Transureteroureterostomy

Transureteroureterostomy (TUU) is a second-line ureteral reconstruction in which an obstructed, injured, or otherwise unusable donor ureter is passed across the midline retroperitoneum and anastomosed end-to-side into the contralateral recipient ureter. It preserves renal drainage without bladder reconstruction or bowel substitution, but it carries a unique hazard: a complication at the recipient ureter can threaten the previously healthy contralateral excretory axis.^[1][2]

For ipsilateral ureter-to-ureter repair, see Ureteroureterostomy. For distal bladder-based salvage, see Ureteral Reimplantation and Boari Flap & Psoas Hitch. For longer substitution, see Ileal Ureter Substitution.

TransureteroureterostomyOriginal schematic · v2026-09-11 · Clinical review pending

A donor ureter crosses retroperitoneally to an end-to-side anastomosis with a suitable recipient ureter, avoiding tension and kinking. Planning depends on the vascular crossing, the health of the recipient ureter and the risk to both renal units. (Original WARWIKI schematic)

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Historical Position

TUU was described in the early 20th century and became an accepted reconstructive option through the experience of Hendren and Hensle, who reported 75 cases beginning in 1969. Their series, mostly pediatric, reported a low complication rate when tension, angulation and devascularization were avoided.^[3] Keeping the crossing retroperitoneal and choosing a normal recipient ureter are standard teaching.

Modern series confirm that TUU can be durable in adults and children, but its role remains selective. It is chosen when ipsilateral reconstruction, bladder-based repair, or bowel substitution would be worse for the patient.^[1][2][4]

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Indications

TUU is indicated when ipsilateral reconstruction is not feasible because of anatomy, tissue quality, prior failure, oncologic resection, radiation, bladder limitations, or the need for urinary diversion without bowel.^[1][2][4]

Benign disease

In the Mayo Clinic mixed-age series, benign disease accounted for 67% of cases.^[2] Benign indications include:

• failed ureteral reimplantation, especially after multiple prior procedures,
• undiversion from cutaneous ureterostomy or conduit back to native urinary tract,
• creation of a continent ureteral conduit for intermittent catheterization,
• massively dilated megaureter not amenable to standard reimplantation,
• ureteral necrosis or extensive devascularization,
• ureterocystoplasty when one ureter is used for bladder augmentation,
• salvage of failed ileal conduit with TUU and cutaneous ureterostomy.^[3][4][5]

Malignant disease

TUU is useful during radical pelvic surgery when unilateral distal ureter is resected with tumor and ipsilateral bladder-based repair is undesirable or impossible. Reported settings include colorectal, cervical, ovarian, and bladder malignancy, often after prior multimodal therapy.^{[6][7][8][9][10]}

Oncologic indications include:

• unilateral distal ureteral involvement during multivisceral pelvic resection,
• renal-sparing radical resection when ureteroneocystostomy would be under tension or in an irradiated field,
• palliative urinary diversion for advanced pelvic malignancy, often with terminal loop cutaneous ureterostomy.^[11][12]

Iatrogenic ureteral injury

TUU is considered when the injured ureter cannot be reconstructed ipsilaterally because of extensive distal ureteral loss, hostile pelvis, prior radiation, inadequate bladder capacity, or failed reimplantation.^[1][6]

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Contraindications

The recipient ureter is the gatekeeper. If it is abnormal, TUU risks converting unilateral disease into bilateral obstruction.

Absolute contraindications

• recipient ureter stricture, tumor involvement, stone disease, or poor drainage,
• clinically important vesicoureteral reflux into the recipient system,
• bilateral ureteral disease when a reliable recipient drainage path cannot be established or reconstructed at the same operation,^[3]
• retroperitoneal fibrosis or hostile crossing bed that would compress the donor ureter,
• inability of the donor ureter to reach the recipient ureter without tension.

Relative contraindications

• history of nephrolithiasis, with attention to current stone burden and recipient ureter patency; postoperative stones occurred in 8 of 63 patients (12.7%) in the Mayo series,^[2]
• prior pelvic radiation, especially with malignancy and chemotherapy,
• solitary functional renal unit on the recipient side,
• active infection, urinoma, or unstable patient who needs drainage first,
• uncertain oncologic margin or need for further pelvic radiation across the planned crossing.

