Ureteral Strictures: Insights into Etiology, Surgical Failure Prediction, and Decision Tree Development from a High-Volume 20-Year Single-Center Experience

Ureteral Strictures: Insights into Etiology, Surgical Failure Prediction, and Decision Tree Development from a High-Volume 20-Year Single-Center Experience | 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 Ureteral Strictures: Insights into Etiology, Surgical Failure Prediction, and Decision Tree Development from a High-Volume 20-Year Single-Center Experience Sasha J Vereecken, Karen M Doersch, Cole W J Ossian, Rohan G Bhalla, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7110073/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract INTRODUCTION AND OBJECTIVES This study examines variations in ureteral stricture reconstruction across a large patient cohort, focusing on surgical history, radiation exposure, and stricture location. By identifying patterns in reconstructive approaches and their impact on outcomes, we aim to support clinical decision-making and improve patient care. METHODS A retrospective review of ureteral reconstruction cases from 2003 to 2024 at a single center was conducted. Surgical success was symptom- and tube-free without further intervention for pain and absent obstruction. Descriptive statistics and chi-square testing evaluated group differences. RESULTS We identified 257 subjects who underwent ureteral reconstruction in the study period. Ureteral strictures present a complex clinical challenge with diverse etiologies, including iatrogenic injury (44.4%), impacted stones (11.7%), retroperitoneal fibrosis (10.1%), and radiation (6.2%). Patients without a surgical history were more likely to require reconstruction of the ureter above the iliac arteries (p < 0.001). In 88% of reported outcomes, surgical success was achieved, with postoperative urinary tract infections (UTIs) and radiation exposure being significant predictors of failure. At 30 days post-operatively, complications Clavien-Dindo Grade III occurred in 0.4% of cases (n=1). The average time from surgery to last recorded follow-up was 326 days. We established a decision tree to aid in clinician judgment for surgery selection. CONCLUSIONS Ureteral reconstruction is highly effective; however, several factors influence outcomes. Prior surgery impacted stricture location, and both radiation exposure and postoperative UTIs were predictors of failure. Previous surgical history significantly influenced stricture location, with non-surgical patients more often presenting with proximal disease. Despite these challenges, ureteral reconstruction remains highly effective, achieving excellent functional and anatomical outcomes. A decision-making algorithm incorporating location, etiology, and surgical history may improve patient selection and reduce secondary reconstructive surgeries. Figures Figure 1 INTRODUCTION Ureteral strictures are bothersome for both the patient and the surgeon and ideal management has not been firmly established for strictures at different lengths and locations. If left untreated, these strictures can lead to progressive renal dysfunction, recurrent urinary tract infections, and increased morbidity. 1, 2 Despite the profound clinical impact of ureteral strictures, the existing literature provides only a fragmentary understanding of their pathophysiology, optimal management strategies, and long-term outcomes. 3 Recognizing this gap, our study aims to contribute our insights from a comprehensive, single-center analysis drawn from over two decades of experience in the diagnosis and treatment of ureteral strictures. By sharing lessons gained from our institutional expertise, we seek to enhance the collective understanding of this complex condition and inform the direction of future therapeutic approaches. Etiology Ureteral strictures are a progressive narrowing of the ureteral lumen that can silently wreak havoc on both the ureter and kidney. As the disease progresses the ureter continues to experience increased intraluminal pressure proximal to the stricture, which can cause dilation and weakening of the ureteral wall. 1 The kidney is affected by the back pressure from the obstructed urine flow, leading to progressive renal dysfunction. Renal function impairment secondary to ureteral stricture, if left untreated, can progress to chronic kidney disease (CKD) and ultimately end-stage renal disease (ESRD). The obstruction also predisposes the kidney to recurrent infections, which can further damage renal parenchyma and increase morbidity. 4 Ureteral strictures can arise from both intrinsic and extrinsic causes, each with distinct underlying mechanisms. Intrinsic factors include ureteral stones, where prolonged impaction can trigger stricture formation. 2,5 Extrinsic causes, on the other hand, typically involve external compression, iatrogenic injury, radiation, or inflammatory processes. 6,7 Iatrogenic injury, often from ureteroscopy, is another common cause, particularly when complicated by ureteral perforation, increased use of ureteral access sheaths, or prolonged surgical time. 8 Furthermore, surgical procedures near the ureters, even when not directly involving them, are a frequent source of injury. Understanding these diverse etiologies is crucial for optimizing prevention, diagnosis, and management strategies. Pathophysiology Ureteral stricture formation is increasingly recognized as a complex, multifactorial process driven by cell-mediated inflammatory responses, with immune and extracellular matrix signaling. 11 Despite only two relevant studies specifically addressing ureteral fibrosis, both in vitro and in vivo data suggest that extracellular matrix signaling and inflammation are central to scar formation. 10,11 Inflammatory pathways like COX-2 are significantly upregulated in human ureteral strictures compared to healthy tissue. 3,12 In porcine models, COX-2 levels rise within six hours of obstruction and remain elevated, while TGF-β expression increases in macrophages and fibroblasts for up to 28 days. 12 Additional studies suggest that injured fibroblasts may further stimulate macrophage-driven TGF-β production. 13 Further contributing to this complex pathophysiology are inflammatory cell infiltrates, including lymphocytes, neutrophils, and eosinophils, which are commonly observed in stricture tissue and can be triggered by indwelling stents, surgical trauma, or infections. 13,14 This leads to a fibrotic process characterized by excessive deposition of extracellular matrix components, such as collagen types I and III, mediated by activated fibroblasts and myofibroblasts in response to cytokines and growth factors. 14 Ureteral perforation and mucosal damage from procedures like ureteroscopy, compounded by ischemia due to compromised blood supply, further trigger a wound-healing response that culminates in stricture formation. 11,15 Collectively, these mechanisms highlight the urgent need for a deeper understanding of ureteral strictures. Utilizing our extensive case database is a crucial first step in identifying patterns and working backward to uncover the cellular and molecular drivers of this condition, ultimately guiding the discovery of novel biomarkers, therapeutic targets, and improved surgical outcomes. Management Patients with ureteral strictures may present with flank pain, new onset impaired renal function, or recurrent UTIs. However, despite the potential for severe renal damage, many patients with ureteral strictures remain asymptomatic, making diagnosis challenging. Given the limitations of history and physical examination alone, imaging is essential to confirm strictures and guide appropriate management .16 For some, ureteral stricture disease necessitates temporizing measures such as stents or nephrostomy tubes, which can be painful, require frequent exchanges, and lead to time off work and increased healthcare utilization. 16-18 Advancements in surgical robotics have revolutionized the world of ureteral reconstruction, offering promising solutions for procedures such as ureteral reimplantation, pyeloplasty, and ureteroureterostomy, as well as the innovative use of buccal mucosal grafting for complex ureteral defect repair. 19-22 Despite these technological strides, predicting stricture recurrence remains an ongoing challenge, underscoring the need for refined prevention strategies to enhance patient counseling and long-term management. 19-22 While ureteral strictures are strongly associated with prior radiation therapy and interventions for ureteral calculi, the specific factors driving recurrence in these high-risk populations remain elusive. 22 Identifying which patients are most vulnerable to recurrence after surgical intervention and implementing strategies to mitigate further damage could significantly improve outcomes. A deeper understanding of key variables such as postoperative complications, renal function recovery, and long-term stricture durability is essential for optimizing surgical success and patient quality of life. Current management strategies range from minimally invasive approaches, such as endoscopic balloon dilation and stent placement, which are often used as temporizing measures, to definitive surgical reconstruction, where damaged ureteral segments are excised or expanded through complex repair techniques. 