British Journal of Urology (1978), 50, 474-478
The Management of Vesicoureteric Reflux in Children M. DUNN, N. SLADE, J. R. W. GUMPERT, P. J. B. SMITH and A. DOUNIS Departments of Paediatric Urology, Royal Hospital for Sick Children, Southmead Hospital and Royal Infirmary, Bristol
Summary-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 Ill reflux treated conservatively developed progressive upper tract dilatation 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 t o management: the finding of abnormal ureteric orifices in the presence of Grade II and Grade Ill reflux indicated early surgical treatment. Surgery was also indicated in the presence of ureteric dilatation on excretion urography and/or micturating cystourography. Vesicoureteric reimplantation gave excellent results, with few complications.
The aetiology, significance and treatment of vesicoureteric reflux in children, despite a considerable volume of literature, still remain controversial. It is well known that reflux is common in childhood whilst relatively rare in adults. Amar et al. (1976) stated that vesicoureteric reflux ceases spontaneously after medical management in 55% of children, which compares well with other published results (Williams, 1971; Scott, 1977). Treatment of vesicoureteric reflux, therefore, varies from conservative for mild cases to surgical for children with severe reflux. However, the majority of children have reflux of an intermediate degree and it is in this group that controversy still exists as to whether they are best treated by con3 4 9 10 I I 12 13+ servative or surgical means. In an effort to try and clarify this confused situaAge (Yrs) tion a detailed retrospective study of the manage- Fig. Reflux in Children: Age Incidence ment of 170 children with vesicoureteric reflux has been made. The children were all treated in the only just over half of the children had had sympDepartment of Paediatric Urology in Bristol and toms for less than 1 year (Table 1). Bath between 1965 and 1977. Whilst some were referred directly to the Department, most were Table 1 Length of History seen in association with our paediatric colleagues.
1L 1
h
L
Patients There were 123 girls and 47 boys, a female to male ratio of 2.6: 1. Their ages at the time of presentation are shown in the Figure. It is interesting that
Acute Illness Less than 6 months 6 months-I year 1 year-2 years 2 years-3 years Greater than 3 years Not specified
Read at the 34th Annual Meeting of the British Association of Urological Surgeons in Brighton, June 1978.
474
Total
25 37 24
19
16 38 11
170
475
THE MANAGEMENT OF VESICOURETERIC REFLUX IN CHILDREN
The commonest presenting symptoms were those of lower urinary infection (frequency, dysuria, and suprapubic discomfort) and in the younger children either febrile convulsions or febrile illnesses. Sixty-one patients complained specifically of pain and this tended to be generalised abdominal pain in the younger children and loin pain in the older children (Table 2). Table 2 Presenting Symptoms Lower urinary tract symptoms Pyrexial illnesses Enuresis Abdominal pain Loin pain Malaise Day time incontinence Febrile convulsion Tiredness Painful haematuria Smelly/"cloudy" urine Failure to thrive Retention of urine Chance finding Septicaemia Pol y urialpol ydypsia Prolapsed ectopic ureterocoele
83 61 42 31 30 27 22 15 13 11 11 8 4 3 1 1 1
In only 23 patients was the urine sterile on presentation but many of these children were already on antibiotic therapy. E. coli was the responsible organism in 94 children with infection (Table 3). Table 3 Urine Culture o n Presentation Urine sterile Significant infection E . Coli Proteus Streptococcus faecalis Pseudomonas Klebsiella Organism not specified Total
tion of the upper tracts was present in 91 children. Upper tract duplication was present in 24 children (Table 4). Vesicoureteric reflux has been graded as follows: Table 4 Initial Excretion Urography Normal Dilated upper tracts Upper tract duplication Reflux nephropathy Bilateral Right
53 65 24 13 25 26 5
Non-function
Grade I. Reflux into ureter only, with no dilatation. Grade ZZ. Reflux reaching the pelvicaliceal system, with no dilatation. Grade ZZZ. Reflux into ureter and/or pelvicaliceal system, with dilatation. The findings of the initial micturating cystogram are shown in Table 5. The small number of children with Grade I vesicoureteric reflux almost certainly reflects the fact that most of the children were referred by paediatricians and it would seem likely that many of the milder cases were never referred. Table 5 Initial Micturating Cystourethrography Vesico-ureteric Reflux
Leji
Right
Bilateral
No. of units
Grade I Grade I1 Grade I11
10 14 42
6 17 30
0 7 44
16 45 160
23 94 10 3 2 1
37 170
At presentation or referral a full history was taken and complete clinical examination performed. Investigations included microscopy and culture of a mid-stream specimen of urine, excretion urography and micturating cystourethrography; in some patients cystourethroscopy was also performed. Excretion urography was normal in 53 children; cortical scarring and/or caliceal clubbing indicating reflux nephropathy was present in 69. Dilata-
In 81 children a cystoscopy was performed. This was done prior to surgery both in the assessment of reflux and to identify any associated bladder abnormalities (Table 6). Treatment One hundred and thirty-four children (79%) have been initially treated conservatively on a regime of multiple micturition and a prolonged course of antibiotic therapy. Ninety-six children were considered to have failed on this regime because of recurrent symptoms, recurrent infections, worsening of the grade of reflux or progressive changes in the upper tracts as shown by excretion urography.
