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Ureteroureterostomy

Ureteroureterostomy (UU) is a ureteral reconstruction in which healthy ureter is anastomosed to healthy ureter after excision, bypass, or rerouting of a diseased segment. In its classic form, UU is an ipsilateral end-to-end repair after ureteral transection or short stricture excision. In duplex systems, it is usually an ipsilateral end-to-side anastomosis from the abnormal moiety ureter into the healthy recipient ureter. When the damaged ureter is routed across the midline into the contralateral ureter, the operation becomes transureteroureterostomy.[1][2][3][5]

For broader selection logic, see Upper Tract Reconstruction Principles. For distal escalation when the ureter cannot reach without tension, see Ureteral Reimplantation and Boari Flap & Psoas Hitch.

Configurations​

ConfigurationTypical UseCore Idea
Ipsilateral end-to-end UUShort upper or mid-ureteral transection, traumatic injury, iatrogenic injury, benign strictureExcise unhealthy ureter and rejoin the two healthy ends over a stent
Ipsilateral end-to-side UUDuplex collecting system with refluxing or obstructed moiety ureterImplant the donor ureter into the healthy recipient ureter while preserving the native ureterovesical junction
TransureteroureterostomyIpsilateral reconstruction not feasible because of hostile field, inadequate distal ureter, radiation, or bladder limitationsBring the affected ureter across the midline and anastomose it end-to-side into the contralateral ureter
PyeloureterostomySelected duplex or proximal salvage anatomyAnastomose pelvis or upper-pole pelvis to ureter when ureter-to-ureter geometry is unfavorable[4]

The shared rule is that the recipient ureter must be healthy, well vascularized, and large enough to accept a wide anastomosis without compromising drainage of either renal unit.

Indications​

Ureteral injury​

UU is a first-line repair for complete upper or mid-ureteral transection when the ends can be brought together without tension.[1][24] The American College of Surgeons best-practice guidance places ureteroureterostomy as the preferred reconstruction for injuries proximal to the iliac vessels; lower-third injuries usually favor ureteroneocystostomy with or without psoas hitch or Boari flap.[1] AUA likewise recommends primary repair over a stent for injuries proximal to the iliac vessels and ureteral reimplantation or primary repair over a stent for distal injuries, when possible (Statements 12a–12b; Recommendation, Grade C).[24] For a ureteral injury recognized after a delay when no laparotomy is planned, ACS 2025 advises retrograde stenting or percutaneous nephrostomy for initial urinary drainage.[1]

Indications include:

  • complete upper or mid-ureteral transection,
  • incomplete transection or longitudinal injury suitable for primary repair over a stent,
  • postoperative iatrogenic injury when the distal stump is intact,
  • selected gynecologic, colorectal, urologic, or emergency-surgery injuries after adequate debridement,
  • radiotherapy-associated stenosis only when tissue quality and length remain favorable.[1][2][6][7]

Benign ureteral stricture​

Ipsilateral end-to-end UU is best for a short, well-demarcated stricture of the proximal or mid ureter. It is less attractive when the stricture is long, ischemic, irradiated, multifocal, or distal enough that reimplantation is simpler and safer.[12][13] One chapter author describes a spatulated repair as feasible for a stricture up to roughly 3-4 cm when mobilization permits tension-free reach and adequate vascularity.[21]

Suitable stricture settings include:

  • congenital midureteral stricture or pediatric midureteral obstruction,[11]
  • fibroepithelial polyp with segmental narrowing,
  • retrocaval ureter after ureteral rerouting,
  • short post-ureteroscopy or post-stone-surgery stricture,
  • short benign stricture after failed endoscopic management.

