The ureteral orifice: its configuration and competency

Ureterovesicoplasty: selection of patients, incidence and avoidance of complications. A review of 3,527 cases

The procedure of ureteral reimplantation has certainly come of age. The incidence of complications can be kept low by careful selection of patients for operation along clear and definite guide lines, by close attention to detail in the surgical procedures and by rigorous followup care. When surgical intervention is deemed advisable the expected cure rate should be more than 94%. While complications do occur resultant damage to the upper urinary tracts should be minimized by its prompt recognition and by institution of appropriate therapy.

Vesico-ureteral reflux and uninhibited neurogenic bladder

Ureteral reflux in female patients who also have latent uninhibited neurogenic bladder occurs synchronously with uninhibited contraction, is blocked by buscopan and is aggravated by besacholine. Intrinsic neuromuscular antireflux mechanism of the vesicoureteral junction (VUJ) appears to be affected by unknown ways with uninhibited contraction. Urethrovesical reflux observed synchronously with uninhibited contraction seems to play an additional role in the genesis of urinary infection. A different look is required in the management of these refluxes, in that concomitant use of the anticholinergic drugs is recommended in addition to the conventional approach for the control of infection, reflux and voiding symptoms.

Ureteral reimplantation: Lich method

In utilizing the ureteral reimplantation procedure we have performed 76 reimplantations and have a 96 per cent success rate on our first operation. We review our clinical indications, material, and complications as well as our over-all results. We believe that this operation as outlined is as good or better than other previously reported types of ureteral reimplantation and has avoided some of the major hazards, including no postoperative obstruction.

Non-obstructive vesicoureteral reflux in adults: value of conservative treatment

Chronic or recurrent non-obstructive urinary tract infection was investigated in 158 adult patients, 39 of whom had vesicoureteral reflux. Conservative, long-term chemotherapy did not eradicate the reflux in these patients. The characteristics of reflux in adults were studied with cystograms, excretory urograms, cystoscopic findings of the ureteral orifices or trigones and the clinical histories of the patients. These data were evaluated and compared to data obtained from adults with chronic or recurrent uncomplicated urinary tract infection and from children with vesicoureteral reflux who were referred to us during the same period. Non-obstructive vesicoureteral reflux in adults may be considered to be congenital in most cases, since the proportion of trigonal anomalies in adults with reflux is equal to that in children and the frequency of abnormalities at the ureteral orifice and trigonal region is significantly more than the frequency noted in control patients with uncomplicated pyelonephritis. Characteristically, excretory urography revealed caliceal scarring in adults with reflux in contrast to children, in whom a normal or dilated pattern of the upper tract was prominent. Recurring renal infection, for which this congenital defect of the ureterovesical valve must be responsible, produces progressive renal damage. Prolonged conservative treatment is of little use and is often destructive in adults with reflux.

The interrelationship between vesico-ureteric reflux, trigonal abnormalities and a bifid pelvicalyceal collecting system: a family study

3 investigations have been undertaken to study the interrelationship between a bifid pelvicalyceal collecting system, vesico-ureteric reflux and lateral ectopia of the ureteric orifice. Firstly, in 30 families investigated to confirm the familial incidence of bifid and double ureters there were 3 families in which siblings were found with primary reflux. Secondly, reflux was found in 62 of 110 patients investigated with a duplex pelvicalyceal system. Reflux was to the ipsilateral kidney in 48 patients but occurred to the contralateral kidney, unaffected by duplicity, in 14. This high incidence of reflux is related to lateral ectopia of the ureteric orifice which may be either bilateral or unilateral. Thirdly, the incidence of a bifid pelvicalyceal system was determined in the parents and siblings of a series of 32 patients with primary reflux. The results support the hypothesis that primary reflux may be inherited by an autosomal dominant gene of variable penetrance in a manner similar to the inheritance of a duplex urinary tract. Thus there is a direct genetic relationship between primary vesico-ureteric reflux, lateral ectopia of the ureteric orifices and a duplex pelvicalyceal system.

Active surgical management of primary vesicoureteral reflux in adults

Of 27 adults with primary vesicoureteral reflux, 23 were treated surgically. These patients had suffered from chronic urinary-tract infections with poor response to conservative therapy. Urography revealed inflammatory changes in one or both kidneys in 18 patients, as well as other renal or ureteral deformities. Micturition cystography showed reflux reaching the renal pelvis and dilatation of the pelvis and ureter in 18 patients (28 ureters). An antireflux operation was performed on 32 ureters and in all cases was followed by disappearance of the reflux. No ureteral stricture developed postoperatively. During an observation period averaging more than three years only three patients had postoperative urinary-tract infections. These occurred when a short period of medication was terminated. On the basis of present experience we consider that antireflux surgery is indicated for all adults with vesicoureteral reflux and urinary-tract infections or progressive dilatation of the upper urinary tract.

