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Reconfigured Colon Ureteral Substitute

The reconfigured colon substitute applies the Yang-Monti principle of detubularization and transverse retubularization to a short colonic segment (about 3 cm) to bridge long ureteral defects. The resulting tube has near-ureteral caliber and minimal mucosal surface and is an option for selected patients when the classic ileal ureter and the Yang-Monti ileal ureter are unsuitable, particularly when small bowel is unavailable, provided a healthy, well-perfused, nonirradiated colonic segment can reach the defect; reduced renal reserve remains a concern with either bowel segment.[1][2][3]

Lineage​

  • 1996. Pope and Koch first reported a reconfigured ascending colon segment to replace a long ureteral defect.[3]
  • 2001. Ubrig, Waldner, and Roth described transverse retubularization of a 3 cm ascending or descending colon segment, harvested through a flank incision, in 4 patients (2 interposition grafts and 2 pyelo-colo-cutaneostomies).[2]
  • 2003. Ubrig and Roth reported 7 selected patients, including 3 solitary-kidney patients treated with a cutaneous conduit.[4]
  • 2012. Lazica et al. reported 14 patients, with follow-up of 52.4 months for the whole cohort and 95.8 months among the 6 survivors.[1]

Why Colon Instead of Ileum​

Colon is rarely used in its native (non-reconfigured) form because of its wide caliber and large mucosal surface. Reconfiguration reduces caliber and mucosal surface. Selection depends on bowel health, vascular reach and renal reserve; comparative clinical superiority over ileum has not been established:[1][2][4]

  • Anatomic proximity. Ascending colon lies adjacent to the right ureter, descending colon to the left, minimizing mesenteric mobilization.
  • Retroperitoneal access. Flank or pararectal incision, with minimal intraperitoneal dissection.
  • Renal insufficiency. Both ileal and colonic urine contact can impose an acid load. Do not select colon on an assumption of metabolic safety; assess renal reserve and alternatives carefully.[9]
  • After pelvic radiation. Confirm that the proposed colon segment and its vascular supply are outside damaged tissue.
  • When ileum is unavailable. Colon is an option after extensive ileal resection or other loss of usable ileum, although inflammatory bowel disease may also make colon unsuitable.
  • Caliber. After reconfiguration, the tube is ureter-sized and does not require tapering.
  • Access. A retroperitoneal approach may be possible in selected anatomy; lower morbidity than ileal substitution is unproven.

Surgical Technique​

The same fundamental principle as the Yang-Monti ileal ureter, with colon as the source segment:[1][2][3][4]

  1. Access. Flank or pararectal incision, predominantly retroperitoneal.
  2. Segment selection. Choose a 3 cm segment of ascending colon (right-sided defects) or descending colon (left-sided), immediately proximal to the ureteral defect to limit mesenteric mobilization. Preserve its mesenteric pedicle and confirm perfusion and reach before retubularization.[2][4]
  3. Bowel continuity. Restore continuity of the remaining colon with a well-perfused, tension-free bowel anastomosis.
  4. Detubularization. Open the segment along the antimesenteric border.
  5. Reconfiguration. Lay the opened segment flat into a rectangular mucosal strip.
  6. Retubularization. Tubularize transversely over a stent, converting the short wide segment into a longer narrow tube. A 3 cm colonic segment yields about 6–8 cm of tube.
  7. Anastomosis. Spatulated proximal end-to-end anastomosis to renal pelvis or proximal ureteral stump; distal anastomosis to the distal ureteral stump, bladder (with or without submucosal tunnel), or afferent limb of an ileal neobladder.[1]
  8. Stenting. Internal ureteral stent for several weeks postoperatively.