Duplex collecting systems​

Ipsilateral end-to-side UU is an established pediatric option for complete duplication when the pathologic moiety ureter drains a functional or salvageable renal segment and the recipient ureter is normal.[3][4]

Common duplex indications:

  • vesicoureteral reflux associated with complete duplication,
  • obstructing ectopic ureterocele,
  • ectopic obstructed upper-pole ureter,
  • massively dilated donor ureter when size mismatch can be handled with tailored spatulation,
  • upper-pole preservation when heminephrectomy would sacrifice meaningful function.[3][8][9][10]

Ipsilateral lower-pole reflux is a caution: UU preserves the native ureterovesical junction, so lower-pole reflux may persist unless treated separately.[9][10]

Retrocaval ureter​

A retrocaval (circumcaval) ureter is rerouted anterolateral to the vena cava, with the reconstruction adapted to the actual anatomy encountered. If the ureter encircles the cava, dismemberment proximal and distal to the circumcaval segment and reanastomosis anterolateral to the cava is described; if it does not encircle the cava, ureterolysis alone without division may suffice. A densely adherent circumcaval segment has also been described as left in situ, dividing the ureter above and below it and completing the ureteroureterostomy with the healthy ends brought anterolateral to the cava. In laparoscopic and robotic descriptions, a double-J stent is placed cystoscopically, the ureter is mobilized off the cava and divided distal to the dilated segment (with excision of redundant dilated or stenotic tissue when present), the ends are transposed anterolateral to the cava and spatulated approximately 1.5-2 cm on opposite sides, and the anastomosis is completed over the stent without tension, with a drain left and the stent generally removed at 4-6 weeks. These strategies come from small case series and technical reports without a comparative study; adapt the extent of mobilization and rerouting to the anatomy found at operation.[22][23]

Renal transplantation​

Ureteroureterostomy can replace ureteroneocystostomy in selected pediatric renal transplants, especially when the donor ureter is short, the bladder is augmented or neurogenic, bladder capacity is poor, or prior reimplantation has failed.[14]

Malignancy (segmental ureterectomy)​

For a proximal or mid-ureteral upper tract urothelial carcinoma amenable to a kidney-sparing approach, segmental ureterectomy with primary ureteroureterostomy (or, for a more proximal tumor, ureterocalicostomy) can preserve a functional ipsilateral renal unit. NCCN includes excision followed by ureteroureterostomy for selected low-grade mid-ureteral tumors and generally directs high-grade mid-ureteral lesions to nephroureterectomy.[25] AUA/SUO 2023 recommends nephroureterectomy or segmental ureterectomy for surgically eligible high-risk UTUC . Its discussion describes the most suitable proximal or mid-ureteral candidates for primary ureteroureterostomy as having small, unifocal tumors, typically 1 cm or smaller, with 2 cm or less of ureter requiring resection. These AUA/SUO criteria apply to oncologic selection for UU.[20]

Oncologic technique differs from the benign repair above. Ligate the ureter proximal to (and, where feasible, distal to) the tumor before manipulation to limit tumor showering, and avoid handling or opening the tumor-bearing segment. AUA/SUO's ureterectomy discussion calls for frozen-section assessment of both proximal and distal margins to ensure a complete resection with negative margins. Re-resect a positive margin. AUA/SUO recommends regional lymphadenectomy for high-risk UTUC at ureterectomy .[20] For eligible patients undergoing segmental ureterectomy, it also recommends a single perioperative intravesical chemotherapy dose to reduce bladder recurrence ; the supporting randomized trials enrolled nephroureterectomy patients.[20] Primary ureteroureterostomy after tumor excision is technically more demanding than for a benign stricture because the resected segment limits ureteral mobility and a tension-free anastomosis is harder to achieve; a tension-reducing maneuver or an alternative reconstruction may be needed. Comparative retrospective series report similar oncologic outcomes after segmental ureterectomy and nephroureterectomy, with inherent differences in patient selection.[20]

Patient Selection​

The operation succeeds when it repairs a short problem with healthy, mobile ureter. It fails when it is forced to bridge a long gap, devascularized tissue, or a hostile distal field.

