Multi-Institutional Evaluation of Bladder Elongation Psoas Hitch (BEPH): A Safe and Durable Solution for Mid to Distal Ureteral Strictures

Multi-Institutional Evaluation of Bladder Elongation Psoas Hitch (BEPH): A Safe and Durable Solution for Mid to Distal Ureteral Strictures | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Multi-Institutional Evaluation of Bladder Elongation Psoas Hitch (BEPH): A Safe and Durable Solution for Mid to Distal Ureteral Strictures Austin Livingston, Kiran Sury, Logan Grimaud, Matt Salvino, Avi Sura, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6796217/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Jan, 2026 Read the published version in World Journal of Urology → Version 1 posted 8 You are reading this latest preprint version Abstract Introduction We present 10-year experience and patient outcomes for the bladder elongation with psoas hitch (BEPH) procedure for mid to distal ureteral strictures. Methods We reviewed all adult patients undergoing BEPH for ureteral stricture disease between 2013 and 2024. The primary outcome was procedural success, defined as no need for further intervention for stricture (redo repair, nephrectomy, nephrostomy tube or stent). The secondary outcome was change in AUA Symptom Scores (AUASS). Results A total of 108 patients underwent surgery during this time, 70 patients met inclusion criteria, with a median age at surgery of 54 years (IQR 43–63). 20 patients (28.5%) had previous radiation therapy, 61 (87%) had prior abdominal surgery, and 30 (42.9%) had prior failed management. Median length of stay was 2 days (IQR 1–4), with 34 (48.6%) of patients leaving by postoperative day 1. Median length of follow-up was 34 months (IQR 21–58). Overall procedural success rate was 98.5% (69/70), with one patient requiring a redo reimplant. Analysis of AUA Symptom scores showed no difference in individual symptom domains, with significant improvement in the mean pre- and postoperative AUA total score (p = 0.03) and Quality of Life score (p < 0.01). Conclusion Bladder elongation with psoas hitch is a durable solution with a high success rate and limited morbidity for patients with a mid-to-distal ureteral stricture. Despite altering bladder morphology, BEPH significantly improves quality of life scores, and is not associated with worsening bladder symptom scores. Ureteral stricture cancer survivorship psoas hitch Figures Figure 1 Figure 2 Introduction Ureteral strictures can develop from multiple causes, including iatrogenic injury, radiation, malignancy, and nephrolithiasis. The incidence of strictures varies based on etiology, with estimates of 1–3%. 1, 2 Despite being a common urologic disease, there are no American Urologic Association (AUA) guidelines aimed toward ureteral strictures aside from discussion of traumatic ureteral injury in the Urotrauma guidelines. 3 Management of ureteral stricture disease is directed by stricture length, location, and etiology. 4 , 5 The ureteral reimplant for distal strictures was described as early as the 19th century. 6 The psoas hitch, as popularized by Zimmerman and Turner-Warwick in the 1960s, allows more support for a potentially tenuous repair. 7 , 8 When ureteral length is compromised, a bladder elongation can also be performed as described by Turner-Warwick (bladder elongation psoas hitch; BEPH) to stretch the bladder and allow for treatment of longer more proximal stricture. 9 It has the advantage of using native bladder, effectively maintaining urothelial continuity and avoiding use of an interposition graft. We present a multi-institutional 10-year experience and patient outcomes for patients undergoing BEPH for mid to distal ureteral obstruction. Methods After Institutional Review Board approval at two academic hospitals (Duke University IRB Pro00101255) we reviewed all adult patients undergoing BEPH for ureteral stricture disease between 2013 and 2024. Human ethics and consent to participate: Not applicable. There were no funding sources. Patients who underwent concurrent bladder surgery or developed early pelvic recurrence of malignancy were excluded. We reviewed records for baseline patient characteristics, including stricture etiology and prior treatments. The primary outcome, limited to patients with minimum of 1 follow up, was procedural success defined as no need for further intervention for stricture (redo repair, nephrectomy, nephrostomy tube or stent). The secondary outcome was change in AUA Symptom Scores (AUASS) as compared with a 2-sided Student’s T-test P < 0.05 for statistical significance. Complications were reviewed within the first 90 days post-operatively and graded according to the Clavien-Dindo classification system. Relevant operative and postoperative details were recorded as well. Ureteral stricture location was defined as follows: proximal = renal pelvis to upper aspect of sacrum; mid = overlying the sacrum; distal = lower aspect of sacrum to bladder. Preoperative management We perform a multimodal evaluation for all patients who present with a ureteral stricture, including functional and anatomic assessment of both kidneys and bladder (Supplementary Fig. 1). Surgical candidates have any indwelling stent removed and percutaneous nephrostomy tube (PCN) placed for ureteral rest, with repeat anatomic evaluation after four to six weeks. 10 If there is concern for reduced bladder function, we use adjunct tests such as cystoscopy or urodynamics. We offer repair with BEPH to patients with mid to distal strictures. Iatrogenic injuries managed with intraoperative repair do not undergo this workup, but surgical technique and post-operative management are the same. Surgical procedure Surgical approach is based on patient history, but we prefer a muscle-sparing extraperitoneal Gibson incision if there are no other contraindications. We start by identifying the ipsilateral psoas muscle and clearing off a space for the eventual hitch, taking care to preserve the genitofemoral nerve. We then work medially until we isolate and transect the ureter just superior to the level of obstruction. The distal remnant is clipped and we use flexible ureteroscopy through the transected ureter to ensure the proximal ureter is healthy without occult strictures or radiation damage. We mobilize the bladder by dividing the peritoneum, developing the prevesical space, and separating the detrusor from the overlying perivesical fat. This usually gives enough mobility without sacrificing either of the superior vesical arteries. Next, we make an anterior transverse curvilinear incision with a width roughly equal to the length of ureteral defect (Fig. 1 A) and hitch the posterior bladder wall to the psoas fascia with interrupted 2 − 0 absorbable suture. This changes the orientation of the incision from transverse to vertical per the Heineke-Mikulicz principle, causing elongation of the bladder along the axis of the ureter (Fig. 1 B). If the bladder does not reach the psoas easily, we make relaxing incisions along the cystotomy to extend the elongation. We spatulate the ureter dorsally and anastomose the posterior wall to the bladder with interrupted 4 − 0 absorbable suture in an end-to-end fashion (Fig. 1 C). We then close the bladder longitudinally from inferior to superior in two layers with running absorbable suture until we reach within 1–2 cm of the ureter (Fig. 1 D). We place a 6 French ureteral stent and complete the anterior anastomosis with interrupted 4 − 0 absorbable suture (Fig. 1 E). After irrigation via foley to confirm no leaks, the anastomosis is covered with a fibrin hemostatic agent such as tisseel and a local peritoneal flap (Fig. 1 F). A drain is placed per surgeon preference. We place fascial blocks with liposomal bupivacaine and close the abdomen in standard fashion. Postoperative Pathway Patients are discharged with foley catheter, stent, and capped nephrostomy tube and return for cystogram and catheter removal after 10–14 days. We obtain an antegrade nephrostogram after 4–6 weeks and remove the ureteral stent if there is no leak. The nephrostomy tube is removed 1–2 weeks later after nephrostogram again confirms patency (Fig. 2 ). We follow them with renal ultrasound at 1 and 3 months to catch early stricture recurrence, then annually thereafter. Results 108 patients underwent the BEPH procedure between 2013–2024. 