Treatment of Scar Tissue at the Ureterovesical Junction (UVJ)
For scar tissue at the ureterovesical junction (UVJ), endoscopic management with ureteral stenting should be attempted first, followed by more invasive surgical approaches such as ureteroneocystostomy if stenting fails.
Initial Management
- Ureteral stenting should be the first-line treatment for UVJ scar tissue to relieve obstruction and maintain urinary drainage 1, 2
- If initial stenting fails due to complete occlusion, percutaneous nephrostomy should be placed to relieve obstruction 2
- Antegrade access with conversion to a percutaneous nephroureteral stent may be required for complicated cases 2
Endoscopic Management
- Ureterotomy under endoscopy using laser or cold-knife is appropriate for benign ureteral strictures of 2-3 cm length 3
- If stent placement is unsuccessful due to complete occlusion, percutaneous nephrostomy with delayed surgical repair is indicated 1
- In any ureteral repair procedure, stent placement is strongly recommended to reduce failures and strictures 1
Surgical Options
- Partial lesions of the ureter should be initially treated conservatively with stenting, with or without a diverting nephrostomy 1
- For distal ureteral injuries or strictures (including UVJ), ureteroneocystostomy (ureteral reimplantation into the bladder) is the preferred surgical approach 1, 3
- A non-refluxing technique with a ureteral nipple or submucosal tunnel method is preferable to minimize vesico-ureteral reflux and infection risk 3
Advanced Surgical Techniques
- For longer UVJ strictures, ureteroneocystostomy in combination with a psoas hitch (covering 6-10 cm of defect) or a Boari flap (covering 12-15 cm) may be necessary 3
- Laparoscopic and robotic-assisted techniques are increasingly being employed for ureteral reconstruction with encouraging results 3
- Open surgical ureteral reimplantation has a high success rate (>90%) but carries greater morbidity than minimally invasive approaches 4, 3
Special Considerations
- Before repeat surgery, precise anatomical identification should be performed using antegrade and retrograde studies 5, 6
- Retrograde pyelography is valuable in identifying concurrent obstructions that might not be visible in the surgical field 6
- In patients with urinary diversion, image-guided percutaneous antegrade access with either immediate or delayed conversion to retrograde percutaneous nephroureterostomy is often preferred 2
- Internal double-J stents tend to occlude quickly in ileal conduits due to mucous plugging and may require more frequent changes 2
Monitoring and Follow-up
- Regular assessment of clinical parameters and imaging is essential to monitor treatment success 1
- If enlarging urinoma, fever, increasing pain, ileus, fistula or infection develop, urinary drainage should be augmented via ureteral stent, percutaneous urinoma drain, percutaneous nephrostomy, or a combination 2