Surgical Revision of the Incompetennt Ureterovesical Junction: A Critical Analysis of Techniques and Requirements

SUMMARY Current knowledge and better understanding of the pathophysiology of the incompetent ureterovesical junction and the accumulated experience with the various surgical techniques for its revision have made it possible to clarify the basic requirements for successful repair. The length of the intravesical ureter alone does not determine the competence of the uretero‐vesical junction. Excision of the distal ureteral segment improves the quality of the musculature at the newly formed ureteral orifice and of the intravesical ureter. This should be an integral part of any technique. It is feasible and in fact imperative to over‐correct all the anatomical aberrations in the ureterovesical junction which occurred as a result of the developmental muscular deficiency of the trigone and intravesical ureter. There are three basic approaches to achieve this anatomical reconstruction: The suprahiatal approaches of Politano‐Leadbetter and Paquin. Williams advancement principle with the development of subtrigonal tunnel. A combination of the above two. Whenever properly indicated, any of these principles will satisfy all the requirements of an ideal repair. The anatomical and functional achievements of these three approaches are basically the same. Markedly dilated ureters should be tailored to normal or near normal calibre. With substantially impaired kidney function associated with redundant dilated ureters, preliminary drainage, preferably obtained by loop ureterostomy, is indicated. The revised ureterovesical junction will never duplicate the normal one, but should offer the essential features of allowing free drainage from the ureter to the bladder while preventing regurgitation in the reverse direction.