Editing Management of Upper Urinary Tract Obstruction (section)

== Ureteroenteric anastomotic stricture ==

* '''Rates of ureteroenteric anastomotic stricture after continent diversion is 3-25%, majority occur within the first 2 years'''
* '''Most patients with a long-term urinary conduit will have an element of chronic hydronephrosis that is not secondary to obstruction; obstruction suggested by a decrease in renal function or loss of reflux on a routine loopogram should prompt diuretic renography to quantitatively assess for functional obstruction'''
* '''Factors predicting stricture after ureteroenteric anastomosis:'''
*# Technique used for ureteral dissection
*# Segment of bowel used for the diversion
*# '''Type of anastomosis performed'''
*#* '''Risk of stricture is less in refluxing anastamoses compared to non-refluxing anastamoses and therefore the use of a reflexing anastamosis is preferred for continent reservoirs (note that there is no difference in risk of stricture for ureteroneocystotomy)'''
*# '''Side of anastomosis'''
*#* '''Higher incidence of stricture formation on the left'''
*#** When performing an ileal conduit, the left ureter is brought underneath the sigmoid mesentery just overlying the aorta. The additional length and dissection needed on the left and the possibility of angulation around the inferior mesenteric artery may lead to increased risk of stricture on the left side

=== Management ===
* '''See Figure in Campbell's'''
*'''Antegrade endourologic management of ureteroenteric or ureterocolic strictures is preferred''', unlike the management of ureteral strictures
* '''Strictures > 2cm or on the left are less likely to succeed with endourologic management'''
** Endourologic success rate for
*** Strictures > 1cm is 6% vs. 50% strictures < 1 cm
*** Left sided-stricture 19% vs. 41% on the right
**** No difference was noted in sidedness with open repair
* '''Although long-term patency of minimally invasive procedures for ureteroenteric strictures is in the range of 50%, such approaches are still used as the initial intervention''', reserving operative management for those patients in whom endourologic intervention fails and for patients with strictures > 1 cm
* '''When considering endoscopic incision of a left ureteroenteric stricture, the risk of hemorrhage is a consideration because the sigmoid mesentery can be in close proximity. This, taken with the lower success rates of all endoscopic approaches on the left side, supports serious consideration for primary repair when treating left ureteroenteric anastomotic strictures'''

=== Retrocaval ureter ===
* '''See Pediatrics Ureter Anomalies Chapter Notes'''