6 were excluded, leaving 102 patients who were reviewed for 90-day complications and AUASS data. 70 patients had follow-up > 1Y and were included in the primary outcomes analysis (Supplementary Fig. 2). Patient Characteristics and Operative Details Patient characteristics are summarized in Table 1 . Median functional bladder capacity, as derived from preoperative voiding diary or cystogram, was 350 mL (IQR 285–478). Operative details are summarized in Supplementary Table 1. Table 1 Patient characteristics. All values are median (interquartile range) or percentage. Age (Years) 54 IQR(43–63) Follow-up (months) 34 IQR(21–58) Female gender 39 (55.7%) Comorbidities Hypertension 29 (41%) Hyperlipidemia 12 (18%) Coronary Artery Disease 11 (16%) Diabetes 8 (12%) Tobacco use (former/current) 27 (38.5%) Prior abdominal surgery 61 (87%) History of radiation 20 (28.5%) Stricture Laterality Left 31 (44.3%) Right 36 (51.2%) Bilateral 3 (4.3%) Stricture Location Distal 60 (85.7%) Mid 10 (14.3%) Presumed etiology Post-surgical 38 (54.3%) Stone disease/treatments 21 (30%) Radiation 15 (21%) External obstruction 3 (4%) History of stent 31 (46%) History of nephrostomy tube 59 (87%) Prior surgical management 30 (44%) Stent only 7 (10%) Dilation/Incision 16 (24%) Surgical Repair 6 (9%) Complications 10 patients (14%) had complications rated Clavien III or higher within the first 90 days. Two required drain placement for hematoma and pelvic fluid collection. One patient had urine leak requiring a drain and stent placement. Two patients had exploratory laparotomy for volvulus and small bowel obstruction. One patient had a wound dehiscence. Two patients had stone episodes requiring ureteroscopy. One patient had a myocardial infarction and one a pulmonary embolism. Procedural Success Median follow up was 34 months (IQR 21–58). Overall procedural success was 98.5% (69/70) and defined strictly as no need for any further stricture intervention (redo repair, nephrectomy, nephrostomy tube or stent). The cohort showed no loss in renal function, with average pre- and post-operative creatinine 1.11 mg/dL and 1.05 mg/dL respectively (p = 0.41). Despite our long-term follow-up, future recurrence for any of these patients is possible. We categorized AUASS into three groups. The first, preoperative scores with PCN in place, after removal of any indwelling stent. Second, early postoperative scores, the first score available after foley, stent, and PCN removal and within one year of surgery. Lastly, late postoperative scores where the latest score available, over one year from surgery. Our final analysis included 37 patients with preoperative scores, 58 with early postoperative scores (median 4.6 months postop; IQR 3.2–8.0), and 44 with late scores (median 19.3 months postop; IQR 15.0–32.3). We present the results of the AUASS analysis in Table 2 . P-values are calculated using the Wilcoxon signed rank test. Table 2 Median Preop and Postop (early) and Postop (late) AUASS Analysis Preop Postop (early) Postop (late) Preop to Postop (early) Preop to Postop (late) Incomplete Emptying 0 1 (p = 0.79) 0 (p = 0.54) Frequency 1 1 (p = 0.66) 1 (p = 0.78) Intermittency 0 0 (p = 0.31) 1 (p = 0.35) Urgency 0 1 (p = 0.74) 1 (p = 0.88) Weak Stream 1 0 (p < 0.01) 1 (p = 0.06) Straining 0 0 (p = 0.03) 0 (p = 0.07) Nocturia 2 2 (p = 0.55) 1 (p = 0.20) AUA Total 7 6 (p = 0.06) 6 (p = 0.03) Quality of Life 4 1 (p < 0.01) 1 (p < 0.01) -Bold p values are statically significant Notably, we see no difference in individual symptom domains, but a significant improvement in the mean pre- and late postoperative AUA total score. There is a significant improvement in the early postoperative Quality of Life (QoL) score that is sustained into the late postoperative period. Subgroup analysis of the 12 patients with scores for all three periods shows no significant difference in the various subdomains except for QoL, which was significantly improved from 4 to 1 (p < 0.01) after reconstruction. Analysis of the 23 patients with a history of radiation shows improvement of QoL from 3 to 2, but this was not significant (p = 0.12). Discussion Ureteral stricture is a burdensome disease that is often initially managed by stenting or PCN tubes, with significant symptoms and a corresponding reduction in quality of life. 11 – 13 Patients undergo multiple tube changes and attempts at endoscopic management at significant expense and patient discomfort. 14 , 15 Initial success rates are high, but can drop to below 50% depending on stricture etiology, location, length, and duration of follow up. 5 , 16 In contrast, surgical repair with ureteral reimplant is considered a more definitive treatment and associated with much higher rates of long-term success ranging from 72–100% with variations in technique. 17 – 20 In the largest contemporary adult cohort, Groen et al. analyze 166 patients who had an open ureteral reimplant with psoas hitch. 21 They report a 92% success rate at a median follow-up of 15 (IQR 6–45) months. Our cohort is heterogenous, with a 24% rate of endoscopic management, 9% prior surgical repair, 29% history of radiation, and 87% prior abdominal surgery. Despite these risk factors, we have a similar success rate of 99% at a median follow up of 34 months and feel there are no absolute contraindications to attempting repair. One patient developed progressive metastatic prostate cancer requiring bilateral ureteral stents three years after surgery, but we did not consider that to be a failure of the reimplant. Four patients with a history of stone disease had subsequent stone interventions on the operative side, but none required PCN or chronic stenting. The single failure had a history of neurofibromatosis with extensive non-urologic manifestations and developed an early postoperative spindle cell nodule at the anastomosis. This responded well to a repeat BEPH with no recurrence at latest follow up. 49% of our patients were discharged on postoperative day one, which we attribute to our minimally invasive, muscle-sparing Gibson incision and fascial blocks. Our pathway (Supplementary Fig. 1) is similar to those published by highly experienced surgeons who perform ureteral reconstruction. 22 We take extra care to screen for a hostile bladder, as there are concerns that the change in bladder morphology can cause new bladder dysfunction. 23 We use a functional capacity of 200 on voiding diary as our lower limit of safety (regardless of stricture size or location), and use cystoscopy and urodynamics if there are any doubts about bladder functionality. Of note, we prefer using this approach rather than a robotic approach for these patients given the high rate of prior pelvic radiation, complex abdominal surgical anatomy, low morbidity from the procedure, and high success rate. While the retrospective design of our study prevents us from stating that BEPH does not cause worsening bladder symptoms, it is reassuring that our AUASS analysis did not reveal any significant worsening of the various subdomains as may be expected if the bladder elongation caused new voiding dysfunction. Instead, we see a significant and sustained improvement in the quality of life metric that likely reflects patient satisfaction in finally being rendered tube-free. Proper renal evaluation is also critical. We always include the contralateral kidney in the functional and anatomic assessment, as this has revealed contralateral occult injury that changed surgical management. It is also important to swap stents for PCNs, as an indwelling stent can obscure the location of the stricture and cause fibrosis that makes repair more challenging. 