividing the ureter. The theoretical advantages are:
- preservation of longitudinal adventitial blood supply,
- less ureteral shortening,
- reduced need for psoas hitch or Boari flap in marginal-length cases,
- a wide side-to-side ureterovesical anastomosis,
- avoidance of devascularizing dissection in radiated or reoperative fields.[1][2]
This is conceptually related to non-transecting onlay ureteroplasty: in both operations, the ureter is opened longitudinally but not divided, preserving vascular continuity across the strictured region.[3]
Indications
The published experience is limited, so indications are narrow. Reported and plausible settings include:[1][2]
| Indication | Why Non-Transection May Help |
|---|---|
| Distal ureteral stricture | Primary reported indication in the index series |
| Radiation-induced ureteral stricture | Aims to limit circumferential dissection and preserve periureteral vascular continuity in radiated tissue; used in 8 of 35 ureteral units in the CORRUS radiation cohort[2][15] |
| Iatrogenic distal ureteral stricture | Useful when proximal ureter is healthy but distal tissues are hostile |
| Recurrent stricture after endoscopic management | Avoids more endoscopic trauma and maintains ureteral continuity |
| Marginal ureteral length | Avoids shortening from transection and debridement |
| High-risk tissue bed | Consider when radiation, prior surgery, or fibrosis makes blood supply preservation a priority |
The technique is not appropriate when the distal ureteral segment must be removed for oncologic reasons, when the proximal ureter is unhealthy, when the stricture is too long to bypass with a safe side-to-side bladder anastomosis, or when bladder capacity or mobility is inadequate.
Why Standard Transection Can Be a Problem
The ureter receives segmental arterial inputs from renal, gonadal, aortic, common iliac, internal iliac, vesical, uterine and vaginal, and deferential branches, with longitudinal channels in the adventitia. Transection interrupts those longitudinal channels at the repair site and can make the anastomosis dependent on already compromised proximal tissue.[1][6]
Transection can compromise ureteral blood supply when tissue biology is poor:
- pelvic radiation,
- prior pelvic surgery,
- prior failed ureteral reconstruction,
- dense periureteral fibrosis,
- marginal ureteral length,
- questionable distal ureteral vascular reserve.
Standard transecting reimplantation remains the established operation for most patients. It removes or bypasses the diseased distal segment and has a long outcome history. In a 2024 retrospective CORRUS cohort, study-defined composite success required no postoperative flank pain, no radiographic obstruction, and no subsequent intervention for recurrent ureteral disease; 56/61 side-to-side, 143/155 refluxing transecting, and 20/21 non-refluxing repairs met that endpoint.[13] Median follow-up was 7.1, 16.2, and 4.0 months, respectively; the side-to-side group also had more prior radiation.[13] The non-transecting operation is a vascular-preservation strategy for selected anatomy.
Surgical Technique
The described operation is robotic and follows the logic of a side-to-side bowel anastomosis, but between ureter and bladder.[1]
Exposure and localization
- Position and port placement follow standard robotic pelvic ureteral reconstruction.
- Identify the ureter proximal to the stricture.
- Mobilize only enough ureter to bring the bladder to the planned ureterotomy without tension.
- Preserve periureteral adventitia and blood supply.
- Use intraoperative ureteroscopy when needed to define the proximal extent of the stricture.
- Intravenous ICG fluorescence may assist perfusion assessment; intraluminal ICG outlines ureteral anatomy but does not establish tissue perfusion. If intraluminal ICG is used first, persistent ureteral fluorescence can prevent a later intravenous ICG assessment of ureteral vascularity.[2][7][15]
Ureterotomy
In the initially described technique, a 3–4 cm longitudinal ureterotomy is made on the anteromedial surface of healthy ureter proximal to the stricture; a cystotomy is made in the posterolateral bladder wall.[15] The ureter is not transected. The diseased distal segment is left in continuity but bypassed by the new ureterovesical communication.[1]
Bladder mobilization
- Mobilize the bladder toward the ureterotomy.
- Perform a psoas hitch when needed to make the bladder reach without tension.[2][7]
- Make a corresponding cystotomy where the bladder will meet the ureterotomy.
- Ensure the cystotomy is not under stretch and that the ureterotomy lies against bladder mucosa naturally.
Side-to-side ureterovesical anastomosis
- Align ureterotomy and cystotomy.
- Sew a broad mucosa-to-mucosa side-to-side anastomosis with absorbable suture, commonly 4-0 or 5-0.
- Create a wide, elliptical communication rather than a small buttonhole.
- Place a double-J ureteral stent across the anastomosis.
- Consider omental wrap in radiation-induced or compromised tissue.[2]
- Place a drain and close the bladder and port sites per routine.