Favor UUFavor Another Reconstruction
Short defect after debridementLong-segment ureteral loss
Healthy adventitia and preserved blood supplyRadiation fibrosis or ischemic ureter at the planned anastomosis
Upper or mid-ureteral injuryDistal lower-third injury better treated with reimplantation
Tension-free reach after limited mobilizationNeed for excessive ureteral mobilization or stretch
Normal recipient ureter in duplex systemRecipient ureter reflux, obstruction, or poor caliber
Stable patient and controlled contaminationDamage-control setting requiring nephrostomy or external drainage

If a tension-free repair is not possible after modest mobilization, escalate rather than forcing the anastomosis. Options include ureteral reimplantation, psoas hitch, Boari flap, buccal mucosa graft onlay, appendiceal onlay or interposition, ileal ureter, transureteroureterostomy, or renal autotransplantation depending on location and length.[12] In unstable or contaminated emergency settings, source control and urinary diversion take priority over definitive reconstruction.[17]

Core Surgical Principles​

Successful UU follows the same reconstructive rules emphasized in genitourinary injury guidance and emergency-surgery urinary-tract injury guidelines:[1][2]

  1. Debride to viable ureter. Excise crushed, cauterized, ischemic, or scarred tissue until the ends bleed and hold sutures.
  2. Preserve adventitia. Ureteral blood supply is longitudinal and periureteral; avoid skeletonizing the ureter.
  3. Mobilize only enough. Over-mobilization can create the very ischemia the operation is trying to solve.
  4. Spatulate both ends. Spatulating the two ends on opposite sides creates a wide oblique anastomosis that resists circumferential narrowing.
  5. Sew mucosa to mucosa. Use fine absorbable sutures, commonly 4-0 or 5-0 depending on size and approach.
  6. Stent according to setting. For ureteral injury proximal to the iliac vessels, place a ureteral stent across an end-to-end repair when feasible.[24] In selected children having open distal end-to-side UU for a duplicated system without lower-pole reflux, stenting can be individualized; a retrospective multicenter series used double-J stents in 56/127 (44%).[27]
  7. Make it watertight and tension-free. A perfect-looking anastomosis under stretch is a future stricture.
  8. Drain and cover. Place a drain when leak risk matters and cover with peritoneum or omentum when available.

For a partial longitudinal injury, the laceration can be repaired transversely over a stent in a Heineke-Mikulicz fashion to avoid narrowing.[1]

Ipsilateral End-to-End Technique​

Exposure​

  • Expose the injured or strictured ureter through open, laparoscopic, or robotic access.
  • Identify healthy ureter above and below the lesion before transection.
  • Preserve periureteral adventitia and avoid circumferential stripping beyond what is necessary.
  • Obtain proximal and distal control in trauma or leak settings.

Excision and preparation​

  1. Excise the diseased segment completely.
  2. Confirm brisk bleeding and healthy mucosa at each end.
  3. Mobilize the ureter only enough for a tension-free apposition.
  4. Spatulate the proximal and distal ends on opposite sides.
  5. Check orientation carefully; rotation is easy in minimally invasive repairs.

Anastomosis​

  1. Place stay sutures at the spatulation apices.
  2. Sew the posterior wall with interrupted or running absorbable suture.
  3. Insert a double-J stent across the repair.
  4. Complete the anterior wall without narrowing the lumen.
  5. Test visually for tension, kinking, and twisting.
  6. Place a drain when there was urinoma, contamination, reoperative dissection, or tenuous tissue.

Length rule. The limiting factor is the gap after full debridement to healthy ureter. A 2 cm injury can become a 4 cm reconstruction once cautery damage and scar are removed.

Ipsilateral End-to-Side Technique for Duplex Systems​

End-to-side UU in duplex systems transfers drainage from a diseased donor ureter into a healthy recipient ureter while preserving the recipient ureterovesical junction. It avoids bladder dissection, avoids creating a new antireflux tunnel, and can preserve upper-pole function.[3][4][9]

Core steps:

  1. Identify donor and recipient ureters; confirm recipient ureter health and orientation.
  2. Mobilize the donor ureter distally enough to prevent tension, but leave a short, safe distal stump when complete excision would risk pelvic injury.
  3. Transect and spatulate the donor ureter.
  4. Create a longitudinal ureterotomy on the recipient ureter.
  5. Sew a wide end-to-side mucosa-to-mucosa anastomosis.
  6. Stent one or both ureters depending on size, surgeon preference, and reconstruction geometry.
  7. Confirm no kinking of the recipient ureter and no obstruction to the lower-pole moiety.

