Psoas Hitch Surgery Explained
A psoas hitch is a bladder-mobilisation technique used during ureteric reimplantation when the healthy ureter is too short to reach the bladder without tension. The bladder is freed, brought upward toward the affected side and secured to the psoas tendon; the ureter is then reimplanted into the repositioned bladder. It is commonly used for distal ureteric injury or stricture, including after pelvic or gynecological surgery. The goal is to bridge a moderate gap using the patient’s own bladder rather than stretching the ureter.
When is a psoas hitch needed?
- A distal ureteric segment has been lost or must be removed.
- Direct reimplant would be under tension.
- The bladder has enough capacity and mobility.
- Tissue is suitable for durable reimplantation.
How is the operation performed?
- The bladder is mobilised from surrounding attachments.
- It is advanced toward the injured ureter.
- The bladder is anchored to the psoas tendon while protecting nearby nerves.
- Healthy ureter is reimplanted into the bladder.
- A DJ stent is usually left across the new join.
- A bladder catheter is kept while healing occurs.
Why use the bladder instead of stretching the ureter?
Tension is a major enemy of urinary reconstruction. Mobilising a well-vascularised bladder reduces tension at the ureter-bladder anastomosis and preserves more healthy ureter.
Psoas hitch vs Boari flap
| Psoas hitch | Boari flap |
|---|---|
| Moves the bladder upward | Creates a tubularised flap from bladder wall. |
| Useful for a moderate distal gap | Can bridge a longer distal or mid-ureter gap. |
| Requires bladder mobility/capacity | Requires adequate capacity and healthy bladder tissue. |
| Often paired with direct reimplant | Creates a longer bladder-based conduit. |
Recovery
Hospital recovery includes bladder-catheter and DJ-stent care. Frequency or urgency can occur with the stent. Activity increases gradually and heavy lifting is avoided during initial healing.
Risks
- Urine leak.
- UTI.
- Recurrent ureteric obstruction.
- Stent-related discomfort.
- Bleeding.
- Bladder symptoms.
- Rare nerve irritation around the psoas region.
Emergency warning signs
- Fever, chills or shivering with flank pain or known urinary obstruction.
- Severe worsening flank or abdominal pain with repeated vomiting.
- Markedly reduced urine output, especially with a solitary functioning kidney or bilateral obstruction.
- New confusion, weakness or feeling very unwell.
- A nephrostomy or stent-dependent patient with fever or failure of the drainage tube.
A practical postoperative timeline
- Early days: bladder catheter drainage, DJ stent and sometimes a pelvic drain. Walking is encouraged once safe.
- After catheter removal: frequency and bladder spasms may persist briefly because the bladder was mobilised and operated upon.
- Stent removal: performed later according to the surgeon’s protocol; temporary flank discomfort or urinary frequency can be stent-related.
- Follow-up: ultrasound or other imaging checks renal drainage after the stent is out. Persistent severe flank pain, fever or rising creatinine needs earlier evaluation.
- Long term: most patients do not feel the bladder “hitched” to the psoas. Chronic hip or thigh neurological symptoms are unusual and should be assessed if present.
What to bring for consultation
- Ultrasound, CT urography/CT abdomen or MR urography reports and images if available.
- Renogram report (DTPA/MAG3) if performed.
- Serum creatinine and recent kidney-function reports.
- Urine routine and culture reports.
- Previous operative notes, discharge summaries and pathology reports if the problem followed surgery.
- Details of any DJ stent or nephrostomy: side, date placed and last change.
- A list of current medicines and any history of radiation, stones, endoscopy or pelvic surgery.
What the psoas hitch contributes
A psoas hitch does not reconstruct the ureter itself. Instead, the bladder is mobilised and brought upward toward the healthy ureter, then fixed to the ipsilateral psoas tendon/muscle so the ureteric reimplant can be completed without tension. This can bridge a distal ureteric gap that would otherwise be too long for a simple reimplantation.
Bladder capacity and mobility therefore matter. Previous pelvic radiation, a small contracted bladder, extensive previous surgery or significant bladder pathology can limit how far the bladder can safely reach. The surgeon may need to divide selected bladder attachments while protecting nerves and vessels.
The ureter is then reimplanted into the mobilised bladder over a temporary stent. Reported success is high when the operation is used for appropriate distal defects. Postoperative urinary frequency can occur while the bladder heals, and rare complications include leak, recurrent obstruction or symptoms related to psoas fixation. The main reconstructive advantage is avoiding a tight ureteric anastomosis.
How the bladder is mobilised safely
The bladder is freed from surrounding attachments so it can move toward the injured side without tension. It is filled or inspected to judge capacity and mobility, then secured to the psoas tendon on the affected side. The ureter is implanted into this elevated bladder rather than being stretched downward.
Care is taken to place the fixation where it will not injure the femoral nerve, which lies within the psoas region. The ureteric anastomosis itself follows the same principles as reimplantation: healthy tissue, good blood supply, a wide mucosal join and internal stenting.
A psoas hitch is therefore not merely an “extra stitch.” It changes the geometry of the reconstruction and can convert a gap that would otherwise be under tension into a straightforward bladder-to-ureter repair. If even the hitched bladder cannot reach, a Boari flap or another option may be required.
Recovery after a psoas hitch
Because the bladder is mobilised and fixed upward, early recovery includes both ureteric and bladder healing. A Foley catheter remains until the bladder closure is secure, and a DJ stent protects the reimplanted ureter. Pelvic drains are used selectively.
Some patients notice urinary frequency or bladder spasms while the catheter or stent is present. Transient discomfort with hip extension can occur because of the psoas fixation, but persistent severe leg or hip pain or neurological symptoms are unusual and should be reviewed.
Long-term follow-up is similar to other ureteric reconstructions: renal function, symptoms and imaging for obstruction. The procedure should ideally leave the patient free of chronic nephrostomy or repeated stent changes once healing is complete.
FAQs
Does psoas hitch involve cutting the leg muscle?
No. The bladder is anchored internally to the psoas tendon or muscle region.
Will my bladder stay higher?
Yes, the mobilisation is part of the reconstruction, but most patients do not notice the internal position.
Does it reduce bladder capacity?
A hitch mainly uses bladder mobility, so capacity is usually preserved better than with a large flap.
Can it be done robotically?
Yes in selected patients where expertise is available.
What if the bladder is small or radiated?
Alternative reconstruction may be needed because bladder mobility and tissue quality are central to success.
Related reading
- Ureteric Reimplantation Explained
- Boari Flap Surgery Explained
- Ureteric Injury During Gynecological Surgery
- Ureteric Stricture After Surgery
- Uretero-Ureterostomy Explained
- Urologist in Latur
References
- European Association of Urology. EAU Guidelines on Urological Trauma, 2026 https://uroweb.org/guidelines/urological-trauma
- Bourillon A, et al. Ureteral stricture: current treatment algorithm and key surgical principles in the robotic upper urinary tract reconstruction era. World J Urol. 2026;44:102. PMID: 41546831 https://pubmed.ncbi.nlm.nih.gov/41546831/
- Hook S, et al. Update on ureteral reconstruction 2024. Die Urologie. 2024;63:25-33. PMID: 37989869 https://pubmed.ncbi.nlm.nih.gov/37989869/