21,23 However, as surgical innovation progresses, the incidence of iatrogenic ureteral injury has concurrently risen, fueling inflammation, fibrosis, and subsequent stricture formation. To combat these challenges, ongoing research is crucial, not only to refine existing treatment modalities but also to develop proactive measures that prevent recurrence and improve the longevity of ureteral repair. This study seeks to increase our knowledge of ureteral strictures and their management by evaluating predictors of surgical success following stricture treating procedures and examining trends in stricture treatment over time. This study evaluates factors influencing the outcomes of ureteral reconstructive surgery and understands changes in practice patterns for the management of ureteral strictures. This study seeks to identify patients who will most benefit from each type of reconstructive ureteral surgery to correct strictures, and which patients are likely to experience a failure of their repair or complication and thus would benefit from closer monitoring. Additionally, we sought to develop and refine an algorithm for the management of ureteral strictures. METHODS This study presents a retrospective review of patients who underwent ureteral reconstruction (UR) between 2003 and 2025. IRB approval was obtained at the host institution to perform retrospective chart reviews (IRB#:23-1572). The inclusion criteria covered patients who underwent ureteral reconstruction (UR) for ureteral stricture. Exclusion criteria included those with incomplete records, non-stricture indications for urologic repair, or primary endoscopic management without reconstruction. Etiology included iatrogenic injury, retroperitoneal fibrosis, malignancy, radiation injury, congenital anomalies, and other causes. The classification of ureteral strictures was based on their anatomical relationship to the iliac vessels. Strictures in the upper segment were located above the iliac vessels, while those in the lower segment were below them. For this analysis, the mid-ureter was considered part of the upper segment. The primary outcome measure was surgical success, defined as patients being asymptomatic and hardware-free postoperatively, without evidence of obstruction on imaging, and with no need for further intervention. Secondary outcomes included stricture location, etiology, surgical approach, and complication rates, which were classified using the Clavien-Dindo system. Descriptive statistics were used to summarize baseline characteristics, while chi-square testing analyzed categorical variables, specifically evaluating the relationship between surgical success and failure to determine statistical significance between these groups. RESULTS Demographics Ureteral stricture represents a complex clinical challenge with diverse etiologies and demographic distributions (Table 1). In this cohort of 257 patients, the mean age at diagnosis was 53 years (range, 19–81 years), with a slight female predominance (male-to-female ratio, 1:1.57). Strictures were more frequently observed on the left side (n=123) than the right (n=104), with 29 patients exhibiting bilateral involvement. The mean body mass index (BMI) was 28.6± (11.9), indicating that most patients fell within the overweight category. Of the surgeries, 49.8% were open (n=128) and 50.2% were robotic (n=129). Mean duration of follow up was 326 days ± (749). Etiology The leading etiologies for ureteral stricture were surgical injury (50.7%, n=114) most commonly following pelvic surgery. Other causes included impacted stones (13.3%, n=30) and radiation (7.1%, n=16). A history of abdominal or pelvic surgery was present in 82.5% of patients (n=212), with major gynecologic procedures being the most common prior surgical procedure (36.8%, n=42). Given the high incidence of iatrogenic strictures, especially post-surgical, these findings underscore the need for preventive strategies and refined surgical techniques to minimize ureteral injury. The broad age range, female predominance, and variability in stricture location highlight the heterogeneity of this condition, necessitating individualized treatment approaches tailored to each patient's anatomical and etiological profile. Surgical failure occurred in 18.8% of patients with a history of prior stricture surgery (19/101), compared to just 7.1% (10/140) among those without prior stricture surgery. Patients without a prior stricture had significantly higher odds of surgical success (p < 0.05), highlighting a history of stricture as a strong predictor of surgical failure. These findings emphasize the impact of previous stricture disease on surgical prognosis and highlight the need for tailored approaches to optimize outcomes in these high-risk patients. Location Involvement of the proximal ureter occurred in 59.7% cases (n=123) and the distal ureter in 40.3% (n=83). The distinction between proximal and distal US was above and below the iliac vessels, respectively. A small number of patients had more extensive disease, including pan-ureteral involvement (n=1) and combined proximal and distal strictures (n=1). 96.3% of distal strictures (79/82) occurred in patients with a history of prior surgery, compared with 72.4% of proximal strictures (89/123), which was statistically significant (p < 0.05). Prior surgery is far less common in patients with distal ureteral strictures. This suggests that surgical injury may play a larger role in distal ureteral strictures, while proximal ureteral strictures are less frequently linked to surgical history. Surgical Success Success, defined as postoperative freedom from symptoms, further surgical intervention, and hardware, was achieved in 88% of all reported patients undergoing UR for stricture (n=212/241), consistent with prior institutional series. 24 Within 30 days of the index surgery, complications greater than or equal to Clavien-Dindo Grade IIIb occurred in 3.1% of cases (n=8). Surgical success was achieved in 81.3% of open cases (n=104) and 86.0% of robotic cases (n=111), while failure occurred in 12.5% (n=16) and 10.1% (n=13), respectively. There was no statistically significant difference in success rates between the two modalities (p=0.49). Overall, 21% (n=54) of patients required additional intervention after the index surgery, with an average time to reintervention of 17 months. Patients with a history of radiation were significantly less likely to achieve surgical success compared to those without radiation exposure (p < 0.05) (Table 2) . The odds of success were markedly lower in the radiation-exposed group compared to the non-radiation group with an odds ratio of 0.35, indicating a reduced likelihood of success in irradiated patients. These results underscore the negative impact of prior radiation on surgical outcomes and highlight the need for tailored approaches to optimize success in this high-risk population. Average stent placement duration was notably longer in the surgical failure group (7.9 weeks) compared to the surgical success group (5.4 weeks). These findings underscore the critical role of infection prevention and stent management in optimizing surgical outcomes. Alternatively, the stents in these subjects may have remained longer due to surgeon concerns. Post-Operative UTI There was no significant difference in any post-operative outcomes between patients who were prescribed antibiotics at discharge and those who were not. However, postoperative UTIs with a stent in place were strongly associated with surgical failure. Among patients who developed a post-operative UTI, 26% (15/57) experienced surgical failure, compared to only 6.5% (13/200) of those without a UTI (p < 0.001). Development of a Surgical Decision-Making Algorithm Despite advancements in ureteral reconstruction and the increasing adoption of surgical techniques, there remains a lack of consensus on the optimal approach for managing ureteral strictures. The absence of standardized guidelines highlights the need for an evidence-based framework to guide decision-making. To our knowledge, this study is the first to develop a comprehensive, evidence-based surgical algorithm for ureteral stricture management. Using a robust single-center database of 257 patients, we identified statistically significant variables influencing surgical outcomes and integrated these findings with prior literature on ureteral and ureteral reconstruction. Given the complexity of ureteral stricture management, a structured approach is essential for selecting the most effective surgical modality. To address this gap, SJV, KMD, and BJF formulated an algorithm (Figure 1.) that incorporates key patient and disease-specific factors, including stricture location, and etiology. Further details of the decision tree (length, UPJ involvement) were then determined and further refined based off our previous narrative reviews of the literature. 