The ureteral orifice: its configuration and competency

Reflux nephropathy and pregnancy

Reflux nephropathy is one of the renal diseases encountered most frequently in women of childbearing age. Patients with severe bilateral atrophy are the most likely to develop proteinuria, hypertension, focal glomerular sclerosis and progressive chronic renal failure, and those with persistent vesicoureteral reflux are the most likely to suffer recurrent pyelonephritic episodes. Often the disease is clinically latent and first manifests itself in pregnancy, mainly by urinary tract infection but also by proteinuria, hypertension, pre-eclampsia or renal failure. Pregnancy is most often successful and uneventful whenever renal function is normal or near normal and hypertension is absent at conception. Urinary tract infection accounts for frequent morbidity but rarely results in fetal mortality. By contrast, when renal function is significantly impaired, that is in patients whose plasma creatinine concentration is in excess of 0.20-0.22 mmol l-1 at conception, especially when hypertension is also present, there is clearly a high risk of fetal growth retardation or intrauterine death. Moreover, there is a striking risk of rapid worsening of renal function and hypertension, with accelerated progression towards end-stage renal failure. Thus, women with reflux nephropathy should attempt to conceive before the plasma creatinine concentration has reached 0.20 mmol l-1, and patients with values higher than these should be clearly advised of the high risk for both the pregnancy and the progression of the disease.

Histological and histochemical study of the vesicoureteric junction in infancy and childhood

The morphology of the vesicoureteric junction was compared using 19 post mortem specimens obtained from male and female Afro-American and Caucasian children with an age range of 1 to 72 months (mean 4). All specimens were serially sectioned and the tissues processed using standard histological and histochemical techniques (acetylcholinesterase ¿AChE¿ and pseudocholinesterase ¿PChE¿). The results failed to reveal any differences in the structure of the vesicoureteric junction with respect to age, sex and ethnic origins. The vesicoureteric junction comprised 3 histologically and histochemically distinct smooth muscle components. Ureteric muscle formed a complete inner layer rich in PChE which continued beyond the ureteric orifices to merge distally with the superficial trigone. An intermediate layer of muscle was also demonstrated whose constituent muscle cells possessed specific histological features and which was rich in both AChE and PChE, which is distinct from that derived from the ureter and detrusor. The presence of detrusor muscle on the outer aspect of the juxtavesical segment of ureter rich in AChE was also confirmed. While this study, using histochemical studies in infants and children, did not reveal any differences in the structure of the vesicoureteric junction with respect to age, sex or ethnic origin, an intermediate layer of muscle was identified with histochemical characteristics more like that of the male genital tract than that derived from the ureter or detrusor muscle.

Observations on anatomical aspects of the ureterovesical junction of the pig

The paper reports the anatomy of the ureterovesical junction in pigs without urinary tract disease and the changes that occur with ageing. In comparison with other mammals the pig has a long intravesical ureter. Its length increases with age, from a mean length of 5 mm. at birth to 36 mm. at maturity. The width of the ureteric orifice also increases with age. The ureteric orifice was horseshoe shaped in 96.5% of cases, the remaining orifices were stadium shaped. The delineation of the anatomy of the porcine UVJ is important in the study of porcine and human pyelonephritis as the pig urinary tract is widely used as a human model.

Reduction in the length of the intravesical ureter associated with pyelonephritis in the adult pig

The ureterovesical junction of pigs with cystitis and pyelonephritis was examined. There was significant shortening of the intravesical portion of the ureter in sows with pyelonephritis. In cases associated with acute pyelonephritis the ureteric orifice was found to be significantly wider than that found in the normal population. The ratio of the intravesical length to the ureteric orifice diameter was also significantly reduced. It is postulated that these changes to the ureterovesical junction originate or are caused by the disease processes in the bladder and may allow vesicoureteric reflux to occur, leading to ascending pyelonephritis.