What is left behind. Unlike transecting reimplantation, the diseased distal ureter is bypassed but not excised and remains anatomically continuous with the native ureteral orifice.[14] This is unacceptable if the segment is suspicious for malignancy, needs pathologic assessment, is infected beyond control, or contains a distal fistula that could remain patent after reconstruction.[15]
Outcomes
Evidence remains small and retrospective. Recurrence after ureteral reconstruction can be asymptomatic; Rosenfeld et al. describe MAG3 renal scans at 3, 6, and 12 months and yearly thereafter for asymptomatic patients at their center, while noting that no guideline-based surveillance protocol exists.[16]
| Study | Population | Findings |
|---|---|---|
| Slawin et al. 2020 | 16 patients, 3 U.S. academic institutions, 2014-2018 | Median operative time 178 minutes, EBL 50 mL, LOS 1 day, no intraoperative complications, no Clavien-Dindo grade 3 or higher postoperative complications, 93.8% clinical improvement in flank pain, radiographic improvement in all patients who underwent follow-up imaging, median follow-up 12.5 months[1] A later review reports that 1/16 required non-refluxing revision for persistent reflux pain.[16] |
| Asghar et al. 2021 CORRUS radiation-induced stricture cohort | 32 patients, 35 ureteral units | Side-to-side reimplantation used in 8/35 ureteral units (22.9%); end-to-end transecting reimplantation used in 21/35 (60.0%); overall success 30/34 evaluable ureteral units (88.2%) after exclusion of one patient who died; median follow-up 13 months, but side-to-side subgroup outcomes were not separately reported[2] |
There is no randomized comparison, no mature durability curve, no late data on the retained blind segment, and no evidence that the theoretical blood-supply preservation improves outcomes over standard transecting reimplantation.
Advantages
| Advantage | Rationale |
|---|---|
| Aims to preserve longitudinal vascular continuity | Avoids ureteral transection; the 16-patient index series did not measure comparative perfusion or compare outcomes with transecting repair[1] |
| Aims to reduce devascularizing dissection | Theoretical benefit in radiated or reoperative tissue[2] |
| Avoids ureteral length loss | No segment is excised, so the repair may need less length-gaining assistance |
| Creates a wide anastomosis | Side-to-side geometry can produce a broad ureterovesical communication[1] |
| Robotic minimally invasive recovery | Index series reported median length of stay of 1 day[1] |
| Low early morbidity in reported series | No grade 3 or higher complications in the 16-patient index series[1] |
Limitations
- Very limited evidence base from small retrospective collaborative experience.
- Short follow-up; long-term durability is unknown.
- The available 2024 comparison is a retrospective, unadjusted cohort with unequal groups and follow-up.[13]
- Distal diseased segment remains in situ.
- Refluxing anastomosis without a formal antireflux tunnel.
- Not suitable for malignant distal ureteral disease.
- Unclear long-term risk of infection, stasis, or symptoms in the bypassed segment.
- Requires healthy accessible proximal ureter and a bladder that can reach without tension.
Adult refluxing reimplantation is generally tolerated when the bladder stores at low pressure.[5] The ACS guideline calls the choice between refluxing and nonrefluxing reimplantation controversial and dependent on surgeon preference, and notes that refluxing anastomoses are more common in trauma.[4]
Comparison With Other Distal Options
| Feature | Non-Transecting Side-to-Side Reimplant | Standard Transecting Reimplant | Onlay Ureteroplasty |
|---|---|---|---|
| Ureter transected | No | Yes | No |
| Diseased distal segment | Bypassed in situ | Excised or bypassed after transection | Incised and augmented |
| Vascular strategy | Preserve longitudinal continuity and minimize dissection | Preserve proximal perfusion and remove nonviable tissue | Preserve a viable ureteral plate and graft bed |
| Anastomosis | Side-to-side ureterovesical | End-to-side ureterovesical | Graft onlay to ureterotomy |
| Best location | Distal ureter | Distal ureter | Usually proximal or mid ureter |
| Antireflux mechanism | No | Optional; commonly refluxing in adults | Not a bladder operation |
| Evidence maturity | Very limited | Established | Growing multi-institutional literature |
For most straightforward distal injuries and strictures, standard ureteroneocystostomy remains the reliable choice. For longer distal defects, psoas hitch and Boari flap are the mature length-gaining tools. Non-transecting reimplantation belongs in the selective tissue-preservation niche where standard transection may be more ischemic than helpful.
Relationship to Other Non-Transecting Ideas
The term "non-transecting" can be confusing because several operations preserve ureteral continuity:
- Non-transecting side-to-side reimplantation: distal ureter-to-bladder bypass.[1]
- Non-transecting oral mucosal graft ureteroplasty: ureter is opened longitudinally and patched with buccal or lingual mucosa, usually proximal or mid ureter.[3]
- Ipsilateral end-to-side ureteroureterostomy: the donor ureter is not implanted into bladder but is joined to a healthy recipient ureter, most often in duplex-system reconstruction.[8]
- Lich-Gregoir extravesical antireflux repair for native-ureter VUR: detrusor tunneling can preserve the existing ureterovesical junction. Transplant Lich-Gregoir ureteroneocystostomy is different: the donor ureter is implanted through a new ureter-to-bladder mucosal anastomosis.[9][10][11][12]
Lich-Gregoir is not the same operation as Slawin-style side-to-side non-transecting reimplantation. Lich-Gregoir is an antireflux technique; side-to-side reimplantation is a bypass for distal ureteral stricture.