25 Ureteral stricture management requires a structured assessment based on stricture location (proximal or distal to the iliac vessels), length (2 cm), etiology (iatrogenic, radiation-induced, inflammatory, congenital), prior interventions, comorbidities, and radiation history. Cases with extensive fibrosis or poor tissue quality may require buccal mucosa graft (BMG) ureteroplasty. Long-segment or recurrent strictures require advanced techniques, with Psoas hitch or Boari flap preferred for distal or mid-ureteral involvement, and ileal ureter interposition for mid to proximal strictures. Radiation-induced or multi-segment strictures require a tailored approach, with BMG ureteroplasty for localized disease and ileal ureter substitution for extensive involvement. Additional considerations include prolonged stenting for UTI-prone patients, escalation to more durable repairs in cases of prior failure, and urinary diversion for those with poor bladder compliance. Postoperative monitoring should focus on stent dependence, UTI prevention, and reintervention rates to refine surgical selection and optimize outcomes. DISCUSSION This study underscores the nuanced relationship between patient-specific factors, surgical selection, and overall surgical success in ureteral stricture reconstruction. These findings hint that subjects with a prior surgical history may be more vulnerable to distal ureteral strictures than those without prior pelvic abdominopelvic surgery. Factors identified to be associated with failure of surgical repair included early post-operative UTIs and history of pelvic radiation, highlighting patient populations who may be at high risk and require closer monitoring. Additionally, there was no difference in outcomes between the robotic and open approaches, indicating that the selection of surgical approach should be driven by patient characteristics and surgeon comfort. A renaissance in ureteral reconstruction is underway, driven by advancements in robotic-assisted surgery that offer improved visualization, precision, and superior patient outcomes. 26 Innovation continues to push the boundaries of surgical management, with the development of grafts enhancing reconstructive options and expanding the possibilities for tissue regeneration. Single-port robotic surgery has emerged as a promising advancement in ureteral reconstruction, offering a simplified surgical approach while improving clinical outcomes in the management of ureteral strictures. 27 As endoscopic treatments remain limited in their durability and effectiveness for complex strictures, these evolving techniques present a promising future, reshaping the landscape of upper urinary tract reconstruction. Strengths, Limitations, & Future Directions This study leverages a large cohort from a high-volume center, drawing from a database of 257 patients treated over 22 years to provide substantial insight into surgical outcomes and algorithm development. As the first study to propose an evidence-based surgical decision-making algorithm for ureteral reconstruction, it integrates key patient and disease-specific factors to optimize individualized treatment strategies. Additionally, by evaluating multiple surgical modalities and identifying statistically significant predictors of success and failure, this study enhances clinical decision-making and postoperative management. The findings also underscore critical postoperative risk factors, such as UTI recurrence and radiation history, offering guidance for patient follow-up and improving long-term outcomes. Several limitations should be considered. As a single-center study, the findings may not be fully generalizable to institutions with different patient populations, surgical expertise, or healthcare infrastructures. The retrospective design introduces selection bias and limits causal inferences. Additionally, while recurrence and complications were assessed, continued follow-up is needed as new methods emerge to allow for further comparison. Multi-institutional validation is also needed to confirm the reproducibility of the proposed algorithm. Furthermore, non-surgical factors such as patient-reported quality of life, cost-effectiveness, and healthcare access were not assessed, warranting further investigation. Future studies should prioritize prospective, multi-institutional validation to enhance applicability across diverse populations. Longitudinal follow-up will provide deeper insights into recurrence patterns and long-term success rates. Integrating patient-reported outcomes will refine decision-making by incorporating functional and quality-of-life considerations. Additionally, obtaining pathological specimens for all strictures could offer valuable insights into pathogenesis and tissue-specific treatment responses. Continued validation of the decision tree across multiple institutions is essential to ensure its reliability and clinical impact. CONCLUSION Preoperative planning and postoperative management are essential to optimizing long-term outcomes in ureteral reconstruction. Postoperative UTIs and prolonged stent use were strongly associated with surgical failure, highlighting the importance of early detection and intervention. Stricture recurrence remains a major concern, particularly in patients with prior radiation or multiple interventions, reinforcing the need for vigilant surveillance and timely management. Stricture location, etiology, and prior surgical history significantly influenced outcomes, underscoring the value of a tailored, risk-stratified approach to treatment. Notably, patients without prior surgery had much higher rates of proximal stricture, suggesting differing pathophysiologic mechanisms and surgical considerations. Despite these complexities, ureteral reconstruction remains highly effective, with excellent rates of functional success. To translate these findings into clinical practice, we developed a decision tree algorithm that integrates statistically significant predictors (such as stricture location and length) into a stepwise framework for operative planning based off our 257-patient cohort. This individualized, evidence-based tool enhances clinical decision-making, improves patient counseling, and reduces the risk of reintervention. As ureteral stricture cases grow in complexity, such structured, data-driven models will be critical for delivering precise and durable surgical care. Declarations Conflict of interest The authors declare no competing interests. Ethical approval This study was reviewed and determined to be exempt from formal review by the Colorado Multiple Institutional Review Board (COMIRB) (IRB#:23-1572). Due to the retrospective nature of the study, the requirement for formal ethical approval was waived. All patients provided written informed consent to participate and agreed to the use of their anonymized data for research purposes. The study complies with the Declaration of Helsinki. Informed consent All patients signed an informed consent form agreeing to share their anonymized data for future research studies. Funding This work was supported in part by the Society of Women in Urology (SWIU) Elizabeth Pickett Research Grant, awarded to KMD. Author Contribution S.J.V., K.M.D., and B.J.F. conceptualized the study. S.J.V., K.M.D., C.W.J.O., and R.G.B. curated the data and conducted the investigation. S.J.V. and K.M.D. performed the formal analysis and developed the software. K.M.D. acquired funding. S.J.V., K.M.D., C.W.J.O., and R.G.B. contributed to the methodology. S.J.V. and K.M.D. managed the project and provided resources. B.J.F. supervised the study. K.M.D. and B.J.F. validated the findings. S.J.V. and K.M.D. created the visualizations. S.J.V., K.M.D., and C.W.J.O. wrote the original manuscript draft. R.G.B. and B.J.F. reviewed and edited the manuscript. All authors reviewed and approved the final version. Data Availability Data is provided within the manuscript. References Tyritzis SI, Wiklund NP (2015) Ureteral strictures revisited… trying to see the light at the end of the tunnel: a comprehensive review. J Endourol 29(2):124–136. 10.1089/end.2014.0522 Sunaryo PL, May PC, Holt SK, Sorensen MD, Sweet RM, Harper JD (2022) Ureteral Strictures Following Ureteroscopy for Kidney Stone Disease: A Population-based Assessment. J Urol 208(6):1268–1275. 10.1097/JU.0000000000002929 Tan J, Yu Z, Ling X et al (2022) Main Pathological Changes of Benign Ureteral Strictures. Front Med (Lausanne) 9:916145 Published 2022 Jul 7. 10.3389/fmed.2022.916145 Yang J, Sun BG, Min HJ et al (2021) Impact of acute kidney injury on long-term adverse outcomes in obstructive uropathy. 