10 , 24 We then perform an intraoperative evaluation of ureteral viability. Surgeons have started using indocyanine green with fluorescent imaging for live assessment of ureteral perfusion. 25 We use ureteroscopy for the same reason. It is a low-cost alternative using readily available equipment that provides an intraluminal assessment of ureteral integrity. Radiated ureters can sometimes appear normal on external evaluation, but pale avascular mucosa indicates a need to transect higher to avoid ischemia. We also find the psoas hitch to be a critical aspect of the repair. During an intraoperative consult with distal ureteral injury, it can be tempting to perform a simple extravesical reimplant. However, we believe the hitch does more than just relieve tension on the ureter. The psoas hitch immobilizes the new ureterovesical junction and prevents the dynamic kinking and intermittent obstruction that can occur during bladder cycling and lead to late failures. 26 , 27 Finally, it is important to distinguish Turner-Warwick’s elongation technique from the Boari flap – especially when considering mid-ureteral strictures. 28 The blood supply at the distal-most end of a flap is dependent on the base of the flap, with risk of ischemia if the base is too narrow. In contrast, bladder elongation uses the Heinecke-Mikulicz principle to change the orientation of the bladder without sacrificing circumferential vascularity (Supplementary Fig. 3). It appears very similar to a flap, however the base is the entire width of the bladder and there is theoretically less risk of vascular compromise. Limitations of our paper stem from its retrospective nature which introduces selection and analytical bias. Given our low number of overall failures and complications, we are unable to perform subgroup analyses to identify risk factors for failure. As both institutions are tertiary referral centers, it is common for patients to follow up locally. We were able to track patients between institutions by electronic medical record and feel we captured an accurate longitudinal follow-up, but it is possible there are more failures of which we are unaware. We were unable to gather a complete set of AUASS questionnaires for every patient, which would have strengthened that analysis. We reviewed for new overactive bladder diagnosis and new prescriptions for bladder relaxants, with preliminary analysis suggesting no increase in either. However, our patients are all discharged with short courses of anticholinergics, and it was not possible to assess for medication use or prescription renewals, particularly with patients who followed locally. Ultimately, we felt the data was too heterogenous to comment on the use of medications. Conclusion Bladder elongation with psoas hitch is a durable solution for patients with a mid-to-distal ureteral stricture, with a high success rate and limited morbidity. For distal ureteral strictures, this repair allows for a tension-free anastomosis compared to a simple reimplant. We have also found this approach to be feasible in mid-ureteral strictures, in which a Boari flap may be employed. Despite altering bladder morphology, BEPH significantly improves quality of life scores, and is not associated with worsening bladder symptom scores. Declarations Author Contributions: All authors listed on this manuscript meet the ICJME authorship criteria for authorship. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Duke University Hospital Institutional Review Board Approval: Pro00101255 Human ethics and consent to participate: Not applicable. Author Contribution Conceptualization: AllMethodology: AllAnalysis: ALivingston, KSInvestigation: AllData Curation: ALivingston, KS, MS, LG, ASWriting - Original Draft: ALivingston, KSWriting - Review and Editing: AllVisualization: ALivingston, KS, MSSupervision: BI, ALentz, AP, JF, BN References Sunaryo, P. L., May, P. C., Holt, S. K. et al.: Ureteral Strictures Following Ureteroscopy for Kidney Stone Disease: A Population-based Assessment. J Urol, 208: 1268, 2022 Tyritzis, S. I., Wiklund, N. P.: Ureteral Strictures Revisited…Trying to See the Light at the End of the Tunnel: A Comprehensive Review. Journal of Endourology, 29: 124, 2015 Morey, A. F., Broghammer, J. A., Hollowell, C. M. P. et al.: Urotrauma Guideline 2020: AUA Guideline. J Urol, 205: 30, 2021 Abboudi, H., Ahmed, K., Royle, J. et al.: Ureteric injury: a challenging condition to diagnose and manage. Nat Rev Urol, 10: 108, 2013 Vasudevan, V. P., Johnson, E. U., Wong, K. et al.: Contemporary management of ureteral strictures. Journal of Clinical Urology, 12: 20, 2019 Witzel, O.: Extraperitoneale Ureterozystoneostomie mit Schraegkanalbildung. Zentbl Gynaek, 11: 289, 1896 Zimmerman, I. J., Precourt, W. E., Thompson, C. C.: Direct uretero-cysto-neostomy with the short ureter in the cure of ureterovaginal fistula. J Urol, 83: 113, 1960 Warwick, R. T., Worth, P. H.: The psoas bladder-hitch procedure for the replacement of the lower third of the ureter. Br J Urol, 41: 701, 1969 Turner-Warwick, R.: The Turner-Warwick Bladder-Elongation Psoas-Hitch Procedure for Substitution Ureteroplasty. In: Controversies and Innovations in Urological Surgery. Edited by J. C. Gingell and P. H. Abrams. London: Springer London, pp. 109-114, 1988 Lee, Z., Lee, M., Lee, R. et al.: Ureteral Rest is Associated With Improved Outcomes in Patients Undergoing Robotic Ureteral Reconstruction of Proximal and Middle Ureteral Strictures. Urology, 152: 160, 2021 Joshi, H. B., Stainthorpe, A., MacDonagh, R. P. et al.: Indwelling ureteral stents: evaluation of symptoms, quality of life and utility. J Urol, 169: 1065, 2003 Goldfarb, R. A., Fan, Y., Jarosek, S., Elliott, S. P.: The burden of chronic ureteral stenting in cervical cancer survivors. Int Braz J Urol, 43: 104, 2017 Fernandez-Cacho, L. M., Ayesa-Arriola, R.: Quality of life, pain and anxiety in patients with nephrostomy tubes. Rev Lat Am Enfermagem, 27: e3191, 2019 Ganatra, A. M., Loughlin, K. R.: Cost of malignant ureteral obstruction treated with ureteral stents. Journal of the American College of Surgeons, 205: S106, 2007 Lim, J. S., Sul, C. K., Song, K. H. et al.: Changes in Urinary Symptoms and Tolerance due to Long-term Ureteral Double-J Stenting. Int Neurourol J, 14: 93, 2010 Lucas, J. W., Ghiraldi, E., Ellis, J., Friedlander, J. I.: Endoscopic Management of Ureteral Strictures: an Update. Curr Urol Rep, 19: 24, 2018 Manassero, F., Mogorovich, A., Fiorini, G. et al.: Ureteral reimplantation with psoas bladder hitch in adults: a contemporary series with long-term followup. ScientificWorldJournal, 2012: 379316, 2012 Ahn, M., Loughlin, K. R.: Psoas hitch ureteral reimplantation in adults--analysis of a modified technique and timing of repair. Urology, 58: 184, 2001 Middleton, R. G.: Routine use of the psoas hitch in ureteral reimplantation. J Urol, 123: 352, 1980 Riedmiller, H., Becht, E., Hertle, L. et al.: Psoas-hitch ureteroneocystostomy: experience with 181 cases. Eur Urol, 10: 145, 1984 Groen, V. H., Lock, M., de Angst, I. B. et al.: Psoas hitch procedure in 166 adult patients: The largest cohort study before the laparoscopic era. BJUI Compass, 2: 331, 2021 Grimes, M. D., Schubbe, M. E., Erickson, B. A.: A systematic approach for successful repair of radiated and non-radiated ureteral injuries. Transl Androl Urol, 11: 30, 2022 Hardesty, J. K., Burns, R. T., Soyster, M. E. et al.: Female bladder dysfunction following Boari bladder flap ureteral reconstruction. Urology, 2024 Reicherz, A., Eltit, F., Scotland, K. et al.: Indwelling stents cause severe inflammation and fibrosis of the ureter via urothelial-mesenchymal transition. Sci Rep, 13: 5492, 2023 Kanammit, P., Sirisreetreerux, P., Boongird, S. et al.: Intraoperative assessment of ureter perfusion after