476
BRITISH JOURNAL OF UROLOGY
Table 7 Changes in Vesicoureteric Retlux during Conservative Treatment
Table 6 Cystoscopic Findings Normal -13 AbnormaC68 Patulous ureteric orifices Trabeculation Tight urethra Paraureteric diverticulum Raised bladder neck Chronic cystitis Ectopic ureterocoele Urethral valves Bladder stone
Bilateral 42
15 (lateralised 2) 21 (lateralised 5) 17 (lateralised 1)
Before treatment
AFer treatment
Degree of reflux
De ree of reiu
No. o f patients
Nil Grade Grade Grade Nil Grade Grade Grade Nil
4
No. of patients
6
5
Grade 1
6
4
4 4
2
Grade I1
14
1
Conservative Treatment Of the 36 children who were managed conservatively, 6 had Grade I, 14 Grade I1 and 16 Grade 111 reflux. The period of conservative treatment varied from 3 months to 6 years (mean 2.75 years). Twenty-three had no symptoms, 7 had occasional symptoms, whilst 4 had recurrent symptoms of urinary tract infection, and in 2 children no details of symptoms were given. The urine was sterile in 25, infected in 6 children, and not known in 5 children. Excretion urography, after a period of conservative management, remained normal in 17 children. In no children did normal urography become abnormal, whilst in 2 upper tract dilatation improved. The changes in the degree of reflux following conservative treatment are shown in Table 7. Surgical Treatment One hundred and thirty-one children have been treated surgically for vesicoureteric reflux by ureteric reimplantation, whilst one had a primary nephroureterectomy. Conservative treatment was used initially in 96 of these children but failed to control either symp-
I II 111
I I1 111
1 0
8 2 3 1
4
Table 8 Changes on Excretion Urography following failed Conservative treatment Normal pre-.treatment Normal Post-Treatment Normal pre-treatment Abnormal Post-Treatment (a) Dilatation (b) Scarring Abnormal pre-treatment Abnormal Post-Treatment (a) N o change (c) Improved Abnormal pre-treatment Normal Post-Treatment (a) Dilatation (b) Scarring No post-treatment Urogram Total
24
2 11
25 13 6 0
3 0 12 96
Twelve children in this group, in whom initially the reflux was unilateral, developed bilateral reflux (1 Grade I, 5 Grade I1 and 6 Grade 111). Table 9 demonstrates the effect of the conservative regime on reflux.