Infection of the urinary tract after anti-reflux surgery

Two hundred twenty-three children who underwent anti-reflux surgery were evaluated. Pyelonephritic scarring was more apt to occur with greater degrees of reflux. Postoperative infection was principally confined to the bladder and occurred primarily in females. The beneficial effect of anti-reflux surgery is discussed.

The natural history of reflux and long-term effects of reflux on the kidney

Spontaneous cessation of vesicoureteral reflux occurred in 42 per cent of 102 patients. It ceased in 65 per cent of the patients with unilateral reflux, in 50 per cent of those with bilateral reflux in normal caliber ureters and in 9 per cent of those with bilateral dilated ureters. Renal parenchymal changes were seen most frequently in patients with urinary infection after diagnosis. The likelihood of such infections lessened if reflux ceased. Proportionately more male than female subjects were free of infection. Renal damage may follow even 1 episode of infection. Lesions appeared with equal frequency during the entire followup period, whereas urinary infection was more common in the 5-year period after diagnosis. Renal damage was more likely to occur in kidneys that were already abnormal. Reflux should be controlled surgically if urinary infections occur after diagnosis and during long-term chemotherapy and careful observation. In the absence of infection indications for operation are infrequent. Non-surgical management may apply to normal caliber ureters and in infancy, while antireflux operation may be considered at diagnosis in dilated ureters, bilateral reflux or in the presence of renal lesions.

Prognosis for resolution of moderate, primary reflux in girls

Detailed cystoscopic grading of ureteral orifices has proved unnecessary in our experience for determining the prognosis of moderate, primary reflux in girls. Medially placed orifices strongly predict spontaneous resolution with preventive medication, while radiographic pyelonephritic scarring and/or grade III reflux strongly predict failure to resolve. While laterally placed ureteral orifices and low volume reflux suggest a need for operation, they are prognostically less useful, particularly when those with grade III reflux are excluded. Cystitis cystica and unrelated anomalies seem to be associated with the ultimate need for operation but are of uncertain significance.

Results of operative treatment of vesicoureteral reflux by the Leadbetter-Politano method in children

In this work the results of vesicoureteroplasty performed by the Leadbetter-Politano method in 77 children are presented. The indications for a vesicoureteroplasty procedure are outlined. Bad results are analysed and the causes of failure and possibilities of preventing them are considered. Probable causes of vesicoureteral reflux on the side opposite to the operated one, and the influence of coexisting congenital anomalies of urinary tract upon operative results are discussed.

Duplex kidneys: a correlation of renal dysplasia with position of the ureteral orifice

A study was made of 51 duplex kidneys, ureters and bladders to assess the types of abnormalities seen in duplex kidneys. The abnormalities affected ectopic and orthotopic segments equally. The occurrence of renal abnormality was closely correlated to the abnormal locations of the segment's ureteral orifice. When the orifice was displaced either cranially (orifice positions B, C and D) or caudally (orifices G and H) the orthotopic and ectopic segments, respectively, showed more severe hypoplasia and dysplasia. Faulty embryogenesis is proposed to explain these findings and the importance of endoscopic positioning of the ureteral orifice is emphasized in determining whether heminephrectomy will be necessary.

Diseases causing end-stage renal failure in New South Wales

The nature of the original renal disease was determined in 403 consecutive cases of end-stage renal failure, in 317 of which the clinical diagnosis was corroborated by histological examination of the kidney. Five diseases accounted for 20 or more cases--glomerulonephritis (31% of the total), analgesic nephropathy (29%), primary vesicoureteral reflux (8%), essential hypertension (6%), and polycystic kidneys (5%). In only four cases did renal failure result from chronic pyelonephritis without a demonstrable primary cause. Greater use of micturating cystography and cystoscopy and routine urine testing for salicylate are advocated for earlier diagnosis of the major causes of "pyelonephritis". The incidence of end-stage renal failure in people aged 15-55 in New South Wales was estimated to be at least 34 new cases per million of total population each year.

Fetal vesicoureteral reflux

Intrauterine fetal vesicoureteral reflux has been demonstrated in a 25-week fetus. A voiding cystourethrogram when the patient was 1 year old showed persistence of the bilateral reflux. No urinary tract infectious have been documented. A survey of other physicians performing fetal transfusions indicates that fetal cystograms are infrequently obtained and that vesicoureteral reflux has been observed by ourselves and one other contributing physician. The incidence of reflux in fetal cystograms reviewed appears to be higher than would be expected when compared to normal premature babies, newborns, infants and children. This procedure provides an unusual opportunity to document intrauterine fetal vesicoureteral reflux and later obtain followup cystourethrograms in these children to determine the resolution or progression of this urinary tract abormality.