Lich-Gregoir Context
In native pediatric VUR repair, extravesical detrusor tunneling can preserve the existing ureterovesical junction. In transplantation, the donor ureter must first be anastomosed to bladder mucosa before detrusor coverage creates the antireflux tunnel. Calling the transplant operation non-detaching or non-transecting is incorrect.[9][10]
In kidney transplantation, ureterovesical anastomotic technique literature supports extravesical approaches as reducing some urologic complications compared with intravesical techniques; Alberts et al. found lower urinary leakage with Lich-Gregoir versus Leadbetter-Politano in meta-analysis.[12]
Operative Pearls
- Use this term precisely: robotic non-transecting side-to-side ureterovesical anastomosis.
- Do not use it for suspected malignant distal ureteral disease.
- The proximal ureterotomy must be in healthy, perfused ureter.
- Make the anastomosis wide; a small side-to-side opening defeats the operation.
- Preserve periureteral adventitia meticulously.
- Mobilize the bladder to the ureter, not the ureter down to the bladder.
- Counsel patients that the operation has been reported only in small retrospective series and is investigational compared with standard reimplantation.
Videos
References
1. Slawin J, Patel NH, Lee Z, et al. Ureteral reimplantation via robotic nontransecting side-to-side anastomosis for distal ureteral stricture. J Endourol. 2020;34(8):836-839. doi:10.1089/end.2019.0877.
2. Asghar AM, Lee Z, Lee RA, et al. Robotic ureteral reconstruction in patients with radiation-induced ureteral strictures: experience from the Collaborative of Reconstructive Robotic Ureteral Surgery. J Endourol. 2021;35(2):144-150. doi:10.1089/end.2020.0643.
3. 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.
4. Johnsen N, Wessells H, Archer-Arroyo K, et al. Best Practices Guidelines: Management of Genitourinary Injuries. American College of Surgeons; 2025.
5. Wenske S, Olsson CA, Benson MC. Outcomes of distal ureteral reconstruction through reimplantation with psoas hitch, Boari flap, or ureteroneocystostomy for benign or malignant ureteral obstruction or injury. Urology. 2013;82(1):231-236. doi:10.1016/j.urology.2013.02.046.
6. de'Angelis N, Schena CA, Marchegiani F, et al. 2023 WSES guidelines for the prevention, detection, and management of iatrogenic urinary tract injuries during emergency digestive surgery. World J Emerg Surg. 2023;18(1):45. doi:10.1186/s13017-023-00513-8.
7. White C, Stifelman M. Ureteral reimplantation, psoas hitch, and Boari flap. J Endourol. 2020;34(S1):S25-S30. doi:10.1089/end.2018.0750.
8. Lashley DB, McAleer IM, Kaplan GW. Ipsilateral ureteroureterostomy for the treatment of vesicoureteral reflux or obstruction associated with complete ureteral duplication. J Urol. 2001;165(2):552-554. doi:10.1097/00005392-200102000-00067.
9. Lapointe SP, Barrieras D, Leblanc B, Williot P. Modified Lich-Gregoir ureteral reimplantation: experience of a Canadian center. J Urol. 1998;159(5):1662-1664. doi:10.1097/00005392-199805000-00085.
10. Soulier V, Scalabre AL, Lopez M, et al. Laparoscopic vesico-ureteral reimplantation with Lich-Gregoir approach in children: medium-term results of 159 renal units in 117 children. World J Urol. 2017;35(11):1791-1798. doi:10.1007/s00345-017-2064-y.
11. Ciancio G, Farag A, Gonzalez J, Vincenzi P, Gaynor JJ. Results of a previously unreported extravesical ureteroneocystostomy technique without ureteral stenting in 500 consecutive kidney transplant recipients. PLoS One. 2021;16(1):e0244248. doi:10.1371/journal.pone.0244248.
12. Alberts VP, Idu MM, Legemate DA, Laguna Pes MP, Minnee RC. Ureterovesical anastomotic techniques for kidney transplantation: a systematic review and meta-analysis. Transpl Int. 2014;27(6):593-605. doi:10.1111/tri.12301.
13. Zhao K, Lee M, Raver M, et al. "Techniques for ureteral reimplantation for distal disease." Urol Video J. 2024;24:100288. doi:10.1016/j.urolvj.2024.100288
14. Shakir NA, Zhao LC. "Robotic-assisted genitourinary reconstruction: current state and future directions." Ther Adv Urol. 2021;13:17562872211037111. doi:10.1177/17562872211037111
15. Walasek A, Lin J, Zhao L. "Minimizing variability: Standardized approach to retroperitoneal single-port robot-assisted ureteral reconstruction." UroPrecision. 2024;2(3):82-93. doi:10.1002/uro2.67
16. Rosenfeld J, Boehm D, Raikar A, et al. "A review of complications after ureteral reconstruction." Asian J Urol. 2024;11(3):348-356. doi:10.1016/j.ajur.2024.02.007