Variations​

  • Pyelo-colo-cutaneostomy. Two combined reconfigured colon segments anastomosed to skin function as a modified colon conduit when bladder reimplantation is not feasible.[2][4]
  • Double Monti sigmoid. Sigmoid-colon double-Monti tube combined with a Boari flap has been reported for total left ureteral substitution with stable split function at 3.25 yr.[6]

Indications​

When simpler options are insufficient and ileum is unsuitable, particularly:[1][2][3][4]

  • No satisfactory native-tissue or graft repair, with sufficient renal reserve to tolerate bowel interposition.
  • Prior pelvic irradiation sparing the colon.
  • Unavailable ileum, provided the selected colon is healthy and well vascularized.
  • Solitary kidney only after careful assessment of function and alternatives.
  • Upper and mid ureteral defects where the colon lies adjacent.
  • Need for cutaneous diversion as a pyelo-colo-cutaneostomy.

Common etiologies: iatrogenic injury, malignancy, retroperitoneal fibrosis, radiation strictures.[1][7]

Long-Term Outcomes​

Lazica 2012 — 14 patients; longer follow-up available in 6 survivors[1]​

The cohort included 10 interpositions and 4 modified cutaneous colon conduits; the reported results were not stratified by configuration.[1]

ParameterResult
Good renal function10/14 at median 52.4 months
Stent-free at longer follow-up6 surviving patients at median 95.8 months
Obstruction of ureteral replacementNone in the 6 survivors (no sign of obstruction)
Metabolic disordersNone
Mucus obstructionNone
Stricture or adhesive ileusNone
Reinterventions7 patients required 11 reinterventions
Procedure-related deathsNone

Ubrig & Roth 2003 — n = 7 (3 solitary kidneys, mean 23 mo follow-up)[4]​

No segment-related complications were reported during the small series' follow-up. The 3 solitary-kidney patients received cutaneous conduits.

Mixed intestinal substitution — Chung 2006, n = 56 (4 colonic, mean 6 yr)[7]​

In this 56-patient series, median creatinine was 1.0 mg/dL before and after substitution, and major complications affected 6/56 patients. Fifty-two received ileum alone, 2 colon alone and 2 ileum plus colon for bilateral replacement; outcomes for the four patients with a colonic segment were not reported separately.[7]

Complications​

ComplicationReported resultNotes
MetabolicNoneNone observed in this small cohort; metabolic risk remains possible, and its rate is unknown.[1][2]
Mucus obstructionNoneMinimal mucosal surface vs non-reconfigured bowel.[1]
Anastomotic strictureNone[1]
Urinary tract infection3 reported episodes; patient-level rate not specifiedAt 4 weeks, 3 months and 112 months.[1]
Prolonged stenting required4 reported cases; patient-level rate not specified[1]
Secondary drainage3 reported cases; patient-level rate not specified[1]
Bowel obstruction1/14 (7%)From peritoneal carcinosis, not the reconstruction.[1]
Ureteral fistula1 of 13 patients in the Ordorica mixed seriesOccurred in an irradiated patient, to a blind Hartmann pouch.[8]
Long-term malignancy of the bowel segmentIncidence unknown for this techniqueLate adenocarcinoma has been reported after other isolated colonic urinary diversions.[11]

Choosing the Bowel Segment​

The reconfigured colon and Yang-Monti ileal tube use less bowel length than a conventional ileal ureter, but add retubularization suture lines and depend on preserved mesenteric perfusion. Choose according to defect geometry, healthy bowel availability, prior operations and radiation, renal reserve, and surgeon experience. Oral mucosal graft ureteroplasty is a bowel-sparing option in selected anatomy; a meta-analysis of single-arm series reported graft repairs up to 8 cm, but mean stricture lengths differed between graft and ileal cohorts (3.73 versus 11.55 cm), preventing a comparative ranking and providing no colon-specific comparison.[10] Appendiceal onlay or interposition has been described for selected, mainly right-sided defects; a 2026 systematic review identified four retrospective appendiceal series (64 patients) with mean stricture lengths of 4.9–7.5 cm and 12–15 months of follow-up.[5][12]

