Benign ureteral stricture after radical cystectomy is a common post-operative complication. In case this scenario occurs in kidney-transplanted patients, the surgeon needs to face a challenging anatomy and the obligation of nephron preservation. We present a 76 year-old male that underwent open renal transplantation in 2019 and open radical cystectomy with ileal conduit in 2021 for a high-grade pT3N0M0 urothelial tumor. After four months, the patient presented with worsening renal function (glomerular filtration rate 21 mL/min/1.73 m2) and grade III–IV graft hydronephrosis at computed tomography scan. A nephrostomy tube was placed, and anterograde pyelography showed a <1 cm stricture of the distal ureter.

The surgical steps were the following. The patient was placed in supine position. Two Amplatz guidewires were placed through a dual lumen ureteral access catheter (5–10 Fr and a length of 24 cm) after nephrostomy tube removal. After positioning of a ureteral access sheath (10–12 Fr) an antegrade flexible-ureterorenoscopy was performed to reach and identify the stricture. Endoscopic balloon dilation was performed reaching a pressure of 30 atmospheres. After inspection, the stricture was incised with thulium laser (15–20 W) until exposure of periureteral fat. A second dilation was performed to ensure successful treatment. A uni-J ureteral catheter (8 Fr) was left for 1 week. After 30 days, anterograde pyelography (via nephrostomy tube) was carried out demonstrating the stenosis resolution.

In conclusion, the endoscopic treatment of ureter-enteric benign strictures in renal transplant patients after radical cystectomy is feasible and safe with optimal outcomes. Renal function preservation is the ultimate goal in these patients and the endourological approach represents an alternative effective technique.