Variations in practice among urologists and nephrologists treating children with vesicoureteral reflux

To analyze the current management recommendations among physicians treating children with vesicoureteral reflux, the American Urological Association Reflux Practice Guidelines Panel surveyed 100 pediatric urologists, 100 general urologists and 100 pediatric nephrologists by questionnaire, and received a 60% response. In the evaluation of a 4-year-old girl with bilateral grade 2 reflux general urologists were more likely than the other 2 groups to recommend cystoscopy and urethral dilation. At followup nuclear cystography was recommended by 76% of pediatric urologists, 48% of general urologists and 71% of pediatric nephrologists, while the latter 2 groups were less likely to recommend any subsequent upper tract evaluation. Pediatric urologists were significantly more likely to recommend antireflux surgery if the child had 1 breakthrough febrile urinary tract infection, poor compliance with medical management or persistent reflux at age 11 years. In a 6-year-old girl with unilateral grade 4 reflux and detrusor instability 44% of pediatric urologists recommended antimicrobial prophylaxis and anticholinergic therapy compared to 12% of general urologists and 6% of pediatric nephrologists. Antireflux surgery was recommended by 29% of pediatric urologists, 60% of general urologists and 59% of pediatric nephrologists. In older girls with persistent grade 2 or 3 reflux pediatric urologists were much more likely to recommend antireflux surgery. In contrast, they were less likely to recommend surgery in young girls and boys with newly diagnosed grade 4 reflux. These data demonstrate significant differences in therapeutic recommendations among pediatric urologists, general urologists and pediatric nephrologists, and suggest the need for outcomes research to determine the optimal management of children with vesicoureteral reflux.

Massive intratubular hemorrhage with herniations into renal veins: report of a case

A 24-year-old man had unilateral gross hematuria that required nephrectomy. Pathological examination revealed massive intratubular hemorrhage and frequent deposition of an amorphous and homogeneous material positive for periodic acid, Schiff stain in the corticomedullary junction. This substance had the characteristics of Tamm-Horsfall protein and frequently herniated into the lumen of thin-walled veins of arcuate size. There was no apparent cause for the bleeding. To the best of our knowledge this is the third reported case with these peculiar findings and no apparent cause. We discuss some hypotheses as to the etiopathogenesis of this rare and intriguing condition.

Reflux nephropathy secondary to intrauterine vesicoureteric reflux

In 107 infants with 182 antenatally diagnosed urinary tract anomalies, 24 had either unilateral (12) or bilateral (12) vesicoureteric reflux (VUR). The VUR was more common in boys (male to female ratio, 16:8) and usually severe (grades IV [16], III [10], II [4], and I [6]). Intravenous pyelography showed the changes of atrophic pyelonephritis in 10 refluxing units, and in another two with an associated pelviureteric junctional hydronephrosis. Lateral ectopia of the ureteric orifices was noted in six of these 10 refluxing renal units. Isotopic renography showed a reduction in function in nine of the 14 patients examined, ranging between 9% and 41%. (45% and above was considered within the normal range). Only two patients developed a urinary infection before intravenous pyelography or isotopic renography was performed, suggesting that renal changes noted were primary rather than secondary. Findings support the hypothesis that foetal VUR may be a contributing factor in the causation of atrophic pyelonephritis (foetal reflux nephropathy) observed in these patients.

Physical growth velocity during conservative treatment and following subsequent surgical treatment for primary vesicoureteric reflux

Physical growth was studied in 6 males and 16 females during 1 year of antimicrobial prophylaxis and during the 2 years following subsequent surgical treatment for severe primary vesicoureteric reflux. Surgery was performed between the ages of 2 and 8 because of either repeated breakthrough infection or persistence of grade III or IV reflux. Height and weight velocities were calculated as yearly rates and then converted into interquartile ratios (IQRs). Neither the mean centile height nor weight attained varied significantly between that at entry, after 1 year of medical treatment and at 2 years after surgery. However, the mean IQR for height velocity (+/- sem) rose significantly from -0.61 (+/- 0.45) during antimicrobial prophylaxis to 0.54 (+/- 0.25) following surgery. Similarly, the mean IQR for weight velocity rose significantly from -0.63 (+/- 0.50) during medical treatment to 0.47 (+/- 0.24) following surgery. These results suggest that surgical treatment is preferable to continued medical treatment in patients with severe primary vesicoureteric reflux who fail to respond to a trial of antimicrobial prophylaxis.

