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

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.