Prior radiation is not an absolute contraindication. In the Mayo Clinic series, 25.4% had received radiation, but the reported complication association was with diversion for malignancy.^[2]

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Preoperative Planning

TUU planning should prove three things before incision:

1. The donor kidney is worth saving. Use renal functional imaging, serum creatinine, infection history, symptoms, and patient goals.
2. The recipient ureter is normal. Evaluate contralateral drainage, stone history, reflux risk, malignancy involvement, and prior surgery.
3. The donor ureter can cross safely. Cross-sectional imaging and prior operative history should suggest that a straight, noncompressive retroperitoneal route is possible.

Useful studies:

• CT urogram or MR urogram for anatomy, tumor, radiation field, stones, and hydronephrosis,
• retrograde or antegrade pyelography to define donor and recipient ureteral caliber,
• renal scan when renal functional salvage is uncertain,
• cystoscopy when bladder involvement, prior reimplantation, or diversion planning matters.

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Surgical Technique

TUU can be performed open, laparoscopically, or retroperitoneoscopically. Open TUU remains the most established approach for trauma, malignancy, and complex pediatric reconstruction.^[1][2][13]

Exposure

• A midline transperitoneal incision is common for open TUU because it exposes both ureters and the retroperitoneal crossing route.
• Open the retroperitoneum bilaterally.
• Identify the diseased donor ureter and the healthy recipient ureter.
• Keep the recipient ureter mobilization minimal to preserve blood supply.

Donor ureter preparation

1. Mobilize the donor ureter proximally with its adventitia intact.
2. Divide the donor ureter proximal to the diseased segment, retaining a viable proximal end for the crossing anastomosis.
3. Ligate or excise the distal stump depending on disease and contamination.
4. Spatulate the donor ureter enough to match the recipient ureterotomy.
5. Confirm that the donor ureter can reach across the midline without stretch.

Retroperitoneal crossing

The donor ureter is brought across the midline through a wide, straight retroperitoneal route. For left-to-right crossings, the ureter passes posterior to the inferior mesenteric artery and sigmoid mesocolon or through a safe sigmoid-mesentery window, routed above the level of the inferior mesenteric artery to avoid acute angulation at that level. For right-to-left crossings, the route must avoid compression by the sigmoid mesentery.^[1][10][14]

Technical goals:

• no tension,
• no angulation,
• no twist,
• no mesenteric compression,
• no sharp turn at either end of the crossing,
• no devascularization from excessive donor mobilization.

Recipient ureterotomy and anastomosis

1. Make a longitudinal ureterotomy, usually 1.5-2 cm, on the medial or anteromedial recipient ureter.
2. Perform a mucosa-to-mucosa end-to-side anastomosis using interrupted or running absorbable suture, commonly 4-0 or 5-0.
3. Stent the donor ureter across the anastomosis. Some surgeons also stent the recipient ureter.
4. Retroperitonealize the anastomosis and cover with peritoneum or omentum when possible.
5. Place a retroperitoneal drain.
6. Keep the ureteral stent until radiological evidence of anastomotic healing, as described in a 253-patient TUU series.^[15]

In one pelvic malignancy series, all three anastomotic complications (two leaks, one stenosis) occurred in patients operated on without stents. They resolved with percutaneous nephrostomy, and the authors recommend stenting.^[9] Another series used stents selectively.^[10]

The TUU bargain. TUU avoids bladder or bowel reconstruction, but it creates shared dependence on the recipient ureter. A narrow recipient ureterotomy, kinked crossing, ischemic recipient ureter, or unstented tenuous anastomosis can threaten both renal units.