Embryogenesis of ureteral anomalies: a unifying theory

Extensive gross, microscopic and clinical studies of various ureteral anomalies have enabled investigators to set forth theories regarding the aetiologies of these anomalies consistent with observed fact. Synthesis of these observations allows for a simplified classification of mega-ureter (primary obstructed, reflux and non-obstructed, non-reflux mega-ureters), ureterocele, duplex ureters and ectopic ureters based upon some combination of mesenchymal differentiation anomalies and location anomalies. A defect early in mesenchymal differentiation would be expected to result in panureteral disease. A defect later in development would result in a focal abnormality anywhere along the course of the ureter. Influence upon ureteral bud mesenchyme by local expansion factors in the bladder base may result in various types of ureterocele. Position of the ureteral orifice on the trigone or in Wolffian duct derivatives would occur in accordance with the Weigert-Meyer principle and would correlate with upper tract dysplasias. Thus, an attempt has been made to systematize and trace the origins of mega-ureter, ureterocele, duplex ureters and ectopic ureters to defects of differentiation of the basic mesoblastic cell in aberrant locations of the ureteral bud.

Reflux nephropathy and pregnancy

Reflux nephropathy is one of the most frequent renal diseases encountered in women of childbearing age. Patients with severe bilateral atrophy are the most likely to develop proteinuria, hypertension, focal glomerular sclerosis and progressive chronic renal failure, and those with persistent vesicoureteral reflux are the most likely to suffer recurrent pyelonephritic episodes. Often the disease is clinically latent and first manifests itself in pregnancy, mainly by urinary tract infection but also by proteinuria, hypertension, pre-eclampsia or renal failure. Pregnancy is most often successful and uneventful whenever renal function is normal or near normal and hypertension is absent at conception. Urinary tract infection accounts for frequent morbidity but rarely results in fetal mortality. By contrast, when renal function is significantly impaired, that is in patients whose plasma creatinine concentration is in excess of 0.18-0.20 mmol/l at conception, especially when hypertension is also present, there is clearly a high risk of severe fetal growth retardation or intrauterine death. Moreover, there is a striking risk of rapid worsening of renal function and hypertension, with accelerated progression towards end-stage renal failure. Thus, women with reflux nephropathy should attempt to conceive before the plasma creatinine concentration has reached 0.18 mmol/l, and patients with values higher than these should be clearly advised of the high risk for both the pregnancy and the progression of the disease.

A nonsurgical approach to the management of primary vesicoureteral reflux

We performed a retrospective review to evaluate the results of a nonsurgical approach to the management of primary vesicoureteral reflux during a 10-year period (1976 to 1986). During that interval patients with reflux were studied initially with a standard voiding cystourethrogram and either an excretory urogram or a renal scan with glomerular filtration rate and/or differential renal function determination. Height, weight, blood pressure, urine cultures and serum creatinine measurements also were obtained. Isotope cystography was used for followup examinations. A single, negative isotope cystogram was the radiological criterion for cessation of reflux. The charts of 545 children (55 per cent had bilateral reflux) with 844 refluxing ureters were reviewed. Based upon the international classification vesicoureteral reflux was grade I in 6.6 per cent of the cases, grade II in 54.2 per cent, grade III in 31.6 per cent, grade IV in 5.7 per cent and grade V in 1.9 per cent. All children were kept on long-term continuous prophylactic antibiotics and they were re-evaluated annually with isotope cystography. The followup rate for the entire group was 88 per cent. During the observation period spontaneous resolution of reflux was noted in 36 per cent of the patients and 39 per cent of the total refluxing ureters. Only 13 per cent of the entire group underwent surgical correction of reflux. Presently, 39 per cent (215) of the patients continue to be followed with reflux. Of the total group 66 patients (12 per cent) were lost to followup. In the 194 patients with spontaneous resolution of reflux the mean duration of reflux was 1.69 years, with 30 to 35 per cent resolving each year. Based on Student's t test there was a significant difference in duration of reflux in patients with grade II compared to grade III reflux (1.56 versus 1.97 years, p less than 0.04). When age at presentation was compared with duration of reflux there was a significantly shorter duration of reflux only in those patients presenting from age 0 to 12 months, compared to those 13 months and older (1.44 versus 1.85 years, p less than 0.02). Renal function was evaluated by serum creatinine, calculated glomerular filtration rate or differential diethylenetriaminepentaacetic acid scan results.(ABSTRACT TRUNCATED AT 400 WORDS)