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Summary of Results Preoperative Data Sex, n (%) N = 257 (%) Female 157 (61.2) Male 100 (38.9) Age, median (IQR)(years) 53.1 (26.1) Body Mass Index, mean(SD) 28.6 (11.9) Stricture Laterality, n (%) N = 256 (%) Left 123 (48.0) Right 104 (40.6) Bilateral 29 (11.3) Stricture Location, n (%) N = 206 (%) Upper Ureter 123 (59.7) Lower Ureter 83 (40.3) Stricture Etiology, n (%) N = 224 (%) Surgical Injury 114 (50.9) Impacted Stone 30 (13.4) Retroperitoneal Fibrosis 26 (11.6) Radiation 16 (7.1) Congenital 12 (5.4) Crossing Vessel 9 (4.0) Idiopathic 8 (3.6) Malignancy 8 (3.6) Trauma 1 (0.4) Intraoperative Data* N = 199 (%) Procedure Preformed n (%) Reimplant 59 (29.6) Pyeloplasty 43 (21.6) Buccal Mucosa Graft Ureteroplasty 25 (12.6) Ileal Ureter 20 (10.1) Ureteruretostomy 18 (9.0) Ureterolysis 17 (8.6) Non-Transecting Ureteroplasty 13 (6.5) Pelviolithotomy 2 (1,0) Urinary undiversion 1 (0.5) Ileal ureteral interposition 1 (0.5) Surgery Length, median (IQR)(minutes) 289 (122) Postoperative Data Admission Length, median (IQR)(days) 3 (4) Length of Stent in Place, median (IQR)(weeks) 5 (2) *Data for Intraoperative data is lower due to availability of data This table summarizes single-variable associations between key surgical factors and success of ureteral stricture reconstruction. Higher success rates were observed in patients with shorter strictures, iatrogenic etiologies, and those undergoing graft-based repairs. Complex or recurrent cases with prior failed interventions showed lower success rates. Table 2. Single Variable Analysis of Surgical Outcomes of Patients Undergoing Urethral Stricture Reconstructive Surgery Surgical Success µ Surgical Failure p Value OR (95% CI) History of Prior Ureteral Stricture N = 212 (%) N = 29 (%) Yes 82 (38.7) 19 (65.5) < 0.05 0.33 (0.47 - 0.74) No 130 (61.3) 10 (34.51) History of Prior Abdominal/Pelvic Surgery N = 211 (%) N = 29 (%) Yes 175 (82.9) 23 (79.3) 0.62 1.26 (0.39 - 3.33) No 36 (17.1) 6 (20.7) History of Prior Abdominal/Pelvic Radiation Therapy N = 212 (%) N = 29 (%) Yes 25 (11.8) 8 (27.6) < 0.05 0.35 (0.55 - 0.87) No 187 (88.2) 21 (72.4) Postoperative UTI N = 229 (%) N = 28 (%) Yes 42 (18.3) 15 (53.6) < 0.01 0.19 (0.50 - 0.44) No 187 (81.7) 13 (46.4) *Percentages may not total 100 due to rounding µ Surgical success defined as symptom- and tube-free postoperatively, with no further intervention required for pain in the absence of obstruction This table presents the association between individual clinical and operative variables and surgical success following urethral stricture reconstruction. Variables assessed include stricture location, etiology, length, surgical technique, prior interventions, and comorbidities. Statistical significance was determined using chi-square as appropriate. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-7110073","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":494753013,"identity":"08987273-483b-4f5b-8359-0854d87314da","order_by":0,"name":"Sasha J Vereecken","email":"data:image/png;base64,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","orcid":"","institution":"University of Colorado Anschutz Medical Campus","correspondingAuthor":true,"prefix":"","firstName":"Sasha","middleName":"J","lastName":"Vereecken","suffix":""},{"id":494753014,"identity":"e48586a5-8ae2-4023-9166-4f3d1b5c6b3a","order_by":1,"name":"Karen M Doersch","email":"","orcid":"","institution":"University of Colorado Anschutz Medical Campus","correspondingAuthor":false,"prefix":"","firstName":"Karen","middleName":"M","lastName":"Doersch","suffix":""},{"id":494753015,"identity":"16d9a507-d641-4523-b794-39f880cc4722","order_by":2,"name":"Cole W J Ossian","email":"","orcid":"","institution":"University of Colorado Anschutz Medical Campus","correspondingAuthor":false,"prefix":"","firstName":"Cole","middleName":"W J","lastName":"Ossian","suffix":""},{"id":494753016,"identity":"67f43d78-f1f3-4075-bd2c-f6b89a450d40","order_by":3,"name":"Rohan G Bhalla","email":"","orcid":"","institution":"University of Colorado Anschutz Medical Campus","correspondingAuthor":false,"prefix":"","firstName":"Rohan","middleName":"G","lastName":"Bhalla","suffix":""},{"id":494753017,"identity":"11af08c6-24db-425e-b13d-677b29c2ac19","order_by":4,"name":"Brian J Flynn","email":"","orcid":"","institution":"University of Colorado Anschutz Medical Campus","correspondingAuthor":false,"prefix":"","firstName":"Brian","middleName":"J","lastName":"Flynn","suffix":""}],"badges":[],"createdAt":"2025-07-12 20:23:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7110073/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7110073/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88408377,"identity":"66c46b32-06a3-46c1-a797-dc05a31b407d","added_by":"auto","created_at":"2025-08-06 08:12:16","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":209574,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical Management of Ureteral Stricture Algorithm\u003c/p\u003e\n\u003cp\u003eAn evidence-based clinical decision-making algorithm guiding the selection of surgical approaches for ureteral stricture based on location, etiology, length, and prior interventions\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7110073/v1/ba0e38dd8e60094dac5f99d0.jpeg"},{"id":93909569,"identity":"f301cdbf-edbb-4f9f-900e-f6a18081145e","added_by":"auto","created_at":"2025-10-20 07:47:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":730344,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7110073/v1/b1d487cc-b300-44c1-8893-44356f33b074.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Ureteral Strictures: Insights into Etiology, Surgical Failure Prediction, and Decision Tree Development from a High-Volume 20-Year Single-Center Experience","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eUreteral strictures are bothersome for both the patient and the surgeon and ideal management has not been firmly established for strictures at different lengths and locations. If left untreated, these strictures can lead to progressive renal dysfunction, recurrent urinary tract infections, and increased morbidity.\u003csup\u003e1, 2\u003c/sup\u003e Despite the profound clinical impact of ureteral strictures, the existing literature provides only a fragmentary understanding of their pathophysiology, optimal management strategies, and long-term outcomes.\u003csup\u003e3\u0026nbsp;\u003c/sup\u003eRecognizing this gap, our study aims to contribute our insights from a comprehensive, single-center analysis drawn from over two decades of experience in the diagnosis and treatment of ureteral strictures. By sharing lessons gained from our institutional expertise, we seek to enhance the collective understanding of this complex condition and inform the direction of future therapeutic approaches.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003eEtiology\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Ureteral strictures are a progressive narrowing of the ureteral lumen that can silently wreak havoc on both the ureter and kidney. As the disease progresses the ureter continues to experience increased intraluminal pressure proximal to the stricture, which can cause dilation and weakening of the ureteral wall.\u003csup\u003e1\u003c/sup\u003e The kidney is affected by the back pressure from the obstructed urine flow, leading to progressive renal dysfunction. Renal function impairment secondary to ureteral stricture, if left untreated, can progress to chronic kidney disease (CKD) and ultimately end-stage renal disease (ESRD). The obstruction also predisposes the kidney to recurrent infections, which can further damage renal parenchyma and increase morbidity.\u003csup\u003e4\u003c/sup\u003e Ureteral strictures can arise from both intrinsic and extrinsic causes, each with distinct underlying mechanisms. Intrinsic factors include ureteral stones, where prolonged impaction can trigger stricture formation.\u003csup\u003e2,5\u003c/sup\u003e Extrinsic causes, on the other hand, typically involve external compression, iatrogenic injury, radiation, or inflammatory processes.\u003csup\u003e6,7\u003c/sup\u003e Iatrogenic injury, often from ureteroscopy, is another common cause, particularly when complicated by ureteral perforation, increased use of ureteral access sheaths, or prolonged surgical time.\u003csup\u003e8\u0026nbsp;\u003c/sup\u003eFurthermore, surgical procedures near the ureters, even when not directly involving them, are a frequent source of injury. Understanding these diverse etiologies is crucial for optimizing prevention, diagnosis, and management strategies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003ePathophysiology\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Ureteral stricture formation is increasingly recognized as a complex, multifactorial process driven by cell-mediated inflammatory responses, with immune and extracellular matrix signaling.\u003csup\u003e11\u003c/sup\u003e Despite only two relevant studies specifically addressing ureteral fibrosis, both in vitro and in vivo data suggest that extracellular matrix signaling and inflammation are central to scar formation.\u003csup\u003e10,11\u003c/sup\u003e Inflammatory pathways like COX-2 are significantly upregulated in human ureteral strictures compared to healthy tissue.\u003csup\u003e3,12\u003c/sup\u003e In porcine models, COX-2 levels rise within six hours of obstruction and remain elevated, while TGF-β expression increases in macrophages and fibroblasts for up to 28 days.\u003csup\u003e12\u003c/sup\u003e Additional studies suggest that injured fibroblasts may further stimulate macrophage-driven TGF-β production.