revascularization of transplanted kidneys using intravenous indocyanine green fluorescence imaging. Transl Androl Urol, 10: 2297, 2021 Turner-Warwick, R., Chapple, C. R.: Functional Reconstruction of the Urinary Tract and Gynaeco-Urology: Wiley, 2002 Prout, G. R., Jr., Koontz, W. W., Jr.: Partial vesical immobilization: an important adjunct to ureteroneocystostomy. J Urol, 103: 147, 1970 Stein, R., Rubenwolf, P., Ziesel, C. et al.: Psoas hitch and Boari flap ureteroneocystostomy. BJU Int, 112: 137, 2013 Additional Declarations No competing interests reported. Supplementary Files SupplementaryFigure1.png SupplementaryFigure2.png SupplementaryFigure3BEPH.docx SupplementaryTable1.png Cite Share Download PDF Status: Published Journal Publication published 21 Jan, 2026 Read the published version in World Journal of Urology → Version 1 posted Editorial decision: Revision requested 10 Aug, 2025 Reviews received at journal 13 Jul, 2025 Reviewers agreed at journal 11 Jul, 2025 Reviewers agreed at journal 08 Jul, 2025 Reviewers invited by journal 08 Jul, 2025 Editor assigned by journal 16 Jun, 2025 Submission checks completed at journal 16 Jun, 2025 First submitted to journal 01 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6796217","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":482594394,"identity":"a4d8ef82-fbac-4130-9390-bff70579708c","order_by":0,"name":"Austin Livingston","email":"data:image/png;base64,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","orcid":"","institution":"Duke University","correspondingAuthor":true,"prefix":"","firstName":"Austin","middleName":"","lastName":"Livingston","suffix":""},{"id":482594395,"identity":"5bab3aaf-1ce7-4017-9a89-79256195c366","order_by":1,"name":"Kiran Sury","email":"","orcid":"","institution":"Duke University","correspondingAuthor":false,"prefix":"","firstName":"Kiran","middleName":"","lastName":"Sury","suffix":""},{"id":482594396,"identity":"6a2e38b3-1ecb-449b-ab2f-9b7d2cd6d22d","order_by":2,"name":"Logan Grimaud","email":"","orcid":"","institution":"Duke University","correspondingAuthor":false,"prefix":"","firstName":"Logan","middleName":"","lastName":"Grimaud","suffix":""},{"id":482594397,"identity":"cf244ecb-197e-4ff6-8c8c-ba55d5e3a7e4","order_by":3,"name":"Matt Salvino","email":"","orcid":"","institution":"Duke University","correspondingAuthor":false,"prefix":"","firstName":"Matt","middleName":"","lastName":"Salvino","suffix":""},{"id":482594398,"identity":"1c49485e-e2ff-4cc2-ab06-c2c119c87616","order_by":4,"name":"Avi Sura","email":"","orcid":"","institution":"Albany Medical Center Hospital","correspondingAuthor":false,"prefix":"","firstName":"Avi","middleName":"","lastName":"Sura","suffix":""},{"id":482594399,"identity":"13878f35-aa30-4bf4-b27a-8ee7594b6a08","order_by":5,"name":"Brian Inouye","email":"","orcid":"","institution":"Albany Medical Center Hospital","correspondingAuthor":false,"prefix":"","firstName":"Brian","middleName":"","lastName":"Inouye","suffix":""},{"id":482594400,"identity":"929f0d52-5e2c-4a65-bae6-2143d78f7c93","order_by":6,"name":"Aaron Lentz","email":"","orcid":"","institution":"Duke University","correspondingAuthor":false,"prefix":"","firstName":"Aaron","middleName":"","lastName":"Lentz","suffix":""},{"id":482594401,"identity":"e81cc1c5-f8a7-443a-aa36-20e21f9e24c2","order_by":7,"name":"Brent Nose","email":"","orcid":"","institution":"Duke University","correspondingAuthor":false,"prefix":"","firstName":"Brent","middleName":"","lastName":"Nose","suffix":""},{"id":482594402,"identity":"6f9b7e82-4f2b-4398-88ce-44c227440226","order_by":8,"name":"Andrew Peterson","email":"","orcid":"","institution":"Duke University","correspondingAuthor":false,"prefix":"","firstName":"Andrew","middleName":"","lastName":"Peterson","suffix":""},{"id":482594403,"identity":"2296538d-c6d9-4bfe-a58c-7748c706aef6","order_by":9,"name":"Jordan Foreman","email":"","orcid":"","institution":"Duke University","correspondingAuthor":false,"prefix":"","firstName":"Jordan","middleName":"","lastName":"Foreman","suffix":""}],"badges":[],"createdAt":"2025-06-01 14:38:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6796217/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6796217/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00345-025-06043-z","type":"published","date":"2026-01-21T15:59:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":86668219,"identity":"48863b17-7ef5-4033-a2c0-7378d7979a26","added_by":"auto","created_at":"2025-07-14 11:18:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1662582,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical technique. A - Curvilinear bladder incision has been marked, oriented towards the transected ureter B - The bladder is hitched to the ipsilateral psoas muscle, causing elongation of the incision. The ureter is spatulated dorsally. C - The posterior anastomosis is completed with interrupted absorbable suture. D - The bladder is closed longitudinally from inferior to superior in two layers with running absorbable suture. A stent is placed across the anastomosis. E - the anterior anastomosis is completed with interrupted absorbable suture. F - The repair is covered with hemostatic agent and local peritoneal flap\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6796217/v1/793e0330fb35b3dcdb734612.png"},{"id":86670226,"identity":"1f8d5cdb-9cff-4350-ac2e-b25528249417","added_by":"auto","created_at":"2025-07-14 11:26:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":106536,"visible":true,"origin":"","legend":"\u003cp\u003eFinal postoperative nephrostogram showing elongated bladder with patent anastomosis\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6796217/v1/16714db0ad31091fa13e8601.png"},{"id":101152062,"identity":"adc16018-f1c0-4c1c-a9c2-0c0f1b2ab2d8","added_by":"auto","created_at":"2026-01-26 16:09:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2453768,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6796217/v1/a4ef0c05-23eb-4ea7-943c-8808c33c3c1a.pdf"},{"id":86668222,"identity":"cd700974-5539-457f-9bde-a71876cc049a","added_by":"auto","created_at":"2025-07-14 11:18:51","extension":"png","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":138068,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-6796217/v1/e87c7e21b01761d37001e84c.png"},{"id":86670227,"identity":"f70601dd-a03b-45b5-95c1-c482c39abbcf","added_by":"auto","created_at":"2025-07-14 11:26:51","extension":"png","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":74638,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-6796217/v1/ca701aaa4197e5be0632a2cd.png"},{"id":86668226,"identity":"9cb525b9-8f4e-48f3-90ae-6bfa4eefdcd7","added_by":"auto","created_at":"2025-07-14 11:18:51","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":139477,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFigure3BEPH.docx","url":"https://assets-eu.researchsquare.com/files/rs-6796217/v1/518faf7eedef0cdf6c779d55.docx"},{"id":86670228,"identity":"d2dd7869-1aa1-49c3-ba47-341ca3d995fa","added_by":"auto","created_at":"2025-07-14 11:26:51","extension":"png","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":80227,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.png","url":"https://assets-eu.researchsquare.com/files/rs-6796217/v1/3b684a6a21788d4447e6307d.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"Multi-Institutional Evaluation of Bladder Elongation Psoas Hitch (BEPH): A Safe and Durable Solution for Mid to Distal Ureteral Strictures","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUreteral strictures can develop from multiple causes, including iatrogenic injury, radiation, malignancy, and nephrolithiasis. The incidence of strictures varies based on etiology, with estimates of 1\u0026ndash;3%.\u003csup\u003e1, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Despite being a common urologic disease, there are no American Urologic Association (AUA) guidelines aimed toward ureteral strictures aside from discussion of traumatic ureteral injury in the Urotrauma guidelines.