Follow-up of renal morphology and growth of 141 children operated for vesicoureteral reflux: a retrospective computerized study

This study relates the postoperative evolution after ureterovesical reimplantation for vesicoureteral reflux (VUR) in 141 children who were ten years old or younger at the time of surgery. Renal growth and morphology were evaluated 2 and 5 years after surgery. We estimated renal growth by measuring the ratio of the bipolar parenchymal thickness to the total length of the kidney. We noticed that whatever the degree of reflux might have been, most of the kidneys partially or totally compensated for their growth failure. This growth resumption required many years to be completed. Surgical correction of VUR had favorable consequences on the radiologic aspect of pyelonephritic scars only on some of the kidneys: in these cases, the child's age appeared to be the only factor that had a statistical importance affecting the postoperative evolution of pyelonephritic scarring: the younger the children were at the time of surgery, the better the results obtained.

[Diagnosis and operative therapy of vesico-renal reflux]

Detection and accurate grading of vesico-renal reflux is rendered difficult by the limited reliability of the different diagnostic procedures. Therapeutic decisions are therefore to a large extent influenced by the clinical situation. Properly performed antireflux surgery combines a high cure rate with a low complication rate.

Suggested terminology for duplex systems, ectopic ureters and ureteroceles

Recommendations are made for the standardization of nomenclature describing duplex systems, ectopic ureters and ureteroceles. The elimination of some terms and redefinition of others are proposed in the hope to eliminate the ambiguity and confusion that exist currently.

Correction of experimentally produced vesicoureteric reflux in the piglet by intravesical injection of Teflon

Vesicoureteric reflux was produced in eight piglets by opening their bladders and slitting the anterior intravesical wall of the ureter. Cystography confirmed the presence of bilateral reflux in six piglets and unilateral reflux in two. Six to eight weeks later the bladder was again opened and Teflon paste injected in the space behind the intravesical ureter, thereby creating a support for the submucosal ureter. Cystography four to six weeks after injection of Teflon paste showed absence of reflux in all animals. Intravenous pyelography showed obstruction at the vesicoureteric junction in only one of the 14 treated ureters and this was later confirmed at necropsy. Animals were followed up from one to six months and then were killed. Gross examination of the vesicoureteric region showed a well circumscribed subureteric Teflon mass of firm consistency, retaining its shape and position at the site of the injection. Histological examination showed encapsulation of the implant by a thin layer of fibrous tissue and a foreign body granulomatous reaction with histiocytes and giant cells within the implant. Hence it is technically feasible to correct experimentally produced vesicoureteric reflux in the piglet by intravesical injection of Teflon paste--a relatively inert material. It may now be possible to treat vesicoureteric reflux in man by endoscopic injection of Teflon behind the intravesical ureter.

Ureterovesical reflux in an adolescent and adult population

The records and radiographic data on 177 adolescents and adults with vesicoureteral reflux were reviewed. The anatomic characteristics of 255 renal units and ureterovesical junctions were characterized using criteria reported previously. A total of 125 renal units demonstrated grades III to V reflux (International). Abnormal ureteral orifices were observed in 145 renal units and 155 submucosal tunnels were short or absent. Excretory urograms outlined renal scars in 192 renal units. Pre-treatment and post-treatment creatinine clearances were analyzed in 188 renal units. Ureteral reconstruction resulted in stabilization or improvement in the mean creatinine levels in 53 renal units. Other forms of surgical and medical treatment also resulted in improved renal function during observation.

The uninhibited bladder in children: effect of treatment on recurrence of urinary infection and on vesicoureteral reflux resolution

We studied and treated prospectively 62 neurologically normal children with vesicoureteral reflux using urodynamic techniques to identify uninhibited bladder contractions with voluntary sphincteric obstruction (dyssynergia). All children received antibiotic prophylaxis. Anticholinergic drugs were used additionally to treat uninhibited bladder contractions. During 6 years of followup treatment of uninhibited contractions produced a 4-fold reduction in the incidence of recurrent urinary infection and tripled the rate of reflux resolution compared to controls. These data suggest that uninhibited contractions with voluntary sphincter obstruction are an important prognostic finding in children with reflux, which when treated successfully can alter the disease course and may make surgical therapy of reflux unnecessary for some.

