Do failed endoscopic manipulations increase the complexity of ureteral stricture? A multicenter experience

Endoscopic management is the preferred initial approach for short ureteral stricture (US), yet the impact of failed attempts on stricture characteristics requiring salvage reconstruction remains unclear. This study aimed to investigate how prior endoscopic interventions influence the complexity of stone-related US.

Between January 2022 and January 2024, patients with stone-related US were included and underwent reconstructive surgery. Stricture length was measured intraoperatively via ureteral catheter or stent. Reconstruction was classified as simple (ureteroureterostomy or pyeloplasty, and reimplantation) or complex (oral mucosa graft onlay, appendiceal flap, Boari flap or psoas hitch, and ileal ureter substitution). Follow-up ranged from 15 months to 39 months, with success defined as resolved obstruction and improved hydronephrosis on imaging, while failure was characterized by persistent obstruction or the need for reintervention. Statistical analyses, including Pearson's correlation and regression models, were used to identify associations and adjust for confounding factors.

Among 142 patients with stone-related US, 76% had US in the upper-mid ureter. Prior endoluminal treatments (22%) were linked to longer US (mean: 2.00 cm vs. 1.00 cm, p<0.001) and independently predicted higher complexity. Treated cases frequently required complex reconstructions, such as oral mucosa grafts (48% vs. 15%, p=0.003), while simpler approaches, like ureteroureterostomy, were more common in untreated cases (80% vs. 48%, p=0.005). For distal US, reimplantation was numerically more frequent in the non-endoluminal group than in the endoluminal group (65% vs. 38%, p=0.2), while ileal ureter substitution was more frequent in treated cases (25% vs. 0%, p=0.049). Treated patients also had longer operative time (mean: 216 min vs. 192 min, p=0.048), though success rates remained comparable (86% vs. 88%, p=0.7).

Prior endoluminal treatment independently predicted increased ureteral reconstruction complexity, characterized by longer US, more intricate procedures, and extended operative time. However, overall reconstruction success rates remained consistent between groups. These findings highlight the need for careful evaluation of risks and benefits when selecting initial treatment strategies.