Large donor-to-recipient size mismatch is not by itself a contraindication. In the classic 100-UU pediatric series, significant ureteral size disparity greater than 2:1 was common and did not preclude success.[3]

Distal stump management​

A retained distal ureteral stump is usually left to avoid unnecessary pelvic morbidity, but it can become symptomatic. In a retrospective series of 74 patients after proximal ureteroureterostomy, Lee et al. reported reoperation for stump infection in 9 (12.2%), at a median 2.4 years. Larger preoperative upper-pole ureter diameter was associated with stump infection.[18]

Surgical Approaches​

ApproachBest FitEvidence Signal
OpenStable trauma patient needing reconstruction, emergency exploration or complex reoperative fieldMost established; preferred when exposure, speed, and vascular control matter[1][2]
LaparoscopicBenign strictures and selected midureteral obstructionSimmons et al. reported a retrospective mixed cohort of UU, reimplantation and Boari flap (12 laparoscopic, 34 open), with less blood loss and shorter hospitalization after laparoscopy[13]
Robot-assistedBenign strictures, duplex anomalies, distal non-neoplastic lesions in experienced handsWristed suturing supports precise intracorporeal UU; a 2025 review of 7 retrospective studies (116 patients) of laparoscopic and robotic UU for non-neoplastic distal lesions reported 81.8% to 100% success across varying definitions, mainly at short or intermediate follow-up[7][12]
Endoscopic recanalization and UUHighly selected obliterated segmentsTsai et al. restored continuity in 10/10 attempts (9 patients; mean follow-up 16 months); three developed strictures requiring dilation, and one ultimately needed reimplantation after dilation failed[16]

In pediatric UU, a network meta-analysis of seven retrospective studies (277 children) found no clear difference in success or complications among open, laparoscopic, and robotic approaches, but confounding posed serious risk of bias.[26] If the ureter is ischemic, under tension, or too long a defect for direct repair, minimally invasive access should not be used to justify an undersized reconstruction.

Outcomes by Indication​

Injury and benign stricture​

Minimally invasive UU for non-neoplastic distal ureteral lesions has emerged as a robotic-era alternative to routine reimplantation in carefully selected cases. In a 2025 review of 7 retrospective studies and 116 patients, success ranged from 81.8% to 100%, using varying definitions and mostly short or intermediate follow-up.[7]

Postoperatively detected lower ureteral injuries are usually managed with reimplantation, but UU can work when the distal stump is intact. In a retrospective series of 9 women with an intact distal stump on retrograde pyelography, Paick et al. reported resolution of hydronephrosis and fistula in all, with no complications at a mean 33.7-month follow-up.[6]

Duplex systems​

The largest classic pediatric experience included 100 ureteroureterostomies in 94 children (mean follow-up 33 months).[3] The authors reported 94% success among evaluated kidneys, defined as no reflux or obstruction and a patent anastomosis: 51/53 for reflux, 21/23 (91%) for ureterocele, and 17/18 (94%) for ectopic obstructed upper-pole ureter.[3] Four kidneys were lost to postoperative evaluation, and 23 underwent recipient-ureter reimplantation with UU.[3] Later series reinforced that severe dilation or size mismatch should not automatically exclude UU when the recipient ureter is healthy.[9]

In a 2025 pediatric cohort, 42/78 operated patients met imaging and ≥3-year follow-up criteria. At median 60 months, 41/42 (98%) had resolved, improved or stable operated-moiety dilation; recipient-moiety hydronephrosis was newly present in 3/42 (7%), all asymptomatic.[15] In a retrospective cohort of 42 children with duplex anomalies evaluated a median 60 months after UU, the authors considered yo-yo reflux clinically irrelevant.[15]

Renal transplantation​

In selected pediatric renal transplants, UU can avoid a difficult bladder. Penna et al. reported 23 primary UUs among 213 transplants and 2 additional salvage UUs. Two leaks occurred across the 25 procedures (8%); no allografts were lost.[14]

Transureteroureterostomy​

TUU is a different operation and should be reserved for scenarios where ipsilateral repair is not feasible. In the 63-patient retrospective series by Iwaszko et al. (mean follow-up 5.8 years), TUU was patent in 54/56 (96.4%) patients with follow-up imaging; mean calculated GFR was 62.8 mL/min preoperatively and 71.8 mL/min at the most recent assessment, and stone disease developed in 8/63 (12.7%).[5]