\u003csup\u003e13\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eFurther contributing to this complex pathophysiology are inflammatory cell infiltrates, including lymphocytes, neutrophils, and eosinophils, which are commonly observed in stricture tissue and can be triggered by indwelling stents, surgical trauma, or infections.\u003csup\u003e13,14\u003c/sup\u003e This leads to a fibrotic process characterized by excessive deposition of extracellular matrix components, such as collagen types I and III, mediated by activated fibroblasts and myofibroblasts in response to cytokines and growth factors.\u003csup\u003e14\u003c/sup\u003e Ureteral perforation and mucosal damage from procedures like ureteroscopy, compounded by ischemia due to compromised blood supply, further trigger a wound-healing response that culminates in stricture formation.\u003csup\u003e11,15\u0026nbsp;\u003c/sup\u003eCollectively, these mechanisms highlight the urgent need for a deeper understanding of ureteral strictures. Utilizing our extensive case database is a crucial first step in identifying patterns and working backward to uncover the cellular and molecular drivers of this condition, ultimately guiding the discovery of novel biomarkers, therapeutic targets, and improved surgical outcomes.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003eManagement\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Patients with ureteral strictures may present with flank pain, new onset impaired renal function, or recurrent UTIs. However, despite the potential for severe renal damage, many patients with ureteral strictures remain asymptomatic, making diagnosis challenging. Given the limitations of history and physical examination alone, imaging is essential to confirm strictures and guide appropriate management\u003csup\u003e.16\u003c/sup\u003e For some, ureteral stricture disease necessitates temporizing measures such as stents or nephrostomy tubes, which can be painful, require frequent exchanges, and lead to time off work and increased healthcare utilization.\u003csup\u003e16-18\u003c/sup\u003e Advancements in surgical robotics have revolutionized the world of ureteral reconstruction, offering promising solutions for procedures such as ureteral reimplantation, pyeloplasty, and ureteroureterostomy, as well as the innovative use of buccal mucosal grafting for complex ureteral defect repair.\u003csup\u003e19-22\u003c/sup\u003e Despite these technological strides, predicting stricture recurrence remains an ongoing challenge, underscoring the need for refined prevention strategies to enhance patient counseling and long-term management.\u003csup\u003e\u0026nbsp;19-22\u003c/sup\u003e While ureteral strictures are strongly associated with prior radiation therapy and interventions for ureteral calculi, the specific factors driving recurrence in these high-risk populations remain elusive.\u003csup\u003e22\u003c/sup\u003e Identifying which patients are most vulnerable to recurrence after surgical intervention and implementing strategies to mitigate further damage could significantly improve outcomes. A deeper understanding of key variables such as postoperative complications, renal function recovery, and long-term stricture durability is essential for optimizing surgical success and patient quality of life.\u003c/p\u003e\n\u003cp\u003eCurrent management strategies range from minimally invasive approaches, such as endoscopic balloon dilation and stent placement, which are often used as temporizing measures, to definitive surgical reconstruction, where damaged ureteral segments are excised or expanded through complex repair techniques.\u003csup\u003e21,23\u0026nbsp;\u003c/sup\u003eHowever, as surgical innovation progresses, the incidence of iatrogenic ureteral injury has concurrently risen, fueling inflammation, fibrosis, and subsequent stricture formation. To combat these challenges, ongoing research is crucial, not only to refine existing treatment modalities but also to develop proactive measures that prevent recurrence and improve the longevity of ureteral repair. This study seeks to increase our knowledge of ureteral strictures and their management by evaluating predictors of surgical success following stricture treating procedures and examining trends in stricture treatment over time. This study evaluates factors influencing the outcomes of ureteral reconstructive surgery and understands changes in practice patterns for the management of ureteral strictures. This study seeks to identify patients who will most benefit from each type of reconstructive ureteral surgery to correct strictures, and which patients are likely to experience a failure of their repair or complication and thus would benefit from closer monitoring. Additionally, we sought to develop and refine an algorithm for the management of ureteral strictures.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis study presents a retrospective review of patients who underwent ureteral reconstruction (UR) between 2003 and 2025. IRB approval was obtained at the host institution to perform retrospective chart reviews (IRB#:23-1572). The inclusion criteria covered patients who underwent ureteral reconstruction (UR) for ureteral stricture. Exclusion criteria included those with incomplete records, non-stricture indications for urologic repair, or primary endoscopic management without reconstruction. Etiology included iatrogenic injury, retroperitoneal fibrosis, malignancy, radiation injury, congenital anomalies, and other causes. The classification of ureteral strictures was based on their anatomical relationship to the iliac vessels. Strictures in the upper segment were located above the iliac vessels, while those in the lower segment were below them. For this analysis, the mid-ureter was considered part of the upper segment.\u003cbr\u003eThe primary outcome measure was surgical success, defined as patients being asymptomatic and hardware-free postoperatively, without evidence of obstruction on imaging, and with no need for further intervention. Secondary outcomes included stricture location, etiology, surgical approach, and complication rates, which were classified using the Clavien-Dindo system. Descriptive statistics were used to summarize baseline characteristics, while chi-square testing analyzed categorical variables, specifically evaluating the relationship between surgical success and failure to determine statistical significance between these groups.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDemographics\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003eUreteral stricture represents a complex clinical challenge with diverse etiologies and demographic distributions (Table 1). In this cohort of 257 patients, the mean age at diagnosis was 53 years (range, 19\u0026ndash;81 years), with a slight female predominance (male-to-female ratio, 1:1.57). Strictures were more frequently observed on the left side (n=123) than the right (n=104), with 29 patients exhibiting bilateral involvement. The mean body mass index (BMI) was 28.6\u0026plusmn; (11.9), indicating that most patients fell within the overweight category. Of the surgeries, 49.8% were open (n=128) and 50.2% were robotic (n=129). Mean duration of follow up was 326 days \u0026plusmn; (749). \u003cstrong\u003e\u003cem\u003eEtiology\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The leading etiologies for ureteral stricture were surgical injury (50.7%, n=114) most commonly following pelvic surgery. Other causes included impacted stones (13.3%, n=30) and radiation (7.1%, n=16). A history of abdominal or pelvic surgery was present in 82.5% of patients (n=212), with major gynecologic procedures being the most common prior surgical procedure (36.8%, n=42). Given the high incidence of iatrogenic strictures, especially post-surgical, these findings underscore the need for preventive strategies and refined surgical techniques to minimize ureteral injury.\u0026nbsp;\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; The broad age range, female predominance, and variability in stricture location highlight the heterogeneity of this condition, necessitating individualized treatment approaches tailored to each patient\u0026apos;s anatomical and etiological profile. Surgical failure occurred in 18.8% of patients with a history of prior stricture surgery (19/101), compared to just 7.1% (10/140) among those without prior stricture surgery. Patients without a prior stricture had significantly higher odds of surgical success (p \u0026lt; 0.05), highlighting a history of stricture as a strong predictor of surgical failure. These findings emphasize the impact of previous stricture disease on surgical prognosis and highlight the need for tailored approaches to optimize outcomes in these high-risk patients.\u003cbr\u003e\u003cstrong\u003e\u003cem\u003eLocation\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Involvement of the proximal ureter occurred in 59.7% cases (n=123) and the distal ureter in 40.3% (n=83). The distinction between proximal and distal US was above and below the iliac vessels, respectively. A small number of patients had more extensive disease, including pan-ureteral involvement (n=1) and combined proximal and distal strictures (n=1). 