Ureteral or ureteric strictures are narrowing of the ureter that result in functional obstruction. They can occur anywhere along the ureter but are commonly seen at the ureteropelvic junction.
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Epidemiology
The incidence of post-ureteroscopy strictures has increased from 0.5 to 1.4% 1,2. Studies also show an increase in the frequency of stricture formation after ureteral injury. The incidence after an impacted stone has been reported to be ~20% (range 17-24%) 1.
Associations
Ureteral stricture formation is also associated with the following 1,3:
ureterorenoscopy
use of flexible hydrophilic access sheaths
pelvic malignancy
congenital anomalies of the ureter
urinary tract infections such as tuberculosis
Diagnosis
Diagnosis is usually established by imaging studies including CT urography, nuclear medicine renal scan, and intravenous or retrograde pyelogram 1.
Clinical presentation
The patient may be asymptomatic or present with abdominal distension and flank pain. They may also have persistent urinary tract infections and pyelonephritis.
Laboratory investigations may show a subnormal renal function.
Pathology
Etiology
The causes of ureteric stricture can be ischemic or mechanical. Mechanical causes can be intrinsic as in the case of ureteric stones or extrinsic such as a mass compressing the ureter. Ischemia is usually secondary to an iatrogenic cause that results in inflammation and fibrosis of the ischemic segment followed by stricture 2,4.
Radiographic features
The segment with stricture is characterized by luminal narrowing with dilatation of the proximal ureteric segment and possibly hydronephrosis.
Treatment and prognosis
Management includes stent placement or percutaneous nephrostomy 4.
Treatment is surgical and dependent on the length of the stricture. Shorter strictures are managed endoscopically using balloon dilatation, holmium laser or cold knife excision. Longer strictures are managed by open or laparoscopic surgery 1,5.
Complications
If the condition progresses it can lead to azotemia and renal failure.
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