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Surgical Approaches

Approach	Role	Notes
Open	Standard approach for complex pediatric, trauma, oncologic, and reoperative cases	Most outcome data; best exposure and recipient ureter control[1][2][3]
Laparoscopic	Selected pediatric or benign cases	Piaggio and Gonzalez reported a 4-trocar transperitoneal pediatric technique with discharge on postoperative days 2-4[13]
Retroperitoneoscopic	Selected salvage diversion cases	Kaiho et al. described retroperitoneoscopic TUU with cutaneous ureterostomy to salvage failed ileal conduit diversion[5]
TUU plus cutaneous ureterostomy	Frail, hostile abdomen, palliative malignancy, failed conduit	Single-stoma cutaneous drainage can avoid bowel interposition[11][12]

Robotic TUU is conceptually feasible, but the evidence base remains much smaller than open TUU and far smaller than robotic reimplantation, Boari flap, or oral mucosal graft ureteroplasty.

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Directionality

TUU can be performed right-to-left or left-to-right. In the Mayo Clinic series, 47.6% were right-to-left and 52.4% were left-to-right.^[2]

Practical differences:

• For either direction, define the crossing level and mesenteric relationships from the individual anatomy; neither direction is universally easier.
• Right-to-left crossing must respect the sigmoid mesentery and avoid compression or angulation behind it.
• The direction should be chosen by donor reach, recipient health, disease field, and future risk to the recipient side.

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Outcomes

Adult and mixed-age cohorts

Series	Population	Outcomes
Iwaszko et al. 2010	63 patients, ages 1-83, mean follow-up 5.8 years	96.4% patency in 54/56 with imaging; mean calculated GFR was 62.8 mL/min preoperatively and 71.8 mL/min at the most recent assessment; complications 23.8%; subsequent intervention 6/58 followed (10.3%); stones in 8/63 (12.7%)[2]
Sugarbaker et al. 2003	11 patients with pelvic malignancy	1 major complication requiring ureteronephrectomy of the crossed system[10]
Richter et al. 2007	15 patients during multivisceral resection	12/15 uncomplicated; 3 unstented patients developed leak or stenosis, resolved with percutaneous nephrostomy[9]
Joung et al. 2008	28 TUU vs 17 mixed ipsilateral reconstructions for non-urologic pelvic malignancy	No difference detected in hydronephrosis, azotemia, urine leak, or pyelonephritis in this nonrandomized comparison; voiding dysfunction tended to be more frequent after ureteroneocystostomy with psoas hitch[8]
Strup et al. 1996	10 complex ureteral problems	1 stricture and 1 leak; good renal function at mean 77.9-month follow-up[6]

Pediatric

Series	Population	Outcomes
Hendren and Hensle 1980	75 cases, mostly pediatric	Low complication rate; many patients had no other reconstructive path[3]
Mure et al. 2000	69 childhood/adolescent TUUs; 63 followed at least 1 year (median 6 years)	50/63 (79.4%) good results with no upper tract dilation; all initially normal donor ureters remained normal; 78.4% of dilated donor ureters improved or normalized; serious complications 4.3%[4]
Piaggio and Gonzalez 2007	3 laparoscopic pediatric TUUs	All procedures completed; one transient urine leak; all clinically well at mean 6-month follow-up; discharge postoperative days 2–4[13]

TUU with cutaneous ureterostomy

Series	Setting	Outcomes
Rainwater et al. 1991	67 patients over 25 years	Renal function improved or remained stable in 75%; common complications included urine leakage, stomal stenosis, and calculus formation[11]
Thrasher and Wettlaufer 1991	8 patients with advanced pelvic malignancy	No complications; hydronephrosis improved and creatinine stabilized; mean survival 5 months[12]

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Complications

Complication	Incidence Signal	Management
Overall postoperative complications	23.8% in the Mayo mixed-age series, more common with diversion for malignancy[2]	Depends on complication and oncologic context
Anastomotic leak	Two leaks among 15 pelvic malignancy TUUs; both affected patients were initially unstented[9]	Drainage, stent, percutaneous nephrostomy
Anastomotic stricture or obstruction	3.6% long-term obstruction signal in Mayo imaging cohort[2]	Balloon dilation, stent, revision, nephrostomy
Stone disease	12.7% in long-term Mayo follow-up[2]	Surveillance, ureteroscopy, PCNL, spontaneous passage
Ischemic stenosis of common trunk	Rare but serious pediatric complication[4]	Reoperation or diversion
Renal deterioration requiring nephrectomy	Rare, about 1.5% in pediatric series[4]	Nephrectomy when salvage fails
Stomal stenosis with cutaneous ureterostomy	Reported in TUU plus cutaneous ureterostomy series[11]	Stomal revision, dilation, or diversion revision