96.3% of distal strictures (79/82) occurred in patients with a history of prior surgery, compared with 72.4% of proximal strictures (89/123), which was statistically significant (p \u0026lt; 0.05). Prior surgery is far less common in patients with distal ureteral strictures. This suggests that surgical injury may play a larger role in distal ureteral strictures, while proximal ureteral strictures are less frequently linked to surgical history.\u003cbr\u003e\u003cstrong\u003e\u003cem\u003eSurgical Success\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u003cbr\u003e\u0026nbsp;\u003c/em\u003eSuccess, defined as postoperative freedom from symptoms, further surgical intervention, and hardware, was achieved in 88% of all reported patients undergoing UR for stricture (n=212/241), \u0026nbsp;consistent with prior institutional series.\u003csup\u003e24\u0026nbsp;\u003c/sup\u003eWithin 30 days of the index surgery, complications greater than or equal to Clavien-Dindo Grade IIIb occurred in 3.1% of cases (n=8). Surgical success was achieved in 81.3% of open cases (n=104) and 86.0% of robotic cases (n=111), while failure occurred in 12.5% (n=16) and 10.1% (n=13), respectively. There was no statistically significant difference in success rates between the two modalities (p=0.49).\u0026nbsp;\u003cbr\u003eOverall, 21% (n=54) of patients required additional intervention after the index surgery, with an average time to reintervention of 17 months. Patients with a history of radiation were significantly less likely to achieve surgical success compared to those without radiation exposure (p \u0026lt; 0.05)\u003cem\u003e\u0026nbsp;\u003c/em\u003e(Table 2)\u003cem\u003e.\u003c/em\u003e The odds of success were markedly lower in the radiation-exposed group compared to the non-radiation group with an odds ratio of 0.35, indicating a reduced likelihood of success in irradiated patients. These results underscore the negative impact of prior radiation on surgical outcomes and highlight the need for tailored approaches to optimize success in this high-risk population. Average stent placement duration was notably longer in the surgical failure group (7.9 weeks) compared to the surgical success group (5.4 weeks). These findings underscore the critical role of infection prevention and stent management in optimizing surgical outcomes. Alternatively, the stents in these subjects may have remained longer due to surgeon concerns.\u0026nbsp;\u003cbr\u003e \u003cstrong\u003e\u003cem\u003ePost-Operative UTI\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;There was no significant difference in any post-operative outcomes between patients who were prescribed antibiotics at discharge and those who were not. However, postoperative UTIs with a stent in place were strongly associated with surgical failure. Among patients who developed a post-operative UTI, 26% (15/57) experienced surgical failure, compared to only 6.5% (13/200) of those without a UTI (p \u0026lt; 0.001).\u0026nbsp;\u003cbr\u003e\u003cstrong\u003e\u003cem\u003eDevelopment of a Surgical Decision-Making Algorithm\u003cbr\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eDespite advancements in ureteral reconstruction and the increasing adoption of surgical techniques, there remains a lack of consensus on the optimal approach for managing ureteral strictures. The absence of standardized guidelines highlights the need for an evidence-based framework to guide decision-making. To our knowledge, this study is the first to develop a comprehensive, evidence-based surgical algorithm for ureteral stricture management. Using a robust single-center database of 257 patients, we identified statistically significant variables influencing surgical outcomes and integrated these findings with prior literature on ureteral and ureteral reconstruction.\u0026nbsp;\u003cbr\u003e Given the complexity of ureteral stricture management, a structured approach is essential for selecting the most effective surgical modality. To address this gap, SJV, KMD, and BJF formulated an algorithm (Figure 1.) that incorporates key patient and disease-specific factors, including stricture location, and etiology. Further details of the decision tree (length, UPJ involvement) were then determined and further refined based off our previous narrative reviews of the literature.\u003csup\u003e25\u003cbr\u003e\u0026nbsp;\u0026nbsp;\u003c/sup\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Ureteral stricture management requires a structured assessment based on stricture location (proximal or distal to the iliac vessels), length (\u0026lt;2 cm vs. \u0026gt;2 cm), etiology (iatrogenic, radiation-induced, inflammatory, congenital), prior interventions, comorbidities, and radiation history. Cases with extensive fibrosis or poor tissue quality may require buccal mucosa graft (BMG) ureteroplasty. Long-segment or recurrent strictures require advanced techniques, with Psoas hitch or Boari flap preferred for distal or mid-ureteral involvement, and ileal ureter interposition for mid to proximal strictures. Radiation-induced or multi-segment strictures require a tailored approach, with BMG ureteroplasty for localized disease and ileal ureter substitution for extensive involvement. Additional considerations include prolonged stenting for UTI-prone patients, escalation to more durable repairs in cases of prior failure, and urinary diversion for those with poor bladder compliance. Postoperative monitoring should focus on stent dependence, UTI prevention, and reintervention rates to refine surgical selection and optimize outcomes.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study underscores the nuanced relationship between patient-specific factors, surgical selection, and overall surgical success in ureteral stricture reconstruction. These findings hint that subjects with a prior surgical history may be more vulnerable to distal ureteral strictures than those without prior pelvic abdominopelvic surgery. Factors identified to be associated with failure of surgical repair included early post-operative UTIs and history of pelvic radiation, highlighting patient populations who may be at high risk and require closer monitoring. Additionally, there was no difference in outcomes between the robotic and open approaches, indicating that the selection of surgical approach should be driven by patient characteristics and surgeon comfort. \u0026nbsp;\u003cbr\u003eA renaissance in ureteral reconstruction is underway, driven by advancements in robotic-assisted surgery that offer improved visualization, precision, and superior patient outcomes.\u003csup\u003e26\u003c/sup\u003e Innovation continues to push the boundaries of surgical management, with the development of grafts enhancing reconstructive options and expanding the possibilities for tissue regeneration. Single-port robotic surgery has emerged as a promising advancement in ureteral reconstruction, offering a simplified surgical approach while improving clinical outcomes in the management of ureteral strictures.\u003csup\u003e27\u003c/sup\u003e As endoscopic treatments remain limited in their durability and effectiveness for complex strictures, these evolving techniques present a promising future, reshaping the landscape of upper urinary tract reconstruction.\u003cbr\u003e\u003cstrong\u003e\u003cem\u003eStrengths, Limitations, \u0026amp; Future Directions\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This study leverages a large cohort from a high-volume center, drawing from a database of 257 patients treated over 22 years to provide substantial insight into surgical outcomes and algorithm development. As the first study to propose an evidence-based surgical decision-making algorithm for ureteral reconstruction, it integrates key patient and disease-specific factors to optimize individualized treatment strategies. Additionally, by evaluating multiple surgical modalities and identifying statistically significant predictors of success and failure, this study enhances clinical decision-making and postoperative management. The findings also underscore critical postoperative risk factors, such as UTI recurrence and radiation history, offering guidance for patient follow-up and improving long-term outcomes.\u0026nbsp;\u003cbr\u003eSeveral limitations should be considered. As a single-center study, the findings may not be fully generalizable to institutions with different patient populations, surgical expertise, or healthcare infrastructures. The retrospective design introduces selection bias and limits causal inferences. Additionally, while recurrence and complications were assessed, continued follow-up is needed as new methods emerge to allow for further comparison. Multi-institutional validation is also needed to confirm the reproducibility of the proposed algorithm. Furthermore, non-surgical factors such as patient-reported quality of life, cost-effectiveness, and healthcare access were not assessed, warranting further investigation.