Postoperative Follow-Up​

After UU, assess symptoms and image the upper tract for recurrent obstruction. After segmental ureterectomy with UU for UTUC, AUA/SUO 2023 advises risk-stratified cystoscopy and upper-tract imaging, with early upper-tract endoscopy .[20] In a retrospective single-center cohort of 136 patients undergoing 144 mixed ureteral reconstructions, renal ultrasound was obtained at 3 and 12 months; persistent symptoms or worsening hydronephrosis prompted nuclear renal scan or ureteroscopy.[28]

Complications​

ComplicationNotes
Urinary leak or prolonged drain outputMost common issue in the pediatric duplex series[3]
Ureteral strictureIn Tsai et al.'s endoscopic recanalization series (9 patients, 10 ureteral segments), 3 patients required balloon dilation for stricture and 1 ultimately required reimplantation; mean follow-up was 16 months[16]
Recipient ureter obstructionDuplex end-to-side UU can theoretically narrow or kink the recipient ureter; mid-term de novo hydronephrosis was uncommon and asymptomatic in the 2025 cohort[15]
Distal ureteral stump UTIReoperation for stump infection in 9/74 (12.2%) after proximal UU in one retrospective study; larger preoperative upper-pole ureter diameter was associated with infection[18]
De novo VURIn Chacko et al.'s retrospective duplex series, 2/11 children undergoing UU alone developed de novo ipsilateral reflux; assess lower-pole reflux before standalone UU[9]
UrinomaTwo transient urinomas requiring drainage occurred after combined UU and recipient-ureter reimplantation without indwelling stents in one retrospective series[9]
Stone formationParticularly relevant after TUU; long-term TUU series reported 12.7% stone disease[5]

Comparison With Alternatives​

FeatureUreteroureterostomyUreteroneocystostomyTransureteroureterostomy
Best locationUpper or mid ureter; selected distal lesionsDistal ureterIpsilateral field unusable
Bladder surgeryAvoidedRequiredAvoided
Native antireflux mechanismPreservedRecreated or modifiedPreserved at the recipient ureterovesical junction; both renal units share recipient drainage
Key requirementHealthy ureter and tension-free reachAdequate bladder capacity and mobilityHealthy contralateral ureter and safe midline crossing
Main limitationGap length and ureteral vascularityBladder limitations, cystotomy, possible hitch/flap needPuts both renal units at some risk if recipient ureter obstructs
Typical useTrauma, iatrogenic injury, short benign stricture, duplex anomalyDistal injury or strictureSalvage when ipsilateral repair or bladder-based repair is poor

Advantages​

  • Preserves bladder integrity and avoids cystotomy in selected cases.
  • Maintains the native ureterovesical junction and antireflux mechanism.
  • When the distal stump is intact, UU can avoid bladder dissection; a retrospective laparoscopic iatrogenic-injury series reported shorter operative time and less blood loss than ureteroneocystostomy.[2]
  • Works across pediatric duplex, adult stricture, injury, and transplant settings.
  • Handles even marked ureteral size disparity when spatulation and recipient selection are correct.[3][6][7][14]
  • Has long-standing pediatric use for reflux associated with ureteral duplication, with preservation of the native ureterovesical junction when recipient anatomy is favorable.[19]

Limitations and Relative Contraindications​

  • lower-third ureteral injuries where reimplantation is more reliable,
  • long ureteral loss after full debridement,
  • ischemic, radiated, crushed, or devascularized ureteral ends,
  • unstable trauma or septic patient needing drainage first,
  • active uncontrolled infection or urinoma without source control,
  • recipient ureter reflux or obstruction in duplex anatomy,
  • need for excessive mobilization to make the ends meet.

Operative Pearls​

  • Decide after debridement, not before it; the true defect is what remains after bad ureter is gone.
  • Keep periureteral tissue attached whenever possible.
  • Spatulate generously and on opposite sides.
  • A drain is cheap insurance when the case began with leak, urinoma, infection, or reoperative scarring.
  • In duplex systems, size mismatch is less important than recipient ureter health and avoiding recipient kinking.
  • In distal injuries, do not force UU just to avoid the bladder; a clean ureteroneocystostomy is often the better operation.
  • If ipsilateral tissues are hostile but the contralateral ureter is healthy, consider TUU deliberately rather than as an intraoperative improvisation.