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eManagement of ureteral stricture disease is directed by stricture length, location, and etiology.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e The ureteral reimplant for distal strictures was described as early as the 19th century.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e The psoas hitch, as popularized by Zimmerman and Turner-Warwick in the 1960s, allows more support for a potentially tenuous repair.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e When ureteral length is compromised, a bladder elongation can also be performed as described by Turner-Warwick (bladder elongation psoas hitch; BEPH) to stretch the bladder and allow for treatment of longer more proximal stricture.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e It has the advantage of using native bladder, effectively maintaining urothelial continuity and avoiding use of an interposition graft. We present a multi-institutional 10-year experience and patient outcomes for patients undergoing BEPH for mid to distal ureteral obstruction.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e After Institutional Review Board approval at two academic hospitals (Duke University IRB Pro00101255) we reviewed all adult patients undergoing BEPH for ureteral stricture disease between 2013 and 2024. Human ethics and consent to participate: Not applicable. There were no funding sources. Patients who underwent concurrent bladder surgery or developed early pelvic recurrence of malignancy were excluded. We reviewed records for baseline patient characteristics, including stricture etiology and prior treatments. The primary outcome, limited to patients with minimum of 1 follow up, was procedural success defined as no need for further intervention for stricture (redo repair, nephrectomy, nephrostomy tube or stent). The secondary outcome was change in AUA Symptom Scores (AUASS) as compared with a 2-sided Student\u0026rsquo;s T-test P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for statistical significance. Complications were reviewed within the first 90 days post-operatively and graded according to the Clavien-Dindo classification system. Relevant operative and postoperative details were recorded as well. Ureteral stricture location was defined as follows: proximal\u0026thinsp;=\u0026thinsp;renal pelvis to upper aspect of sacrum; mid\u0026thinsp;=\u0026thinsp;overlying the sacrum; distal\u0026thinsp;=\u0026thinsp;lower aspect of sacrum to bladder.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePreoperative management\u003c/h2\u003e\u003cp\u003eWe perform a multimodal evaluation for all patients who present with a ureteral stricture, including functional and anatomic assessment of both kidneys and bladder (Supplementary Fig.\u0026nbsp;1). Surgical candidates have any indwelling stent removed and percutaneous nephrostomy tube (PCN) placed for ureteral rest, with repeat anatomic evaluation after four to six weeks.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e If there is concern for reduced bladder function, we use adjunct tests such as cystoscopy or urodynamics. We offer repair with BEPH to patients with mid to distal strictures. Iatrogenic injuries managed with intraoperative repair do not undergo this workup, but surgical technique and post-operative management are the same.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSurgical procedure\u003c/h3\u003e\n\u003cp\u003eSurgical approach is based on patient history, but we prefer a muscle-sparing extraperitoneal Gibson incision if there are no other contraindications. We start by identifying the ipsilateral psoas muscle and clearing off a space for the eventual hitch, taking care to preserve the genitofemoral nerve. We then work medially until we isolate and transect the ureter just superior to the level of obstruction. The distal remnant is clipped and we use flexible ureteroscopy through the transected ureter to ensure the proximal ureter is healthy without occult strictures or radiation damage.\u003c/p\u003e\u003cp\u003eWe mobilize the bladder by dividing the peritoneum, developing the prevesical space, and separating the detrusor from the overlying perivesical fat. This usually gives enough mobility without sacrificing either of the superior vesical arteries. Next, we make an anterior transverse curvilinear incision with a width roughly equal to the length of ureteral defect (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA) and hitch the posterior bladder wall to the psoas fascia with interrupted 2\u0026thinsp;\u0026minus;\u0026thinsp;0 absorbable suture. This changes the orientation of the incision from transverse to vertical per the Heineke-Mikulicz principle, causing elongation of the bladder along the axis of the ureter (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). If the bladder does not reach the psoas easily, we make relaxing incisions along the cystotomy to extend the elongation. We spatulate the ureter dorsally and anastomose the posterior wall to the bladder with interrupted 4\u0026thinsp;\u0026minus;\u0026thinsp;0 absorbable suture in an end-to-end fashion (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). We then close the bladder longitudinally from inferior to superior in two layers with running absorbable suture until we reach within 1\u0026ndash;2 cm of the ureter (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD). We place a 6 French ureteral stent and complete the anterior anastomosis with interrupted 4\u0026thinsp;\u0026minus;\u0026thinsp;0 absorbable suture (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eE). After irrigation via foley to confirm no leaks, the anastomosis is covered with a fibrin hemostatic agent such as tisseel and a local peritoneal flap (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eF). A drain is placed per surgeon preference. We place fascial blocks with liposomal bupivacaine and close the abdomen in standard fashion.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003ePostoperative Pathway\u003c/h3\u003e\n\u003cp\u003ePatients are discharged with foley catheter, stent, and capped nephrostomy tube and return for cystogram and catheter removal after 10\u0026ndash;14 days. We obtain an antegrade nephrostogram after 4\u0026ndash;6 weeks and remove the ureteral stent if there is no leak. The nephrostomy tube is removed 1\u0026ndash;2 weeks later after nephrostogram again confirms patency (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWe follow them with renal ultrasound at 1 and 3 months to catch early stricture recurrence, then annually thereafter.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e108 patients underwent the BEPH procedure between 2013\u0026ndash;2024. 6 were excluded, leaving 102 patients who were reviewed for 90-day complications and AUASS data. 70 patients had follow-up \u0026gt;\u0026thinsp;1Y and were included in the primary outcomes analysis (Supplementary Fig.\u0026nbsp;2).\u003c/p\u003e\n\u003ch3\u003ePatient Characteristics and Operative Details\u003c/h3\u003e\n\u003cp\u003ePatient characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Median functional bladder capacity, as derived from preoperative voiding diary or cystogram, was 350 mL (IQR 285\u0026ndash;478). Operative details are summarized in Supplementary Table\u0026nbsp;1.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient characteristics. All values are median (interquartile range) or percentage.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (Years)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIQR(43\u0026ndash;63)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow-up (months)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIQR(21\u0026ndash;58)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale gender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(55.