\u003cbr\u003eFuture studies should prioritize prospective, multi-institutional validation to enhance applicability across diverse populations. Longitudinal follow-up will provide deeper insights into recurrence patterns and long-term success rates. Integrating patient-reported outcomes will refine decision-making by incorporating functional and quality-of-life considerations. Additionally, obtaining pathological specimens for all strictures could offer valuable insights into pathogenesis and tissue-specific treatment responses. Continued validation of the decision tree across multiple institutions is essential to ensure its reliability and clinical impact. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003ePreoperative planning and postoperative management are essential to optimizing long-term outcomes in ureteral reconstruction. Postoperative UTIs and prolonged stent use were strongly associated with surgical failure, highlighting the importance of early detection and intervention. Stricture recurrence remains a major concern, particularly in patients with prior radiation or multiple interventions, reinforcing the need for vigilant surveillance and timely management. Stricture location, etiology, and prior surgical history significantly influenced outcomes, underscoring the value of a tailored, risk-stratified approach to treatment. Notably, patients without prior surgery had much higher rates of proximal stricture, suggesting differing pathophysiologic mechanisms and surgical considerations.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;Despite these complexities, ureteral reconstruction remains highly effective, with excellent rates of functional success. To translate these findings into clinical practice, we developed a decision tree algorithm that integrates statistically significant predictors (such as stricture location and length) into a stepwise framework for operative planning based off our 257-patient cohort. This individualized, evidence-based tool enhances clinical decision-making, improves patient counseling, and reduces the risk of reintervention. As ureteral stricture cases grow in complexity, such structured, data-driven models will be critical for delivering precise and durable surgical care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eConflict of interest\u003cbr\u003e\u0026nbsp;The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eEthical approval\u003cbr\u003e\u0026nbsp;This study was reviewed and determined to be\u0026nbsp;exempt from formal review by the Colorado Multiple Institutional Review Board (COMIRB) (IRB#:23-1572). Due to the retrospective nature of the study, the requirement for formal ethical approval was waived. All patients provided written informed consent to participate and agreed to the use of their anonymized data for research purposes. The study complies with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eInformed consent\u003cbr\u003e\u0026nbsp;All patients signed an informed consent form agreeing to share their anonymized data for future research studies.\u003c/p\u003e\n\u003cp\u003eFunding\u003cbr\u003eThis work was supported in part by the\u0026nbsp;Society of Women in Urology (SWIU) Elizabeth Pickett Research Grant, awarded to KMD.\u003cbr\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eS.J.V., K.M.D., and B.J.F. conceptualized the study. S.J.V., K.M.D., C.W.J.O., and R.G.B. curated the data and conducted the investigation. S.J.V. and K.M.D. performed the formal analysis and developed the software. K.M.D. acquired funding. S.J.V., K.M.D., C.W.J.O., and R.G.B. contributed to the methodology. S.J.V. and K.M.D. managed the project and provided resources. B.J.F. supervised the study. K.M.D. and B.J.F. validated the findings. S.J.V. and K.M.D. created the visualizations. S.J.V., K.M.D., and C.W.J.O. wrote the original manuscript draft. R.G.B. and B.J.F. reviewed and edited the manuscript. All authors reviewed and approved the final version.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData is provided within the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTyritzis SI, Wiklund NP (2015) Ureteral strictures revisited\u0026hellip; trying to see the light at the end of the tunnel: a comprehensive review. 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Am J Transpl 23(11):1800\u0026ndash;1805. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ajt.2023.06.009\u003c/span\u003e\u003cspan address=\"10.1016/j.ajt.2023.06.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"348\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 348px;\"\u003e\n \u003cp\u003eTable 1. Summary of Results \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003ePreoperative Data\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 228px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003eSex, n (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 228px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; N = 257 (%) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Female\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e157 (61.2)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Male\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e100 (38.9)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eAge, median (IQR)(years)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e53.1 (26.1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eBody Mass Index, mean(SD)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e28.6 (11.9)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eStricture Laterality, n (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003eN = 256 (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Left\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e123 (48.0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Right\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e104 (40.6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Bilateral\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e29 (11.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eStricture Location, n (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003eN = 206 (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Upper Ureter\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e123 (59.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Lower Ureter\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e83 (40.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eStricture Etiology, n (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003eN = 224 (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Surgical Injury\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e114 (50.9)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Impacted Stone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e30 (13.4)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Retroperitoneal Fibrosis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e26 (11.6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Radiation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e16 (7.1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Congenital\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e12 (5.4)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Crossing Vessel\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e9 (4.0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Idiopathic\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e8 (3.6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Malignancy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e8 (3.6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Trauma\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e1 (0.4)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eIntraoperative Data*\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003eN = 199 (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eProcedure Preformed n (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Reimplant\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e59 (29.6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Pyeloplasty\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e43 (21.6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Buccal Mucosa Graft Ureteroplasty\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e25 (12.6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Ileal Ureter\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e20 (10.1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Ureteruretostomy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e18 (9.0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Ureterolysis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e17 (8.6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Non-Transecting Ureteroplasty\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e13 (6.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Pelviolithotomy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e2 (1,0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Urinary undiversion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e1 (0.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Ileal ureteral interposition\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e1 (0.