Videos​

Robotic Ureteroureterostomy for Retrocaval Ureter
Karanikolas T, et al. Urology Video Journal 2026 (CC BY-NC 4.0)
Open source videoRead the article
Single-Port Retroperitoneal Robotic Ureteroureterostomy
Huang E, et al. Urology Video Journal 2025 (CC BY-NC-ND 4.0)
Open source videoRead the article
Robotic Ureteroureterostomy and Nephropexy After Spinal Fixation
Klein Nulend R, et al. Urology Video Journal 2026 (CC BY 4.0)
Open source videoRead the article

References​

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6. Paick JS, Hong SK, Park MS, Kim SW. Management of postoperatively detected iatrogenic lower ureteral injury: should ureteroureterostomy really be abandoned? Urology. 2006;67(2):237-241. doi:10.1016/j.urology.2005.08.041.

7. Rosato E, Miano R, Pastore A, et al. Ureteroureterostomy for the management of non-neoplastic distal ureteral lesions: a new challenger of care in the era of robotic surgery? J Endourol. 2025;39(2):157-165. doi:10.1089/end.2024.0735.

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14. Penna FJ, Lorenzo AJ, Farhat WA, Butt H, Koyle MA. Ureteroureterostomy: an alternative to ureteroneocystostomy in select cases of pediatric renal transplantation. J Urol. 2017;197(3 Pt 2):920-924. doi:10.1016/j.juro.2016.09.120.

15. Eftekharzadeh S, Aghababian A, Abdulfattah S, et al. Ureteroureterostomy as definitive intervention for duplex anomalies: a mid-term analysis. Urology. 2025;204:159-163. doi:10.1016/j.urology.2025.05.028.

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18. Lee YS, Hah YS, Kim MJ, et al. Factors associated with complications of the ureteral stump after proximal ureteroureterostomy. J Urol. 2012;188(5):1890-1894. doi:10.1016/j.juro.2012.07.015.

19. Jelloul L, Valayer J. Ureteroureteral anastomosis in the treatment of reflux associated with ureteral duplication. J Urol. 1997;157(5):1863-1865. doi:10.1016/s0022-5347(01)64887-0

20. Coleman JA, Clark PE, Bixler BR, et al. Diagnosis and management of non-metastatic upper tract urothelial carcinoma: AUA/SUO guideline. J Urol. 2023;209(6):1071-1081. doi:10.1097/JU.0000000000003480

21. Peterson AC. Ureteral Stricture Repair and Ureterolysis. In: Smith JA Jr, Dmochowski RR, Thomas JC, Preminger GM, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2025:295-302.

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23. Nakada SY, Knoedler MA, Best SL. Management of upper urinary tract obstruction. In: Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, eds. Campbell-Walsh-Wein Urology. 13th ed. Elsevier; 2025:1903–1941.

24. Morey AF, Broghammer JA, Hollowell CMP, et al. Urotrauma Guideline 2020: AUA Guideline. J Urol. 2021;205(1):30–35. doi:10.1097/JU.0000000000001408. Full guideline, published 2014; amended April 2017 and August 2020.

25. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Bladder Cancer. Version 3.2026. August 6, 2026. UTT-3; Discussion MS-45. Guideline.

26. Kim JK, Batra NV, Misseri R, et al. "Comparative effectiveness of surgical approaches in pediatric ureteroureterostomy: a systematic review and network meta-analysis of open, laparoscopic, and robotic techniques." J Endourol. 2026;40(3):335-343. doi:10.1177/08927790251412397

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28. Cedars BE, Nguyen AT, Witthaus MW, et al. "Post-Operative Upper Tract Reconstruction Renal Ultrasound Protocol: Safe and Effective Ureteral Stricture Surveillance and Outcomes." Urol Pract. 2026 Sep 2;online ahead of print. doi:10.1097/UPJ.0000000000001083