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComorbidities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypertension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(41%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHyperlipidemia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(18%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCoronary Artery Disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(16%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiabetes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(12%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTobacco use (former/current)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(38.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrior abdominal surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(87%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistory of radiation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(28.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStricture Laterality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(44.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(51.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBilateral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(4.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStricture Location\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDistal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(85.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMid\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(14.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePresumed etiology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePost-surgical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(54.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStone disease/treatments\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(30%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRadiation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(21%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExternal obstruction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistory of stent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(46%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistory of nephrostomy tube\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(87%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrior surgical management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(44%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStent only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(10%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDilation/Incision\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(24%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical Repair\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eComplications\u003c/h2\u003e\u003cp\u003e10 patients (14%) had complications rated Clavien III or higher within the first 90 days. Two required drain placement for hematoma and pelvic fluid collection. One patient had urine leak requiring a drain and stent placement. Two patients had exploratory laparotomy for volvulus and small bowel obstruction. One patient had a wound dehiscence. Two patients had stone episodes requiring ureteroscopy. One patient had a myocardial infarction and one a pulmonary embolism.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eProcedural Success\u003c/h3\u003e\n\u003cp\u003eMedian follow up was 34 months (IQR 21\u0026ndash;58). Overall procedural success was 98.5% (69/70) and defined strictly as no need for any further stricture intervention (redo repair, nephrectomy, nephrostomy tube or stent). The cohort showed no loss in renal function, with average pre- and post-operative creatinine 1.11 mg/dL and 1.05 mg/dL respectively (p\u0026thinsp;=\u0026thinsp;0.41). Despite our long-term follow-up, future recurrence for any of these patients is possible.\u003c/p\u003e\u003cp\u003eWe categorized AUASS into three groups. The first, preoperative scores with PCN in place, after removal of any indwelling stent. Second, early postoperative scores, the first score available after foley, stent, and PCN removal and within one year of surgery. Lastly, late postoperative scores where the latest score available, over one year from surgery. Our final analysis included 37 patients with preoperative scores, 58 with early postoperative scores (median 4.6 months postop; IQR 3.2\u0026ndash;8.0), and 44 with late scores (median 19.3 months postop; IQR 15.0\u0026ndash;32.3). We present the results of the AUASS analysis in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. P-values are calculated using the Wilcoxon signed rank test.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMedian Preop and Postop (early) and Postop (late) AUASS Analysis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePreop\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003ePostop (early)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003ePostop (late)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePreop to Postop (early)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003ePreop to Postop (late)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIncomplete Emptying\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e(p\u0026thinsp;=\u0026thinsp;0.79)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003e(p\u0026thinsp;=\u0026thinsp;0.54)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFrequency\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e(p\u0026thinsp;=\u0026thinsp;0.66)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003e(p\u0026thinsp;=\u0026thinsp;0.78)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIntermittency\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e(p\u0026thinsp;=\u0026thinsp;0.31)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003e(p\u0026thinsp;=\u0026thinsp;0.35)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUrgency\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e(p\u0026thinsp;=\u0026thinsp;0.74)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003e(p\u0026thinsp;=\u0026thinsp;0.88)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWeak Stream\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e(p\u0026thinsp;\u0026lt;\u0026thinsp;0.01)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003e(p\u0026thinsp;=\u0026thinsp;0.06)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStraining\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e(p\u0026thinsp;=\u0026thinsp;0.03)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003e(p\u0026thinsp;=\u0026thinsp;0.07)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNocturia\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e(p\u0026thinsp;=\u0026thinsp;0.55)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003e(p\u0026thinsp;=\u0026thinsp;0.20)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAUA Total\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e(p\u0026thinsp;=\u0026thinsp;0.06)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e(p\u0026thinsp;=\u0026thinsp;0.03)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eQuality of Life\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e(p\u0026thinsp;\u0026lt;\u0026thinsp;0.01)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e(p\u0026thinsp;\u0026lt;\u0026thinsp;0.01)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e-Bold p values are statically significant\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eNotably, we see no difference in individual symptom domains, but a significant improvement in the mean pre- and late postoperative AUA total score. There is a significant improvement in the early postoperative Quality of Life (QoL) score that is sustained into the late postoperative period.