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eSurgery Length, median (IQR)(minutes)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e289 (122)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003ePostoperative Data\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eAdmission Length, median (IQR)(days) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e3 (4)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eLength of Stent in Place, median (IQR)(weeks)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e5 (2)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 348px;\"\u003e\n \u003cp\u003e*Data for Intraoperative data is lower due to availability of data\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 348px;\"\u003e\n \u003cp\u003e\u0026nbsp;This table summarizes single-variable associations between key surgical factors and success of ureteral stricture reconstruction. Higher success rates were observed in patients with shorter strictures, iatrogenic etiologies, and those undergoing graft-based repairs. Complex or recurrent cases with prior failed interventions showed lower success rates.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"864\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 864px;\"\u003e\n \u003cp\u003eTable 2. Single Variable Analysis of Surgical Outcomes of Patients Undergoing Urethral Stricture Reconstructive Surgery \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 360px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 190px;\"\u003e\n \u003cp\u003eSurgical Success \u003csup\u003e\u0026micro;\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003eSurgical Failure\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;p\u0026nbsp;\u003c/em\u003eValue\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eOR (95% CI)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 360px;\"\u003e\n \u003cp\u003eHistory of Prior Ureteral Stricture \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 190px;\"\u003e\n \u003cp\u003eN = 212 (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003eN = 29 (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 360px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 190px;\"\u003e\n \u003cp\u003e82 (38.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e19 (65.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026lt; 0.05\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.33 (0.47 - 0.74)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 360px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; No\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 190px;\"\u003e\n \u003cp\u003e130 (61.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e10 (34.51)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 360px;\"\u003e\n \u003cp\u003eHistory of Prior Abdominal/Pelvic Surgery\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 190px;\"\u003e\n \u003cp\u003eN = 211 (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003eN = 29 (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 360px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 190px;\"\u003e\n \u003cp\u003e175 (82.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e23 (79.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.62\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1.26 (0.39 - 3.33)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 360px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; No\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 190px;\"\u003e\n \u003cp\u003e36 (17.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e6 (20.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 360px;\"\u003e\n \u003cp\u003eHistory of Prior Abdominal/Pelvic Radiation Therapy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 190px;\"\u003e\n \u003cp\u003eN = 212 (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003eN = 29 (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 360px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 190px;\"\u003e\n \u003cp\u003e25 (11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e8 (27.6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026lt; 0.05\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.35 (0.55 - 0.87)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 360px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; No\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 190px;\"\u003e\n \u003cp\u003e187\u0026nbsp;(88.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e21 (72.4)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 360px;\"\u003e\n \u003cp\u003ePostoperative UTI \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 190px;\"\u003e\n \u003cp\u003eN = 229 (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003eN = 28 (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 360px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 190px;\"\u003e\n \u003cp\u003e42 (18.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e15 (53.6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026lt; 0.01\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.19 (0.50 - 0.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 360px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;No\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 190px;\"\u003e\n \u003cp\u003e187 (81.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e13 (46.4)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 864px;\"\u003e\n \u003cp\u003e*Percentages may not total 100 due to rounding \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e\u0026micro;\u003c/sup\u003eSurgical success defined as symptom- and tube-free postoperatively, with no further intervention required for pain in the absence of obstruction\u003cbr\u003e\u0026nbsp;This table presents the association between individual clinical and operative variables and surgical success following urethral stricture reconstruction. Variables assessed include stricture location, etiology, length, surgical technique, prior interventions, and comorbidities. Statistical significance was determined using chi-square as appropriate.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7110073/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7110073/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eINTRODUCTION AND OBJECTIVES\u003cbr\u003e\n This study examines variations in ureteral stricture reconstruction across a large patient cohort, focusing on surgical history, radiation exposure, and stricture location. By identifying patterns in reconstructive approaches and their impact on outcomes, we aim to support clinical decision-making and improve patient care.\u003cbr\u003e\n METHODS\u003cbr\u003e\n A retrospective review of ureteral reconstruction cases from 2003 to 2024 at a single center was conducted. Surgical success was symptom- and tube-free without further intervention for pain and absent obstruction. Descriptive statistics and chi-square testing evaluated group differences.\u003cbr\u003e\n RESULTS \u003cbr\u003e\n We identified 257 subjects who underwent ureteral reconstruction in the study period. Ureteral strictures present a complex clinical challenge with diverse etiologies, including iatrogenic injury (44.4%), impacted stones (11.7%), retroperitoneal fibrosis (10.1%), and radiation (6.2%). Patients without a surgical history were more likely to require reconstruction of the ureter above the iliac arteries (p \u0026lt; 0.001). In 88% of reported outcomes, surgical success was achieved, with postoperative urinary tract infections (UTIs) and radiation exposure being significant predictors of failure. At 30 days post-operatively, complications Clavien-Dindo Grade III occurred in 0.4% of cases (n=1). The average time from surgery to last recorded follow-up was 326 days. We established a decision tree to aid in clinician judgment for surgery selection.\u003cbr\u003e\n CONCLUSIONS \u003cbr\u003e\nUreteral reconstruction is highly effective; however, several factors influence outcomes. Prior surgery impacted stricture location, and both radiation exposure and postoperative UTIs were predictors of failure. Previous surgical history significantly influenced stricture location, with non-surgical patients more often presenting with proximal disease. Despite these challenges, ureteral reconstruction remains highly effective, achieving excellent functional and anatomical outcomes. A decision-making algorithm incorporating location, etiology, and surgical history may improve patient selection and reduce secondary reconstructive surgeries.\u003c/p\u003e","manuscriptTitle":"Ureteral Strictures: Insights into Etiology, Surgical Failure Prediction, and Decision Tree Development from a High-Volume 20-Year Single-Center Experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-06 08:12:11","doi":"10.21203/rs.3.rs-7110073/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a30d8c0a-c286-472e-9dc4-a4cf1af9606a","owner":[],"postedDate":"August 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-20T07:39:07+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-06 08:12:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7110073","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7110073","identity":"rs-7110073","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}