THE MANAGEMENT OF VESICOURETERIC REFLUX IN CHILDREN
477
attributed to the hydrodynamic effect of reflux but no good evidence has substantiated this belief (Johnston, 1968). Further experimental evidence Before treatment Afier treatment and clinical experience have shown that vesicoureteric reflux alone does not produce anatomical Degree of No. of Degree of No. of Reflux Patients Reflux Patients or functional renal damage (King and Sellards, 1971; King et al., 1974). Nil 3 It would seem, therefore, that by controlling Grade I 9 Grade I 4 infection in these children with reflux by 1 Grade I1 Grade 111 1 prolonged courses of antibiotics, their kidneys Nil 1 would be protected from damage, and eventually Grade I1 22 Grade I 1 reflux would cease. Based on this evidence over Grade I1 9 the past 12 years, the Department of Paediatric Grade I11 11 Urology has approached vesicoureteric reflux conNil 0 servatively. Grade I11 67 Grade I 0 It is clear from the results of this study that Grade I1 3 Grade 111 64 Grade I reflux is easily controlled by conservative means, as are approximately half of the patients with Grade I1 reflux. Thirty-five children have been treated surgically Ninety-six out of 134 children (72%) who had with no initial period of conservative therapy. Thirty-two had primary vesicoureteric reimplanta- initially been treated conservatively have now tion and 3 cutaneous ureterostomy followed by undergone antireflux surgery because of either persisting symptoms, persisting infection in spite reimplantation. of continuous antibiotic therapy, no change or Seventy-three children had bilateral reimplantation whilst 58 had unilateral reimplantation, mak- worsening of vesicoureteric reflux, or progressive ing a total of 204 reimplantations. The follow-up changes, e.g. dilation of the upper tract and/or period ranged from 6 months to 12 years (mean reflux therapy. Thirteen children in this group had 3.8 years). One hundred children (76%) became normal excretion urograms a t the time of diagnosis symptom-free, 25 (19%) symptomatically but by the time the conservative regime was consiimproved, whilst 6 (5%) remained symptomati- dered to have failed, 2 had upper tract dilation and cally unchanged. Contralateral reflux has occurred 1 1 had changes of reflux nephropathy. This was in post-operatively in 7 children. Reflux persisted in spite of continuous antibiotic therapy. In a further 19 children with upper tract dilata5 ureters (2.4%),persisted but improved in 3, and remained unchanged in 2. Four children tion or scarring on initial excretion urography, developed an obstructed ureter post-operatively, after a period of conservative treatment, progresneeding re-exploration; 3 children subsequently sion was noted on repeat urography. It is possible that these kidneys were damaged had nephrectomy for non-functioning kidneys. No further episodes of infection occurred in 94 initially but it is not until after a period of several children (72%).Infection occurred less frequently years that differential growth in the kidney reveals in 28 (21%) and remained unchanged in 9 (7%). the scarred areas. It is equally possible that these children forgot to take their medicine and further infection developed with minimal or no symptoms. Discussion Finally, it is also possible that persistent reflux in The aetiology and management of vesicoureteric the absence of infection would produce these reflux remain somewhat controversial. Primary changes, although this contradicts recent animal reflux is considered a congenital defect of the work (Ransley and Risdon, 1974). ureterovesical junction and is the most common It would seem clear from this retrospective study type. Reflux due to infection and secondary reflux that the child with ureteric dilatation on excretion associated with bladder outlet obstruction, urography and on cystourethrography should be neuropathic bladder and ureteric ectopia are treated surgically. The results of surgery in this important but less common causes (King et al., series are excellent and compare well with others 1968). (Politano, 1963; Amar and Singer, 1973; Scott, Initially, the changes in reflux nephropathy were 1977). Table 9 Changes in Vesicoureteric Reflux after Failed Conservative Treatment ~
~~
~~
478 This series shows a persisting post-operative urinary infection rate of 28%, and is in line with the results of other workers who report a similar incidence varying from 20-36% (Politano, 1963; Jakobsen ef al., 1977; Scott, 1977). In addition, it has been found in this series that there has been no development or progression of reflux nephropathy in these children with persisting infection. This finding is in accord with those of Hutch et al. (1 968) and Dwoskin and Perlmutter (1 973). Cystourethroscopy would appear to be an important investigation making the decision to manage the child conservatively or surgically much easier (Lyonetal., 1969). Thus those children with abnormal ureteric orifices in the presence of Grade I1 or 111reflux should be managed surgically from the outset. In this series, 81 children had cystourethroscopy. The examination in 13 was normal, but in no less than 57 it was possible to demonstrate some abnormality of the ureteric orifice. Cystourethroscopy contributed to the decision on the management of 65 children who had antireflux surgery, and the 16 who continued on a conservative regime.
References Amar. A. D., Singer, B. and Chabra, K. (1976). The practical management of vesico-ureteral reflux in children. Clinical Paediatrics, 15, 562-569. Amar, A. D. and Singer, B. (1973). Vesico-ureteral reflux: a 10 year study of 280 patients. Journal of Urology, 109, 9991001. Dwoskm, J. Y. and Perlmutter, A. D. (1973). Vesico-ureteral reflux in children; a computerized review. Journal of Urology, 109, 888-894. Hutch, J. A., Smith, D. R. and Osborne, R. (1968). Review of a series of ureterovesicoplasties. Journal of Urology, 100, 285-289.