\u003c/p\u003e\u003cp\u003eSubgroup analysis of the 12 patients with scores for all three periods shows no significant difference in the various subdomains except for QoL, which was significantly improved from 4 to 1 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) after reconstruction. Analysis of the 23 patients with a history of radiation shows improvement of QoL from 3 to 2, but this was not significant (p\u0026thinsp;=\u0026thinsp;0.12).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eUreteral stricture is a burdensome disease that is often initially managed by stenting or PCN tubes, with significant symptoms and a corresponding reduction in quality of life.\u003csup\u003e\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Patients undergo multiple tube changes and attempts at endoscopic management at significant expense and patient discomfort.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Initial success rates are high, but can drop to below 50% depending on stricture etiology, location, length, and duration of follow up.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e In contrast, surgical repair with ureteral reimplant is considered a more definitive treatment and associated with much higher rates of long-term success ranging from 72\u0026ndash;100% with variations in technique.\u003csup\u003e\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn the largest contemporary adult cohort, Groen et al. analyze 166 patients who had an open ureteral reimplant with psoas hitch.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e They report a 92% success rate at a median follow-up of 15 (IQR 6\u0026ndash;45) months. Our cohort is heterogenous, with a 24% rate of endoscopic management, 9% prior surgical repair, 29% history of radiation, and 87% prior abdominal surgery. Despite these risk factors, we have a similar success rate of 99% at a median follow up of 34 months and feel there are no absolute contraindications to attempting repair. One patient developed progressive metastatic prostate cancer requiring bilateral ureteral stents three years after surgery, but we did not consider that to be a failure of the reimplant. Four patients with a history of stone disease had subsequent stone interventions on the operative side, but none required PCN or chronic stenting. The single failure had a history of neurofibromatosis with extensive non-urologic manifestations and developed an early postoperative spindle cell nodule at the anastomosis. This responded well to a repeat BEPH with no recurrence at latest follow up. 49% of our patients were discharged on postoperative day one, which we attribute to our minimally invasive, muscle-sparing Gibson incision and fascial blocks.\u003c/p\u003e\u003cp\u003eOur pathway (Supplementary Fig.\u0026nbsp;1) is similar to those published by highly experienced surgeons who perform ureteral reconstruction.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e We take extra care to screen for a hostile bladder, as there are concerns that the change in bladder morphology can cause new bladder dysfunction.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e We use a functional capacity of 200 on voiding diary as our lower limit of safety (regardless of stricture size or location), and use cystoscopy and urodynamics if there are any doubts about bladder functionality. Of note, we prefer using this approach rather than a robotic approach for these patients given the high rate of prior pelvic radiation, complex abdominal surgical anatomy, low morbidity from the procedure, and high success rate. While the retrospective design of our study prevents us from stating that BEPH does not cause worsening bladder symptoms, it is reassuring that our AUASS analysis did not reveal any significant worsening of the various subdomains as may be expected if the bladder elongation caused new voiding dysfunction. Instead, we see a significant and sustained improvement in the quality of life metric that likely reflects patient satisfaction in finally being rendered tube-free.\u003c/p\u003e\u003cp\u003eProper renal evaluation is also critical. We always include the contralateral kidney in the functional and anatomic assessment, as this has revealed contralateral occult injury that changed surgical management. It is also important to swap stents for PCNs, as an indwelling stent can obscure the location of the stricture and cause fibrosis that makes repair more challenging.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e We then perform an intraoperative evaluation of ureteral viability. Surgeons have started using indocyanine green with fluorescent imaging for live assessment of ureteral perfusion.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e We use ureteroscopy for the same reason. It is a low-cost alternative using readily available equipment that provides an intraluminal assessment of ureteral integrity. Radiated ureters can sometimes appear normal on external evaluation, but pale avascular mucosa indicates a need to transect higher to avoid ischemia.\u003c/p\u003e\u003cp\u003eWe also find the psoas hitch to be a critical aspect of the repair. During an intraoperative consult with distal ureteral injury, it can be tempting to perform a simple extravesical reimplant. However, we believe the hitch does more than just relieve tension on the ureter. The psoas hitch immobilizes the new ureterovesical junction and prevents the dynamic kinking and intermittent obstruction that can occur during bladder cycling and lead to late failures.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eFinally, it is important to distinguish Turner-Warwick\u0026rsquo;s elongation technique from the Boari flap \u0026ndash; especially when considering mid-ureteral strictures.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e The blood supply at the distal-most end of a flap is dependent on the base of the flap, with risk of ischemia if the base is too narrow. In contrast, bladder elongation uses the Heinecke-Mikulicz principle to change the orientation of the bladder without sacrificing circumferential vascularity (Supplementary Fig.\u0026nbsp;3). It appears very similar to a flap, however the base is the entire width of the bladder and there is theoretically less risk of vascular compromise.\u003c/p\u003e\u003cp\u003eLimitations of our paper stem from its retrospective nature which introduces selection and analytical bias. Given our low number of overall failures and complications, we are unable to perform subgroup analyses to identify risk factors for failure. As both institutions are tertiary referral centers, it is common for patients to follow up locally. We were able to track patients between institutions by electronic medical record and feel we captured an accurate longitudinal follow-up, but it is possible there are more failures of which we are unaware. We were unable to gather a complete set of AUASS questionnaires for every patient, which would have strengthened that analysis. We reviewed for new overactive bladder diagnosis and new prescriptions for bladder relaxants, with preliminary analysis suggesting no increase in either. However, our patients are all discharged with short courses of anticholinergics, and it was not possible to assess for medication use or prescription renewals, particularly with patients who followed locally. Ultimately, we felt the data was too heterogenous to comment on the use of medications.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBladder elongation with psoas hitch is a durable solution for patients with a mid-to-distal ureteral stricture, with a high success rate and limited morbidity. For distal ureteral strictures, this repair allows for a tension-free anastomosis compared to a simple reimplant. We have also found this approach to be feasible in mid-ureteral strictures, in which a Boari flap may be employed. Despite altering bladder morphology, BEPH significantly improves quality of life scores, and is not associated with worsening bladder symptom scores.