The Mayo study observed more complications in patients undergoing diversion for malignancy.^[2]

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Renal Function

Across series, TUU generally preserves renal function when the recipient ureter remains patent:

• In the retrospective Mayo mixed-age series, mean calculated GFR was 62.8 mL/min preoperatively and 71.8 mL/min at latest follow-up in the imaged cohort (p = 0.04).^[2]
• Kawamura pelvic malignancy series: median eGFR was maintained after reconstruction.^[7]
• Rainwater TUU plus cutaneous ureterostomy series: renal function improved or remained stable in 75%.^[11]
• Pediatric Mure series: all initially normal donor ureters remained normal, and most dilated donor ureters improved or normalized.^[4]

TUU preserves function when both kidneys drain through a healthy recipient ureter without compression, reflux-related injury, stone obstruction or anastomotic narrowing.

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Advantages

• Avoids bowel interposition and its mucus, metabolic, stone, and bowel-harvest morbidity.
• Preserves bladder integrity and can avoid cystotomy.
• Maintains urethral voiding when the bladder is usable.
• Can shorten operative time compared with ileal conduit in palliative settings.^[12]
• Can be combined with cutaneous ureterostomy, reimplantation, continent diversion, or undiversion.^[3][4][11]
• Works in either right-to-left or left-to-right direction when anatomy permits.^[2]

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Limitations

• Risks the contralateral renal unit by making it the recipient drainage path.
• Requires reliable recipient ureter drainage, either already present or established by concomitant reconstruction.^[3][4]
• Requires enough donor ureter length to cross without tension.
• Is poorly suited to bilateral ureteral disease, retroperitoneal fibrosis, recipient-side stones, or recipient ureter tumor.
• Long-term stone risk is real and requires surveillance.^[2]
• Minimally invasive TUU data remain limited compared with open TUU.

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Comparison With Alternatives

Feature	TUU	Ureteroneocystostomy / Psoas Hitch	Ileal Conduit or Ileal Ureter
Best use	Ipsilateral reconstruction not feasible; recipient ureter normal	Distal ureteral injury or stricture with usable bladder	Bladder absent/nonfunctional, long ureteral loss, hostile native ureter
Bladder surgery	Avoided for isolated TUU; may be needed for concomitant reimplantation or ureterocystoplasty[3][4]	Required	Often bypassed or reconstructed with bowel
Bowel harvest	Avoided	Avoided	Required
Voiding function	Preserved if bladder intact	Usually preserved, but pelvic reconstruction may affect voiding	Diversion or bowel-substitution physiology
Contralateral risk	Yes	No	No direct recipient-ureter risk
Metabolic/mucus burden	None	None	Present with bowel
Main limitation	Recipient ureter becomes shared risk point	Requires bladder capacity and mobility	Bowel morbidity and long-term metabolic surveillance

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Special Settings

Oncologic resection

TUU can allow renal-sparing radical pelvic resection when a distal ureter must be removed en bloc with tumor. It is particularly useful when ureteroneocystostomy would land in an irradiated or scarred bladder field, or when preserving normal voiding is important.^{[7][8][9][10]}

Palliative diversion

In advanced pelvic malignancy with short life expectancy or hostile abdomen, TUU with terminal loop cutaneous ureterostomy can decompress both kidneys through one stoma while avoiding bowel interposition.^[12]

Pediatric reconstruction

TUU remains useful after multiple failed reimplantations, for undiversion, for complex megaureter, and for selected continent catheterizable reconstructions.^[3][4]

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Operative Pearls

• Treat recipient ureter selection as a principal decision.
• Cross the donor ureter in a straight retroperitoneal path; no kinks, twists, or mesenteric pinch points.
• Keep the recipient ureter minimally mobilized.
• Make the recipient ureterotomy generous enough to avoid a functional bottleneck.
• Stent the donor side across the anastomosis; consider recipient stenting in tenuous repairs.
• Select a well-perfused recipient segment and crossing bed outside severe fibrosis where possible; do not sacrifice reach or vascularity to meet a fixed anatomic level.
• Counsel patients that a successful TUU can be durable, but failure may affect both kidneys.