BRITISH JOURNAL OF UROLOGY
Jakobsen, B. E., Genster, H., Olesen, S. and Nygaard, E. (1977). Vesico-ureteral reflux in children. British Journal of Urology, 49, 119- 127. Johnston, J. H. (1 968). Vesico-ureteral reflux. In Paediatric Urology, ed. Williams, D. 1. London: Butterworths. King, L. R., Surian, M. A., Wendel, R. M. and Burden, J. J. (1 968). Vesico-ureteral reflux; a classification based on cause and the results of treatment. Journal of American Medical Association, 203, 169-174. King, L. R. and Sellards, H. G. (1 971). The effect of vesicoureteral reflux on renal growth and development in puppies. Investigative Urology, 9, 95-97. King, L. R., Kami, S. 0. and Belman, A. B. (1974). Natural history of vesico-ureteral reflux: outcome of a trial of nonoperative therapy. Urology Clinics of North America; 1, 44 1-455. Lyon, R. P., Marshall, S. and Tanagho, E. A. (1969). The ureteral orifice: its configuration and competency. Journal of Urology, 102, 504-509. Politano, V. A. (1963). One hundred reimplantations and five years. Journal of Urology, 90, 696-701. Ransley, P. G. and Risdon, R. A. (1974). Renal papillae and intrarenal reflux in the pig. Lancet, 2, 1 1 14. Scott, J. E. S. (1977). The management of ureteric reflux in children. British Journal of Urology, 49, 109-1 18. Williams, D. I. ( 1 97 I ) , The natural history of reflux: A Review. Urologia Internationalis, 26, 350-366.
The Authors M. Dunn, ChM, FRCS, Senior Urological Registrar, Bristol Royal Infirmary and Royal Hospital for Sick Children, Bristol. N. Slade, FRCS, Consultant Urologist, Southmead Hospital, Bristol. J. R. W. Gumpert, FRCS, Consultant General Surgeon, Brighton General Hospital, Brighton. P. J. B. Smith, ChM, FRCS, Consultant Urological Surgeon. United Bath Hospitals. A. Dounis, MD, Honorary Senior Urological Registrar, Bristol Royal Infirmary, Bristol. Requests for reprints to: M. Dunn, Department of Paediatric Urology, Southmead General Hospital, Westbury-on-Trym, Bristol BSlO 5NB.
The Management of Vesicoureteric Reflux in Children M. DUNN, N. SLADE, J. R. W. GUMPERT, P. J. B. SMITH and A. DOUNIS Departments of Paediatric Urology, Royal Hospital for Sick Children, Southmead Hospital and Royal Infirmary, Bristol
Summary-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 Ill reflux treated conservatively developed progressive upper tract dilatation 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 t o management: the finding of abnormal ureteric orifices in the presence of Grade II and Grade Ill reflux indicated early surgical treatment. Surgery was also indicated in the presence of ureteric dilatation on excretion urography and/or micturating cystourography. Vesicoureteric reimplantation gave excellent results, with few complications.
The aetiology, significance and treatment of vesicoureteric reflux in children, despite a considerable volume of literature, still remain controversial. It is well known that reflux is common in childhood whilst relatively rare in adults. Amar et al. (1976) stated that vesicoureteric reflux ceases spontaneously after medical management in 55% of children, which compares well with other published results (Williams, 1971; Scott, 1977). Treatment of vesicoureteric reflux, therefore, varies from conservative for mild cases to surgical for children with severe reflux. However, the majority of children have reflux of an intermediate degree and it is in this group that controversy still exists as to whether they are best treated by con3 4 9 10 I I 12 13+ servative or surgical means. In an effort to try and clarify this confused situaAge (Yrs) tion a detailed retrospective study of the manage- Fig. Reflux in Children: Age Incidence ment of 170 children with vesicoureteric reflux has been made. The children were all treated in the only just over half of the children had had sympDepartment of Paediatric Urology in Bristol and toms for less than 1 year (Table 1). Bath between 1965 and 1977. Whilst some were referred directly to the Department, most were Table 1 Length of History seen in association with our paediatric colleagues.
1L 1
h
L
Patients There were 123 girls and 47 boys, a female to male ratio of 2.6: 1. Their ages at the time of presentation are shown in the Figure. It is interesting that
Acute Illness Less than 6 months 6 months-I year 1 year-2 years 2 years-3 years Greater than 3 years Not specified
Read at the 34th Annual Meeting of the British Association of Urological Surgeons in Brighton, June 1978.
