Idiopathic retroperitoneal fibrosis is a rare disorder characterized by fibrotic tissue proliferation in the retroperitoneum, frequently resulting in ureteral encasement and obstructive uropathy. Progressive obstruction may lead to ureterohydronephrosis and, eventually, renal function deterioration. Initial treatment typically involves ureteral stenting and, in selected cases, medical therapy with corticosteroids or immunosuppressive agents. However, disease recurrence and stent dependency may ultimately require definitive surgical intervention.

This video shows the minimally invasive management of a 53-year-old male diagnosed with idiopathic retroperitoneal fibrosis causing left ureteral obstruction. Obstruction was confirmed via diuretic renogram, which showed impaired drainage. The patient initially underwent double-J stent placement, resulting in symptomatic and radiological improvement for approximately four years. He was also treated with corticosteroid therapy followed by two cycles of rituximab, with only partial and transient benefit. Subsequently, progressive worsening of hydronephrosis was observed despite adequate stent replacement and even placement of a metallic (tumour) stent, prompting surgical management. The patient also reported storage lower urinary tract symptoms with significant impact on quality of life. A laparoscopic approach was performed. Key procedural steps included: identification of the ureter, ureterolysis with release of fibrotic adhesions, preservation of ureteral vascularity and mobilization of the ureter. The ureter was then transposed intraperitoneally. An omental flap was interposed between the ureter and the retroperitoneum to minimize the risk of recurrent fibrosis and re-encasement.

The procedure was successfully completed using a fully laparoscopic approach without intraoperative complications or need for conversion to open surgery. Adequate ureteral mobilization and tension-free intraperitoneal positioning were achieved. The postoperative course was uneventful, and the patient was discharged on post-operative day 2. At 8-month follow-up, after stent removal at 4 weeks pos-operative, the patient remained asymptomatic, with no evidence of flank pain or urinary symptoms. Follow-up computed tomography demonstrated a reduction in hydronephrosis and diuretic renogram showed no obstacle at the urine drainage, supporting the effectiveness of the surgical approach in relieving obstruction.

Laparoscopic ureterolysis with intraperitonealization and omental interposition is a safe and effective technique for the management of refractory ureteral obstruction in patients with idiopathic retroperitoneal fibrosis. This minimally invasive approach provides resolution of the obstruction and reduces dependence on long-term double-Js and the associated symptoms, thereby improving quality of life, especially in young patients.