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References

1. 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.

2. Iwaszko MR, Krambeck AE, Chow GK, Gettman MT. Transureteroureterostomy revisited: long-term surgical outcomes. J Urol. 2010;183(3):1055-1059. doi:10.1016/j.juro.2009.11.031.

3. Hendren WH, Hensle TW. Transureteroureterostomy: experience with 75 cases. J Urol. 1980;123(6):826-833. doi:10.1016/s0022-5347(17)56151-0.

4. Mure PY, Mollard P, Mouriquand P. Transureteroureterostomy in childhood and adolescence: long-term results in 69 cases. J Urol. 2000;163(3):946-948. doi:10.1016/s0022-5347(05)67859-7.

5. Kaiho Y, Ito A, Numahata K, Ishidoya S, Arai Y. Retroperitoneoscopic transureteroureterostomy with cutaneous ureterostomy to salvage failed ileal conduit urinary diversion. Eur Urol. 2011;59(5):875-878. doi:10.1016/j.eururo.2009.06.003.

6. Strup SE, Sindelar WF, Walther MM. The use of transureteroureterostomy in the management of complex ureteral problems. J Urol. 1996;155(5):1572-1574. doi:10.1016/s0022-5347(01)66129-9

7. Kawamura J, Tani M, Sumida K, et al. The use of transureteroureterostomy during ureteral reconstruction for advanced primary or recurrent pelvic malignancy in the era of multimodal therapy. Int J Colorectal Dis. 2017;32(1):135-138. doi:10.1007/s00384-016-2672-9.

8. Joung JY, Jeong IG, Seo HK, et al. The efficacy of transureteroureterostomy for ureteral reconstruction during surgery for a non-urologic pelvic malignancy. J Surg Oncol. 2008;98(1):49-53. doi:10.1002/jso.21086.

9. Richter S, Kollmar O, Lindemann W, Schilling MK. Transureteroureterostomy allows renal sparing radical resection of advanced malignancies with rectosigmoid invasion. Int J Colorectal Dis. 2007;22(8):949-953. doi:10.1007/s00384-006-0235-1.

10. Sugarbaker PH, Gutman M, Verghese M. Transureteroureterostomy: an adjunct to the management of advanced primary and recurrent pelvic malignancy. Int J Colorectal Dis. 2003;18(1):40-44. doi:10.1007/s00384-002-0399-2.

11. Rainwater LM, Leary FJ, Rife CC. Transureteroureterostomy with cutaneous ureterostomy: a 25-year experience. J Urol. 1991;146(1):13-15. doi:10.1016/s0022-5347(17)37702-9.

12. Thrasher JB, Wettlaufer JN. Transureteroureterostomy and terminal loop cutaneous ureterostomy in advanced pelvic malignancies. J Urol. 1991;146(4):977-979. doi:10.1016/s0022-5347(17)37979-x.

13. Piaggio LA, Gonzalez R. Laparoscopic transureteroureterostomy: a novel approach. J Urol. 2007;177(6):2311-2314. doi:10.1016/j.juro.2007.02.004.

14. Ulchaker JC, Sankari BR. Ureteral substitution. In: Montague DK, Gill IS, Angermeier KW, Ross JH, eds. Textbook of Reconstructive Urologic Surgery. Informa Healthcare; 2008:182–184.

15. Noble IG, Lee KT, Mundy AR. "Transuretero-ureterostomy: a review of 253 cases." Br J Urol. 1997;79(1):20-23. doi:10.1046/j.1464-410x.1997.02794.x