474
Total
25 37 24
19
16 38 11
170
475
THE MANAGEMENT OF VESICOURETERIC REFLUX IN CHILDREN
The commonest presenting symptoms were those of lower urinary infection (frequency, dysuria, and suprapubic discomfort) and in the younger children either febrile convulsions or febrile illnesses. Sixty-one patients complained specifically of pain and this tended to be generalised abdominal pain in the younger children and loin pain in the older children (Table 2). Table 2 Presenting Symptoms Lower urinary tract symptoms Pyrexial illnesses Enuresis Abdominal pain Loin pain Malaise Day time incontinence Febrile convulsion Tiredness Painful haematuria Smelly/"cloudy" urine Failure to thrive Retention of urine Chance finding Septicaemia Pol y urialpol ydypsia Prolapsed ectopic ureterocoele
83 61 42 31 30 27 22 15 13 11 11 8 4 3 1 1 1
In only 23 patients was the urine sterile on presentation but many of these children were already on antibiotic therapy. E. coli was the responsible organism in 94 children with infection (Table 3). Table 3 Urine Culture o n Presentation Urine sterile Significant infection E . Coli Proteus Streptococcus faecalis Pseudomonas Klebsiella Organism not specified Total
tion of the upper tracts was present in 91 children. Upper tract duplication was present in 24 children (Table 4). Vesicoureteric reflux has been graded as follows: Table 4 Initial Excretion Urography Normal Dilated upper tracts Upper tract duplication Reflux nephropathy Bilateral Right
53 65 24 13 25 26 5
Non-function
Grade I. Reflux into ureter only, with no dilatation. Grade ZZ. Reflux reaching the pelvicaliceal system, with no dilatation. Grade ZZZ. Reflux into ureter and/or pelvicaliceal system, with dilatation. The findings of the initial micturating cystogram are shown in Table 5. The small number of children with Grade I vesicoureteric reflux almost certainly reflects the fact that most of the children were referred by paediatricians and it would seem likely that many of the milder cases were never referred. Table 5 Initial Micturating Cystourethrography Vesico-ureteric Reflux
Leji
Right
Bilateral
No. of units
Grade I Grade I1 Grade I11
10 14 42
6 17 30
0 7 44
16 45 160
23 94 10 3 2 1
37 170
At presentation or referral a full history was taken and complete clinical examination performed. Investigations included microscopy and culture of a mid-stream specimen of urine, excretion urography and micturating cystourethrography; in some patients cystourethroscopy was also performed. Excretion urography was normal in 53 children; cortical scarring and/or caliceal clubbing indicating reflux nephropathy was present in 69. Dilata-
In 81 children a cystoscopy was performed. This was done prior to surgery both in the assessment of reflux and to identify any associated bladder abnormalities (Table 6). Treatment One hundred and thirty-four children (79%) have been initially treated conservatively on a regime of multiple micturition and a prolonged course of antibiotic therapy. Ninety-six children were considered to have failed on this regime because of recurrent symptoms, recurrent infections, worsening of the grade of reflux or progressive changes in the upper tracts as shown by excretion urography.
476
BRITISH JOURNAL OF UROLOGY
Table 7 Changes in Vesicoureteric Retlux during Conservative Treatment
Table 6 Cystoscopic Findings Normal -13 AbnormaC68 Patulous ureteric orifices Trabeculation Tight urethra Paraureteric diverticulum Raised bladder neck Chronic cystitis Ectopic ureterocoele Urethral valves Bladder stone
Bilateral 42
15 (lateralised 2) 21 (lateralised 5) 17 (lateralised 1)
Before treatment
AFer treatment
Degree of reflux
De ree of reiu
No. o f patients
Nil Grade Grade Grade Nil Grade Grade Grade Nil
4
No. of patients
6
5
Grade 1
6
4
4 4
2
Grade I1
14
1
Conservative Treatment Of the 36 children who were managed conservatively, 6 had Grade I, 14 Grade I1 and 16 Grade 111 reflux. The period of conservative treatment varied from 3 months to 6 years (mean 2.75 years). Twenty-three had no symptoms, 7 had occasional symptoms, whilst 4 had recurrent symptoms of urinary tract infection, and in 2 children no details of symptoms were given. The urine was sterile in 25, infected in 6 children, and not known in 5 children. Excretion urography, after a period of conservative management, remained normal in 17 children. In no children did normal urography become abnormal, whilst in 2 upper tract dilatation improved. The changes in the degree of reflux following conservative treatment are shown in Table 7. Surgical Treatment One hundred and thirty-one children have been treated surgically for vesicoureteric reflux by ureteric reimplantation, whilst one had a primary nephroureterectomy. Conservative treatment was used initially in 96 of these children but failed to control either symp-
I II 111
I I1 111
1 0
8 2 3 1
4
Table 8 Changes on Excretion Urography following failed Conservative treatment Normal pre-.treatment Normal Post-Treatment Normal pre-treatment Abnormal Post-Treatment (a) Dilatation (b) Scarring Abnormal pre-treatment Abnormal Post-Treatment (a) N o change (c) Improved Abnormal pre-treatment Normal Post-Treatment (a) Dilatation (b) Scarring No post-treatment Urogram Total
24
2 11
25 13 6 0
3 0 12 96
Twelve children in this group, in whom initially the reflux was unilateral, developed bilateral reflux (1 Grade I, 5 Grade I1 and 6 Grade 111). Table 9 demonstrates the effect of the conservative regime on reflux.