Influence of diuresis on the degree of vesicoureteral reflux. An experimental investigation in rats

The influence of bladder filling volume (BV), bladder pressure (BP) and diuresis (V) on the occurrence of vesicoureteral reflux (VUR) in Sprague-Dawley rats, where spontaneous VUR is common, has been investigated. The BV and BP at which VUR occurred during constant low diuresis (group I), high inconstant diuresis (group II) and moderately high, constant diuresis (group III), was measured. The abdomen was opened for visual observation of the VUR. The bladder was catheterized with a double-lumen metal catheter for infusion of a Lissamine green saline solution and to enable recording of BP. VUR occurred at significantly lower BV in group II than in group I and at significantly lower BV and BP in group I than in group III.

Acquired renal scars in children

To determine the important factors involved in the etiology of renal scarring we studied 37 children with renal scars seen at our hospital since 1965. This is the second largest series reported to date. Children who had neurogenic bladders or any structural abnormalities of the urinary tract other than vesicoureteral reflex were excluded. The study group included 36 girls and 1 boy. The average age at first detection of renal scars was 5.7 years. Acute pyelonephritic episodes, which were treated early and aggressively, infrequently led to renal scarring. However, the initial prolonged or poorly treated episode of acute pyelonephritis was followed invariably by the development of renal scarring. The severity of renal scarring was related to the grade of vesicoureteral reflux (p less than 0.05), although some scars did develop in the absence of reflux. Neither the shape and position of the ureteral orifice nor the ureteral tunnel length correlated with the severity of renal scarring. Treatment with prophylactic antibiotics may have lessened the severity of renal scarring (0.1 less than p less than 0.2) but treatment with reimplantation surgery did not appear to alter the course of renal scarring. This study suggests that the key to the prevention of renal scarring is the early and aggressive treatment of acute pyelonephritis.

Characteristics of normal and refluxing ureterovesical junctions

In order to quantitatively define the mechanism of urereterovesical junction (UVJ) competence and vesicoureteral reflux, we measured ureteral pressures using a continuously perfused catheter with a single side opening. Studies were performed under general anesthesia on 11 competent and 9 refluxing UVJs. The amplitude of ureteral contractions was essentially the same in refluxing and non-refluxing systems, but peristaltic frequency was significantly lower in the presence of even the milder forms of reflux. With the bladder empty, a high pressure zone was observed at the UVJ in both refluxing and non-refluxing systems, with no significant pressure difference between the 2 groups. No relaxation was observed during urine transport across the UVJ. With bladder filling, a greater increase in profile pressure occurred at the UVJ of non-refluxing than refluxing systems. The UVJ-bladder pressure gradient of non-refluxing systems increased with bladder filling, whereas the gradient in the refluxing systems decreased. It appears that refluxing ureters have a decreased peristaltic frequency and fail to maintain a pressure gradient at the UVJ with bladder filling.

Uterus didelphia with left hematocolpos and ipsilateral renal agenesis

We report a rare case of uterus didelphia with left hematocolpos and ipsilateral renal agenesis, associated with contralateral vesicoureteral reflux and chronic atrophic pyelonephritis. In the literature 9 cases of uterus didelphia with left hematocolpos but without concomitant reflux and recurrent bacterial pyelonephritis are reported. The embryogenesis of müllerian duct abnormalities, associated clinical findings, including abdominal tenderness and pelvic mass, diagnostic modalities of cystoscopy, excretory urography, laparoscopy and hysterosalpinography are discussed. Early accurate diagnosis and treatment will decrease morbidity and unnecessary surgical procedures.

Morphogenesis of nephropathy with partial ureteral obstruction and vesicoureteral reflux