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAuthor Contributions: All authors listed on this manuscript meet the ICJME authorship criteria for authorship.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Duke University Hospital Institutional Review Board Approval: Pro00101255\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Human ethics and consent to participate: Not applicable.\u003c/p\u003e\n\u003cp\u003eAuthor Contribution\u003c/p\u003e\n\u003cp\u003eConceptualization: AllMethodology: AllAnalysis: ALivingston, KSInvestigation: AllData Curation: ALivingston, KS, MS, LG, ASWriting - Original Draft: ALivingston, KSWriting - Review and Editing: AllVisualization: ALivingston, KS, MSSupervision: BI, ALentz, AP, JF, BN\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSunaryo, P. 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Rev Lat Am Enfermagem, \u003cstrong\u003e27:\u003c/strong\u003e e3191, 2019\u003c/li\u003e\n\u003cli\u003eGanatra, A. M., Loughlin, K. R.: Cost of malignant ureteral obstruction treated with ureteral stents. Journal of the American College of Surgeons, \u003cstrong\u003e205:\u003c/strong\u003e S106, 2007\u003c/li\u003e\n\u003cli\u003eLim, J. S., Sul, C. K., Song, K. H. et al.: Changes in Urinary Symptoms and Tolerance due to Long-term Ureteral Double-J Stenting. Int Neurourol J, \u003cstrong\u003e14:\u003c/strong\u003e 93, 2010\u003c/li\u003e\n\u003cli\u003eLucas, J. W., Ghiraldi, E., Ellis, J., Friedlander, J. I.: Endoscopic Management of Ureteral Strictures: an Update. Curr Urol Rep, \u003cstrong\u003e19:\u003c/strong\u003e 24, 2018\u003c/li\u003e\n\u003cli\u003eManassero, F., Mogorovich, A., Fiorini, G. et al.: Ureteral reimplantation with psoas bladder hitch in adults: a contemporary series with long-term followup. ScientificWorldJournal, \u003cstrong\u003e2012:\u003c/strong\u003e 379316, 2012\u003c/li\u003e\n\u003cli\u003eAhn, M., Loughlin, K. R.: Psoas hitch ureteral reimplantation in adults--analysis of a modified technique and timing of repair. Urology, \u003cstrong\u003e58:\u003c/strong\u003e 184, 2001\u003c/li\u003e\n\u003cli\u003eMiddleton, R. G.: Routine use of the psoas hitch in ureteral reimplantation. J Urol, \u003cstrong\u003e123:\u003c/strong\u003e 352, 1980\u003c/li\u003e\n\u003cli\u003eRiedmiller, H., Becht, E., Hertle, L. et al.: Psoas-hitch ureteroneocystostomy: experience with 181 cases. Eur Urol, \u003cstrong\u003e10:\u003c/strong\u003e 145, 1984\u003c/li\u003e\n\u003cli\u003eGroen, V. H., Lock, M., de Angst, I. B. et al.: Psoas hitch procedure in 166 adult patients: The largest cohort study before the laparoscopic era. BJUI Compass, \u003cstrong\u003e2:\u003c/strong\u003e 331, 2021\u003c/li\u003e\n\u003cli\u003eGrimes, M. D., Schubbe, M. E., Erickson, B. A.: A systematic approach for successful repair of radiated and non-radiated ureteral injuries. Transl Androl Urol, \u003cstrong\u003e11:\u003c/strong\u003e 30, 2022\u003c/li\u003e\n\u003cli\u003eHardesty, J. K., Burns, R. T., Soyster, M. E. et al.: Female bladder dysfunction following Boari bladder flap ureteral reconstruction. Urology, 2024\u003c/li\u003e\n\u003cli\u003eReicherz, A., Eltit, F., Scotland, K. et al.: Indwelling stents cause severe inflammation and fibrosis of the ureter via urothelial-mesenchymal transition. Sci Rep, \u003cstrong\u003e13:\u003c/strong\u003e 5492, 2023\u003c/li\u003e\n\u003cli\u003eKanammit, P., Sirisreetreerux, P., Boongird, S. et al.: Intraoperative assessment of ureter perfusion after revascularization of transplanted kidneys using intravenous indocyanine green fluorescence imaging. Transl Androl Urol, \u003cstrong\u003e10:\u003c/strong\u003e 2297, 2021\u003c/li\u003e\n\u003cli\u003eTurner-Warwick, R., Chapple, C. R.: Functional Reconstruction of the Urinary Tract and Gynaeco-Urology: Wiley, 2002\u003c/li\u003e\n\u003cli\u003eProut, G. R., Jr., Koontz, W. W., Jr.: Partial vesical immobilization: an important adjunct to ureteroneocystostomy. J Urol, \u003cstrong\u003e103:\u003c/strong\u003e 147, 1970\u003c/li\u003e\n\u003cli\u003eStein, R., Rubenwolf, P., Ziesel, C. et al.: Psoas hitch and Boari flap ureteroneocystostomy. BJU Int, \u003cstrong\u003e112:\u003c/strong\u003e 137, 2013\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Ureteral stricture, cancer survivorship, psoas hitch","lastPublishedDoi":"10.21203/rs.3.rs-6796217/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6796217/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe present 10-year experience and patient outcomes for the bladder elongation with psoas hitch (BEPH) procedure for mid to distal ureteral strictures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe reviewed all adult patients undergoing BEPH for ureteral stricture disease between 2013 and 2024. The primary outcome was procedural success, defined as no need for further intervention for stricture (redo repair, nephrectomy, nephrostomy tube or stent). The secondary outcome was change in AUA Symptom Scores (AUASS).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 108 patients underwent surgery during this time, 70 patients met inclusion criteria, with a median age at surgery of 54 years (IQR 43–63). 20 patients (28.5%) had previous radiation therapy, 61 (87%) had prior abdominal surgery, and 30 (42.9%) had prior failed management. Median length of stay was 2 days (IQR 1–4), with 34 (48.6%) of patients leaving by postoperative day 1. Median length of follow-up was 34 months (IQR 21–58). Overall procedural success rate was 98.5% (69/70), with one patient requiring a redo reimplant. Analysis of AUA Symptom scores showed no difference in individual symptom domains, with significant improvement in the mean pre- and postoperative AUA total score (p = 0.03) and Quality of Life score (p \u0026lt; 0.01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBladder elongation with psoas hitch is a durable solution with a high success rate and limited morbidity for patients with a mid-to-distal ureteral stricture. Despite altering bladder morphology, BEPH significantly improves quality of life scores, and is not associated with worsening bladder symptom scores.\u003c/p\u003e","manuscriptTitle":"Multi-Institutional Evaluation of Bladder Elongation Psoas Hitch (BEPH): A Safe and Durable Solution for Mid to Distal Ureteral Strictures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-14 11:18:46","doi":"10.21203/rs.3.rs-6796217/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-10T08:57:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-13T21:27:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"49582212283333639038553473256270777726","date":"2025-07-11T06:27:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"108514949435305679085957107484905567003","date":"2025-07-08T21:39:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-08T17:41:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-16T17:04:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-16T15:37:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Urology","date":"2025-06-01T14:25:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2aebcae7-43ee-4ef1-a5a9-9feb27d71eec","owner":[],"postedDate":"July 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-26T16:05:43+00:00","versionOfRecord":{"articleIdentity":"rs-6796217","link":"https://doi.org/10.1007/s00345-025-06043-z","journal":{"identity":"world-journal-of-urology","isVorOnly":false,"title":"World Journal of Urology"},"publishedOn":"2026-01-21 15:59:00","publishedOnDateReadable":"January 21st, 2026"},"versionCreatedAt":"2025-07-14 11:18:46","video":"","vorDoi":"10.1007/s00345-025-06043-z","vorDoiUrl":"https://doi.org/10.1007/s00345-025-06043-z","workflowStages":[]},"version":"v1","identity":"rs-6796217","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6796217","identity":"rs-6796217","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}