THE MANAGEMENT OF VESICOURETERIC REFLUX IN CHILDREN
477
attributed to the hydrodynamic effect of reflux but no good evidence has substantiated this belief (Johnston, 1968). Further experimental evidence Before treatment Afier treatment and clinical experience have shown that vesicoureteric reflux alone does not produce anatomical Degree of No. of Degree of No. of Reflux Patients Reflux Patients or functional renal damage (King and Sellards, 1971; King et al., 1974). Nil 3 It would seem, therefore, that by controlling Grade I 9 Grade I 4 infection in these children with reflux by 1 Grade I1 Grade 111 1 prolonged courses of antibiotics, their kidneys Nil 1 would be protected from damage, and eventually Grade I1 22 Grade I 1 reflux would cease. Based on this evidence over Grade I1 9 the past 12 years, the Department of Paediatric Grade I11 11 Urology has approached vesicoureteric reflux conNil 0 servatively. Grade I11 67 Grade I 0 It is clear from the results of this study that Grade I1 3 Grade 111 64 Grade I reflux is easily controlled by conservative means, as are approximately half of the patients with Grade I1 reflux. Thirty-five children have been treated surgically Ninety-six out of 134 children (72%) who had with no initial period of conservative therapy. Thirty-two had primary vesicoureteric reimplanta- initially been treated conservatively have now tion and 3 cutaneous ureterostomy followed by undergone antireflux surgery because of either persisting symptoms, persisting infection in spite reimplantation. of continuous antibiotic therapy, no change or Seventy-three children had bilateral reimplantation whilst 58 had unilateral reimplantation, mak- worsening of vesicoureteric reflux, or progressive ing a total of 204 reimplantations. The follow-up changes, e.g. dilation of the upper tract and/or period ranged from 6 months to 12 years (mean reflux therapy. Thirteen children in this group had 3.8 years). One hundred children (76%) became normal excretion urograms a t the time of diagnosis symptom-free, 25 (19%) symptomatically but by the time the conservative regime was consiimproved, whilst 6 (5%) remained symptomati- dered to have failed, 2 had upper tract dilation and cally unchanged. Contralateral reflux has occurred 1 1 had changes of reflux nephropathy. This was in post-operatively in 7 children. Reflux persisted in spite of continuous antibiotic therapy. In a further 19 children with upper tract dilata5 ureters (2.4%),persisted but improved in 3, and remained unchanged in 2. Four children tion or scarring on initial excretion urography, developed an obstructed ureter post-operatively, after a period of conservative treatment, progresneeding re-exploration; 3 children subsequently sion was noted on repeat urography. It is possible that these kidneys were damaged had nephrectomy for non-functioning kidneys. No further episodes of infection occurred in 94 initially but it is not until after a period of several children (72%).Infection occurred less frequently years that differential growth in the kidney reveals in 28 (21%) and remained unchanged in 9 (7%). the scarred areas. It is equally possible that these children forgot to take their medicine and further infection developed with minimal or no symptoms. Discussion Finally, it is also possible that persistent reflux in The aetiology and management of vesicoureteric the absence of infection would produce these reflux remain somewhat controversial. Primary changes, although this contradicts recent animal reflux is considered a congenital defect of the work (Ransley and Risdon, 1974). ureterovesical junction and is the most common It would seem clear from this retrospective study type. Reflux due to infection and secondary reflux that the child with ureteric dilatation on excretion associated with bladder outlet obstruction, urography and on cystourethrography should be neuropathic bladder and ureteric ectopia are treated surgically. The results of surgery in this important but less common causes (King et al., series are excellent and compare well with others 1968). (Politano, 1963; Amar and Singer, 1973; Scott, Initially, the changes in reflux nephropathy were 1977). Table 9 Changes in Vesicoureteric Reflux after Failed Conservative Treatment ~