Hydronephrotic kidneys associated with partial ureteral obstruction and vesicoureteral reflux are similar and should exhibit similar morphology if the hydronephrosis was caused by abnormal urodynamic effects or back pressure. Kidneys with partial obstruction were compared quantitatively and statistically to kidneys with reflux to identify the macroscopic and microscopic structures that would indicate similar or dissimilar etiologies of the hydronephrosis. With partial ureteral obstruction the kidneys exhibited a generalized paucity of parenchyma, occurring in the cortex and medulla, and increasing with the degrees of hydronephrosis. Kidneys with reflux, and mild and similar grades of hydronephrosis compared to those of the obstructive forms were indistinguishable microscopically. Kidneys with reflux and more severe grades of hydronephrosis were different in that the cortex and medulla exhibited hypoplasia combined with dysplasia and, although the cortex was approximately equal in thickness, the glomerular counts were smaller. These features in kidneys with reflux were proportional to the degree of lateral ectopia of the corresponding ureteral orifice. Obstructive atrophy of renal parenchyma explains the morphology of the obstructive hydronephrosis, whereas the hypoplasia and dysplasia corresponding with orifice position in the kidneys with reflux are explained more readily by the bud theory, in which the ureteral bud, metanephric mesenchyme and induction capabilities of each are all at fault. In the absence of infection the kidneys may undergo progressive atrophy with partial obstruction of the ureter, whereas the kidneys with reflux exhibit performed grades of hydronephropathy, which are determined embryologically.

Intravenous radionuclide cystography for the detection of vesicorenal reflux

Intravenous radionuclide cystography using a single intravenous injection of 99mtechnetium diethylenetriaminepentaacetic acid, provides information on individual kidney function, coarse anatomy and vesicorenal reflux. This study investigates the effectiveness of intravenous radionuclide cystography in detecting reflux. In 58 children intravenous radionuclide cystography detected 53 ureters with reflux compared to 32 detected by voiding cystography. This difference was investigated further with patients in whom other test suggested reflux. While there was no statistically significant difference for patients having pyelonephritis or hydronephrosis, intravenous radionuclide cystography detected significantly more ureters with reflux in patients with abnormal ureteral orifices or infected urine and, therefore, predisposed to reflux. Intravenous radionuclide cystography is a more comprehensive and sensitive test for vesicorenal reflux than voiding cystography.

Renal clubbing and scarring in adults: a retrospective study of 110 cases

A urographic pattern of renal clubbing and scarring was found in 182 scarred kidneys of 110 adult patients. Homolateral vesicoureteric reflux was demonstrated by reliable techniques in 90/135 scarred kidneys. Urinary tract infections occurred in 75 patients. Hypertension developed in 20 patients with normal renal function and was not related to the extent of scarring. Chronic renal failure occurred in 30 patients with diffuse bilateral scarring. Four patients showed histologic changes of chronic pyelonephritis. Two hypertensive patients had a typical histologic pattern of Ask-Upmark kidney (segmental hypoplasia). Development of renal scars in adulthood was demonstrated in 2 cases.

The interrelationship between paraureteric diverticula, vesicoureteric reflux and duplication of the pelvicaliceal collecting system: a family study

The incidence of a bifid pelvicaliceal system, vesicoureteric reflux, its sequelae and paraureteric diverticulum was determined in the patients and siblings of 22 patients with a paraureteric diverticulum. The results support the hypothesis that there is a direct genetic relationship between a paraureteric diverticulum, duplication of the pelvicaliceal system and vesicoureteric reflux. This suggests that the vesicoureteric reflux associated with a parauretic diverticulum is primary and related to lateral ectopia of the ureteric orifice. This syndrome complex may be inherited by multiple genes producing a cumulative effect, thus determining the length of the intravesical ureter, or by an autosomal dominant gene of variable penetrance.

"Stasis"--a test for vesico-ureteric orifice competence in children with reflux

Intravenous radionuclide cystography (IVRNC) with one injection on 99m-Tc-DTPA measures renal function and detects vesico-renal reflux [1, 2, 3]. This paper describes a possible means of detecting incompetent ureteric orifices during IVRNC examinations. In some patients a hold-up of material in the renal areas (stasis) was observed which suddenly cleared at micturition. A prospective study of 58 patients who had IVRNC and cystoscopy within 28 days of each other revealed that 76.3% had anatomically abnormal ureteric orifices on the same side as the stasis. This contrasted with only 12.8% of abnormal uretic orifices found in patients not showing stasis (p less than 0.005). As incompetent ureteric orifices are recognised as the major aetiological factor in vesico-renal reflux [4, 5, 6] this additional information gained at IVRNC could be of clinical use and perhaps avoid some cystoscopies.

