Pyeloplasty and Ureteroureterostomy 
George E. Koch, Niels V. Johnsen  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
 
Primary repair of a ureteropelvic junction or 
proximal ureteral injury should be undertaken in the 
stable patient, over a stent, using absorbable, 
interrupted sutures. The ureter should be debrided 
and mobilized only as much as needed to exclude 
potentially devitalized tissue and ensure a tension-
free anastomosis. If associated with other abdominal 
injuries, the repair may be excluded using an omental 
or peritoneal flap when possible. A drain should be 
left at the site of the repair and a foley catheter placed 
at least overnight. 
 
Repair of upper ureter injuries proceeds in the 
following steps:  
● Entry into the retroperitoneum and identification 
of the injury 
● Debridement of the ureter if necessary 
● Mobilization 
● Spatulation  
● Anastomosis of the posterior wall 
● Insertion of a double-J stent 
● Anastomosis of the anterior wall 
● Coverage and drainage of the repair 
 
Steps:  
1. The colon should be medialized along the White 
Line of Toldt to expose the retroperitoneum. 
2. If the site of the injury is not apparent, the ureter 
can be identified and exposed by beginning 
dissection at a known ureteral landmark like the 
iliac bifurcation or ureteropelvic junction and 
tracing it to the site of injury. 
 
Mobilize the ureter, taking care not to damage the blood supply, 
which is contained in the tissue surrounding it. Source: Burks 
FN, Santucci RA. Therapeutic Advances in Urology. 
 https://doi.org/10.1177/1756287214526767 
 
 
 
A partial ureteral transection (Green arrow) is identified after 
dissection.  
 
3. Once identified, the injured tissue should be 
inspected. Bruised or discolored tissue raises 
concern for devitalization and should be 
debrided. 
 
Debride the injured tissue back to clean tissue. Source: Burks 
FN, Santucci RA. Therapeutic Advances in Urology. 
 https://doi.org/10.1177/1756287214526767 
 
4. After debridement, the ureter should be 
mobilized judiciously proximal and distal to the 
injury until the ends can be brought together 
without tension. 
5. Each end is spatulated for ~1 cm. 
Pyeloplasty and Ureteroureterostomy 
George E. Koch, Niels V. Johnsen  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
“Spatulate” each end of the anastomosis until it is open about 
1cm, to increase the anastomotic surface and decrease the 
chance of stricture.  
 
6. Anastomosis of the posterior wall should be 
completed with good mucosal apposition using 
5-0 or 4-0 absorbable suture in full thickness, 
interrupted stitches. 
 
The spatulated ends are aligned opposite from each other and 
approximated together using interrupted 4-0 or 5-0 absorbable 
stitches, doing the back wall first and then placing a double-J 
stent (not shown.) Source: Burks FN, Santucci RA. Therapeutic 
Advances in Urology. 
https://doi.org/10.1177/1756287214526767 
 
 
7. A double-J stent is placed proximally into the 
renal pelvis and distally into the bladder. 
8. The anterior wall of the anastomosis is then 
closed in the same fashion. 
 
Excision of the injured segment has been completed and 
primary repair done with full thickness interrupted absorbable 
stitches.  
 
9. A drain should be left next to the site of the 
repair. 
10. If possible, the omentum or peritoneum should 
be secured circumferentially around the repair to 
exclude it from other injured organs. 
11. The stent is removed after 6 weeks with flexible 
or rigid cystoscopy. In settings without 
cystoscopy, some surgeons will make a small 
incision in the bladder and use a foley catheter to 
pass the stent’s string out the urethra. This allows 
the stent to be removed later by simply pulling on 
the string. However, patients sometimes have 
difficulty managing a string coming from the 
urethra. This is especially true for children or 
people with diminished mental capacity. It is not 
infrequent in such occasions for the string to be 
pulled causing premature removal of the stent.  
 
Pitfalls:  
● Failure to adequately debride devitalized tissue 
can lead to delayed urine leakage into the 
abdomen. The mechanism of injury and tissue 
quality under direct inspection are both key. 
● Overly aggressive ureteral mobilization is 
equally problematic as this can disrupt the small 
vessels running in the ureteral adventitia and lead 
to devitalization and either breakdown of the 
repair or subsequent ureteral stricture. If primary 
repair is not possible without aggressive 
mobilization, consider performing a cutaneous 
ureterostomy, externalization of a ureteral stent, 
or ureteral ligation with nephrostomy tube 
A 
Pyeloplasty and Ureteroureterostomy 
George E. Koch, Niels V. Johnsen  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
placement with plans for delayed definitive 
treatment. Alternatively, surgeons can consider 
additional reconstructive techniques such as a 
Boari flap or an ileal ureter, depending on the 
situation. 
● Maximal drainage with a stent and surgical drain 
is important and should not be omitted, as these 
steps can serve to temporize a failed repair while 
the patient recovers. 
 
 
 
George E. Koch MD  
Vanderbilt University Medical Center 
USA 
 
Niels V. Johnsen MD, MPH 
Vanderbilt University Medical Center 
USA 
 