~~
~~
478 This series shows a persisting post-operative urinary infection rate of 28%, and is in line with the results of other workers who report a similar incidence varying from 20-36% (Politano, 1963; Jakobsen ef al., 1977; Scott, 1977). In addition, it has been found in this series that there has been no development or progression of reflux nephropathy in these children with persisting infection. This finding is in accord with those of Hutch et al. (1 968) and Dwoskin and Perlmutter (1 973). Cystourethroscopy would appear to be an important investigation making the decision to manage the child conservatively or surgically much easier (Lyonetal., 1969). Thus those children with abnormal ureteric orifices in the presence of Grade I1 or 111reflux should be managed surgically from the outset. In this series, 81 children had cystourethroscopy. The examination in 13 was normal, but in no less than 57 it was possible to demonstrate some abnormality of the ureteric orifice. Cystourethroscopy contributed to the decision on the management of 65 children who had antireflux surgery, and the 16 who continued on a conservative regime.
References Amar. A. D., Singer, B. and Chabra, K. (1976). The practical management of vesico-ureteral reflux in children. Clinical Paediatrics, 15, 562-569. Amar, A. D. and Singer, B. (1973). Vesico-ureteral reflux: a 10 year study of 280 patients. Journal of Urology, 109, 9991001. Dwoskm, J. Y. and Perlmutter, A. D. (1973). Vesico-ureteral reflux in children; a computerized review. Journal of Urology, 109, 888-894. Hutch, J. A., Smith, D. R. and Osborne, R. (1968). Review of a series of ureterovesicoplasties. Journal of Urology, 100, 285-289.
BRITISH JOURNAL OF UROLOGY
Jakobsen, B. E., Genster, H., Olesen, S. and Nygaard, E. (1977). Vesico-ureteral reflux in children. British Journal of Urology, 49, 119- 127. Johnston, J. H. (1 968). Vesico-ureteral reflux. In Paediatric Urology, ed. Williams, D. 1. London: Butterworths. King, L. R., Surian, M. A., Wendel, R. M. and Burden, J. J. (1 968). Vesico-ureteral reflux; a classification based on cause and the results of treatment. Journal of American Medical Association, 203, 169-174. King, L. R. and Sellards, H. G. (1 971). The effect of vesicoureteral reflux on renal growth and development in puppies. Investigative Urology, 9, 95-97. King, L. R., Kami, S. 0. and Belman, A. B. (1974). Natural history of vesico-ureteral reflux: outcome of a trial of nonoperative therapy. Urology Clinics of North America; 1, 44 1-455. Lyon, R. P., Marshall, S. and Tanagho, E. A. (1969). The ureteral orifice: its configuration and competency. Journal of Urology, 102, 504-509. Politano, V. A. (1963). One hundred reimplantations and five years. Journal of Urology, 90, 696-701. Ransley, P. G. and Risdon, R. A. (1974). Renal papillae and intrarenal reflux in the pig. Lancet, 2, 1 1 14. Scott, J. E. S. (1977). The management of ureteric reflux in children. British Journal of Urology, 49, 109-1 18. Williams, D. I. ( 1 97 I ) , The natural history of reflux: A Review. Urologia Internationalis, 26, 350-366.
The Authors M. Dunn, ChM, FRCS, Senior Urological Registrar, Bristol Royal Infirmary and Royal Hospital for Sick Children, Bristol. N. Slade, FRCS, Consultant Urologist, Southmead Hospital, Bristol. J. R. W. Gumpert, FRCS, Consultant General Surgeon, Brighton General Hospital, Brighton. P. J. B. Smith, ChM, FRCS, Consultant Urological Surgeon. United Bath Hospitals. A. Dounis, MD, Honorary Senior Urological Registrar, Bristol Royal Infirmary, Bristol. Requests for reprints to: M. Dunn, Department of Paediatric Urology, Southmead General Hospital, Westbury-on-Trym, Bristol BSlO 5NB.