Treatment of vesicoureteral reflux: point system based on twenty years of experience

Five hundred girls with recurrent urinary tract infections and documented reflux were seen in our private practice during the last twenty years. All patients received medical treatment for three to forty-eight months (an average of fifteen months) after which the 250 who were not cured were submitted to corrective surgery. The primary reason for antireflux surgery is to protect the kidney from the damaging effect of a combination of high pressure and infection. Thus our criteria for operation included persistent infection, renal changes typical of past pyelonephritis, major reflux, and abdominal or flank pain. Our surgical cure rate after careful long-term follow-up is 96%. Our medical-surgical cure rate at the end of two years reached 88%. This experience has enabled us to evolve a rigorous point system providing common denominators regardind indications for operation. It emphasizes the desirability of attempting a medical cure for at least one year after urethral dilatation, except where major orifice defects and major reflux exist. This system should help to increase communication and coordination of efforts between pediatrician, radiologist, and urologist.

Vesico-ureteral reflux in non-paediatric patients

In the period 1968-1975 we treated 55 female and 19 male adolescent or adult patients for vesico-ureteral reflux (v. u. r.) to a total of 116 renal units. The reflux was primary in 69 units, secondary in 20 and or mixed type in 27 units. It was of moderate degree in 50 units, 31 (62%) of which showed radiologic nephropathy. Of the 18 units with gross reflux, 16 (89%) showed nephropathy. Re-implantation of 75 ureters in the bladder ad modum Politano-Leadbetter was followed by cessation of reflux in 66 units (88%), with cure of symptoms and bacteriuria in a corresponding number of patients. Infravesical surgery or antibacterial medication were less effective when used alone. Two patients with severely impaired renal function (serum creatinine greater than 440 mumol/l) failed to improve, despite technically successful surgery. Primary v. u. r. in adolescents and adults has often been present since childhood, and many of these patients show radiologic evidence of nephropathy. Effective antireflux treatment should be given early, in order to prevent progressive renal damage.

Observations on vesico-ureteric reflux and intrarenal reflux: a review and survey of material

Objectives of this study were to evaluate some of the factors influencing vesico-ureteric reflux and intrarenal reflux. Reflux occurs in about one-third to a half of Caucasian children with urinary tract infection and although not greatly influenced by examination technique or sex it is affected by age, diuretics and race. Intrarenal reflux occurs in about 10% of cases with total reflux and does not appear to cause scars on its own. Autopsy studies can provide valuable information on papillary morphology and reaction to pressure, but information is of doubtful reliability in the first months of life and in fixed specimens. The literature pertaining to vesico-ureteral reflux, intrarenal reflux and related research projects is briefly reviewed.

Association of urinary tract infection and reflux with uninhibited bladder contractions and voluntary sphincteric obstruction

We studied 53 neurologically normal children with recurrent urinary tract infection who were found to have bladder-sphincter incoordination characterized by voluntary sphincteric constriction during involuntary uninhibited bladder contraction. Increased intravesical pressure was documented during these events and was associated with vesicoureteral reflux in nearly 50 per cent of the children and with abnormalities of the ureteral orifice in 30 per cent of those without reflux. We hypothesize that increased intravesical pressure causes urinary infection in these children and produces a spectrum of intravesical anatomic distortion that predisposes to vesicoureteral reflux. In a prospective uncontrolled study treatment of the uninhibited bladder contractions allowed 58 per cent of the patients to maintain sterile urine without subsequent antimicrobial therapy after cure of the initial infection.

The vesicoureteral hiatus and paraureteral diverticula

Two ureteral sheaths and the vesical musculature combine to form a watertight ureterovesical junction but the precise anatomy and function of each component are still somewhat contentious. The morphology was studied in postmortem specimens of children with and without paraureteral diverticula and urethral obstruction, and function by deductive reasoning from radiographic and surgical observations in living children. Waldeyer's fascia (the superficial sheath) of the ureter was found to seal the potential space between the tunnel wall and the ureter, and deficiencies were associated with hiatal hernias. The deep sheath provided anchorage of the ureter to the trigone and through the attachments of the superficial sheath to the bladder wall. Both sheaths and the tunnel muscles could be identified clearly and dissected precisely at operations involving the ureterovesical junction to facilitate the surgical procedures.