Bowel substitution requires surveillance for obstruction, infection, renal decline and metabolic complications. Ileus, adhesive obstruction and incisional hernia have been reported in intestinal ureter series dominated by ileal repairs, without an established reconfigured-colon-specific rate.[5][7] The 2026 EAU trauma text advises avoiding intestinal interposition in patients with impaired renal function or known intestinal disease.[9] When bowel substitution is performed, follow-up includes serum chemistry to detect hyperchloremic metabolic acidosis.[9]

Onlay Variation​

Reconfigured colon (or ileum) can also be used as an onlay flap rather than a circumferential interposition: the strip is laid over a preserved but strictured ureteral plate (opened longitudinally) without complete resection, sparing native ureteral tissue and blood supply. Ordorica et al. reported mixed repairs in 13 patients and 16 ureters (13 ileal, 1 colonic and 2 appendiceal). The 14 remaining renal units drained after one patient required cystectomy for radiation-related fistula and another lost function in one renal unit.[8]

Special Populations​

  • Solitary kidney. All 3 solitary-kidney patients in the Ubrig & Roth series had no complications related to the colon segment.[4]
  • Cutaneous diversion needed. Pyelo-colo-cutaneostomy (two combined reconfigured colon segments to skin) functions as a modified colon conduit.[2][1]

See Also​

References​

1. Lazica DA, Ubrig B, Brandt AS, von Rundstedt FC, Roth S. Ureteral substitution with reconfigured colon: long-term followup. J Urol. 2012;187(2):542–548. doi:10.1016/j.juro.2011.09.156

2. Ubrig B, Waldner M, Roth S. Reconstruction of ureter with transverse retubularized colon segments. J Urol. 2001;166(3):973–976. doi:10.1016/s0022-5347(05)65876-4

3. Pope J, Koch MO. Ureteral replacement with reconfigured colon substitute. J Urol. 1996;155(5):1693–1695. doi:10.1016/s0022-5347(01)66166-4

4. Ubrig B, Roth S. Reconfigured colon segments as a ureteral substitute. World J Urol. 2003;21(3):119–122. doi:10.1007/s00345-003-0320-9

5. Xiong S, Zhu W, Li X, et al. Intestinal interposition for complex ureteral reconstruction: a comprehensive review. Int J Urol. 2020;27(5):377–386. doi:10.1111/iju.14222

6. Castellan M, Gosalbez R. Ureteral replacement using the Yang-Monti principle: long-term follow-up. Urology. 2006;67(3):476–479. doi:10.1016/j.urology.2005.09.005

7. Chung BI, Hamawy KJ, Zinman LN, Libertino JA. The use of bowel for ureteral replacement for complex ureteral reconstruction: long-term results. J Urol. 2006;175(1):179–183; discussion 183–184. doi:10.1016/S0022-5347(05)00061-3

8. Ordorica R, Wiegand LR, Webster JC, Lockhart JL. Ureteral replacement and onlay repair with reconfigured intestinal segments. J Urol. 2014;191(5):1301–1306. doi:10.1016/j.juro.2013.11.027

9. Waterloos M, Campos-Juanatey F, Hallscheidt P, et al. EAU Guidelines on Urological Trauma. Limited update, March 2026. Section 4.2.4.b.2.c (long-segment ureteral injury). Guideline

10. 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

11. Sterpetti AV, Costi U, Grande R, D'Ermo G, Sapienza P. "De novo secondary adenocarcinoma in the colon used as urinary diversion not in contact with the fecal stream: systematic review and meta-analysis." Ann Surg Oncol. 2020;27(8):2750-2759. doi:10.1245/s10434-020-08300-4

12. Ditonno F, Costantino S, Treccani LP, et al. "Autologous Tissue Substitutes for Ureteral Reconstruction: A Systematic Review of Surgical Techniques and Outcomes." Eur Urol Open Sci. 2026;86:30-41. doi:10.1016/j.euros.2026.02.007