Narrative review of the current management of radiation-induced ureteral strictures of the pelvis

Abstract

Radiation therapy to the pelvis is indicated for cervical, prostate, rectal, and gastrointestinal (GI) malignancies. A rare, but known adverse effect of this treatment is radiation-induced ureteral stricture (RIUS). RIUS can cause infection, hydronephrosis, kidney stone formation, and ultimately, renal failure. Management of RIUS is a challenge to urologists as the strictures tend to be long, bilateral, and ischemic in etiology. Management of RIUS is divided into endoscopic, open, and minimally invasive techniques. Stents and percutaneous nephrostomy (PCN) tubes are generally used as temporizing measures until definitive repair, but they may be a long-term option for patients unfit for surgery. Balloon dilatation and endoureterotomy have shown efficacy between 60–80% but are less effective in radiation-induced stricture due to the ischemic nature of the insult. Ureteroureterostomy (UU) is best suited for short strictures in the mid-to-proximal ureter. Ureteroneocystostomy is better suited for longer strictures in the distal ureter and may be paired with psoas hitch or Boari flap to increase coverage length. Importantly, for radiation patients, bladder fibrosis may be a contraindication to these procedures. Buccal graft ureteroplasty is increasingly being used with success rates between 80–90%, although this number decreases to around 30% in longer strictures. Finally, bowel substitutes are suitable for longer strictures and bilateral disease. Most recently, appendiceal interposition has been studied for both rightand left-sided strictures around 3–5 cm, with success rates around 70%. More invasive and potentially morbid techniques like transureteroureterostomy (TUU) and renal autotransplantation are reserved for extremely long or pan-ureteral strictures and are usually unsuitable for cancer patients who have undergone radiotherapy. In general, minimally invasive approaches, while less studied, have demonstrated similar clinical outcomes and complication rates, with less pain and shorter hospital stays. In this review, we will summarize the most up-to-date literature in this field, detailing the current management of RIUS.