Extravesical ureteroplasty

The results of extravesical ureteroplasty (Lich-Gregoir technique) for primary extravesical reflux in 62 children with 82 refluxing renal units are evaluated. Postoperative radiograms revealed persistent reflux in 5 (6.1 per cent) and obstruction in 1 (1.2 per cent) of the renal units. Of 7 patients in whom bilateral reflux had been noted previously but who had unilateral reflux at the time of operation, unilateral repair resulted in absence of reflux on the contralateral side in 6. The favorable success rate, low morbidity and median 5-day hospitalization support the use of extravesical ureteroplasty for uncomplicated reflux.

Normal position of the ureteral orifice in infancy and childhood: a quantitative study

Normal values for the distance between the vesicoureteral orifice and the internal urethral orifice are given for different ages, heights, weights, crown-to-rump lengths and surface areas of infants and children. A simple estimate of approximate mean values for these measurements also is included.

The management of vesicoureteric reflux in children

One hundred and seventy children with vesicoureteric reflux have been reviewed. Conservative therapy was the treatment of choice in Grade I reflux. Children with Grade II and Grade II reflux treated conservatively developed progressive upper tract dilation and scarring. Unilateral reflux sometimes became bilateral. In addition, the grade of reflux could worsen in the absence of symptoms or overt infection. Cystourethroscopy was an important investigation as an aid to management: the findings of abnormal ureteric orifices in the presence of Grade II and Grade III reflux indicated early surgical treatment. Surgery was also indicated in the presence of ureteric dilatation on excretion urography aand/or micturating cystourography. Vesicouretic reimplantation gave excellent results with few complications.

Reflux nephropathy

The whole subject of reflux nephropathy, which may affect 1 in every 300 of the white female population, and is the second most common disease of the kidney in the young, is still bedevilled by a lack of information regarding many of its important aspects, and the absence of any coordinated action to obtain it. What is required above all else is a means of its early detection in very young children, so that it may be prevented, at least in its more severe forms. Its financial cost can only be surmised, but the treatment of its end-stages is likely to be in the region of a hundred million dollars a year. The cost in wastage involving, as it does, young people, particularly females, is incalculable.

In vivo trigonal measurements and their relationship to competence of the ureterovesical junction

In vivo measurements of the trigone were obtained in 73 children undergoing cystourethroscopy for evaluation of urinary tract infection with and without associated vesicoureteral reflux. These data revealed greater mobility or distensibility of the trigone in children with reflux. In addition, those children with large trigones had shorter submucosal tunnels. Bladder capacity was not statistically different between the 2 groups.

Reflux in complete duplication in children

Reflux is the most common abnormality associated with complete ureteral duplication. Several authors have emphasized early surgical correction of reflux when it occurs in duplicated systems. because of a negligible success rate in non-operative therapy. Our practice has been to judge an orifice with reflux on its own merit, that is position, appearance and submucosal tunnel length. Realizing that this philosophy is not in total agreement with most of the literature on reflux in ureteral duplication we have reviewed 59 cases to ascertain whether our non-operative approach has justification. In this study early operation was elected in 61 per cent of those patients with reflux in association with total duplication. However, in 48 per cent of patients followed with non-operative surveillance reflux has either stopped spontaneously or is medically stable.

Megalourethra

Two cases of megalourethra are presented, the ninth and tenth cases to be documented in the literature. Both patients exhibited mesodermal abnormalities which justify categorization among the minor forms of prune belly syndrome. One patient, the youngest to have undergone surgical correction, presented with azotemia, dilated posterior urethra, megacystis, and megaureters. The second patient with incomplete or scaphoid form of megalourethra also exhibited undescended testis, corrected by orchiopexy at the time of urethoplasty. In all instances the goal of treatment is preservation of renal function with subsequent functional and anatomic reconstruction of the urinary tract.

Management of vesicoureteral reflux

The retrospective analysis of 210 patients between 1 month and 17 years old with 314 primary vesicoureteral units with reflux was reviewed. Our results show that there was a direct correlation between the grade of reflux and the per cent of abnormal ureteral orifices. Medical management of low grade reflux produced successful results in 60 per cent of the cases. Operation was highly successful in grade I, II, and III reflux as opposed to grade IV. The distal tunnel (Glenn-Anderson) and Politano-Leadbetter procedures were equally effective in curing reflux. Postoperative urinary infection occurred equally in all grades and usually was confined to the bladder.