British Journal of Urology (1978). 50. 233-286
Ureteric Reimplantation for Vesico-Ureteric Reflux in the Adult A. DOUNIS, M. DUNN and P. J. B. SMITH Department of Urology, Bristol Royal Infirmary, Bristol, and Royal United Hospital, Bath
Summary-A retrospective study of 3 2 adult patients undergoing ureteric reimplantation for reflux has been carried out. Reflux and reimplantation in relation to urolithiasis, pregnancy, renal failure, hypertension and bladder neck obstruction have been discussed. Eighty-four per cent of patients with primary reflux had pyelonephritic scarring compared with only 34% of patients where reflux was secondary. Reimplantation has been technically successful in preventing reflux in every patient in this series, with 1 8 patients (65%) becoming symptom free. Pyelonephritis, hypertension and renal failure were not significantly improved but no progressive changes were observed in the follow-up period after reimplantation.
Vesico-ureteric reflux in adults has rarely received the clinical attention that it deserves. Its association with chronic pyelonephritis and, to a lesser extent, hypertension is well recognised but little is known of its aetiology or pathogenesis. In its mildest forms reflux may be either asymptomatic or, when symptomatic, may be easily managed conservatively. The reported incidence of vesico-ureteric reflux in adults is variable. Estes and Brooks (1970), after studying 903 cystourethrographies in adults with chronic urinary infections, obstructive uropathy, neurogenic bladder incontinence and urinary trauma, found 5 % to have reflux, but other authors quote incidences varying from 4 to 25% (Valadka et al., 1960; Dodge, 1963; Ross, 1965). It is likely that the apparent increase in the diagnosis of reflux may be due to the more frequent use of micturating cystourethrography (Lipsky and Chisholm, 1971) in the investigations of the adult urinary tract. Material and Methods During the 11 year period from 1965 to 1976 a study was made of all patients at the United Bristol Hospitals undergoing ureteric reimplantaReceived 1 December 1977. Accepted for publication 10 February 1978.
tion for vesico-ureteric reflux. This study revealed a total of 32 patients with vesico-ureteric reflux who had ureteric reimplantation following failure of conservative management. This represents 49% of all the ureteric reimplantation in adults carried out in the 11 year period. The youngest patient in this series.was 17 years and the eldest 57 years (mean age 33 years). An excretion urogram and a micturating cystourethrogram were carried out on all patients. The severity of reflux was recorded using the following scale: Grade Iminimal reflux into the lower ureter. Grade IIreflux to the kidney without dilatation of either ureter or pelvis. Grade 111-reflux to the kidney with ureteric and pelvic dilatation. Using these criteria, the severity of reflux in this group is as shown in Table 1. The various causes of reflux are shown in Table 2, the commonest cause being primary vesico-ureteric reflux. Three patients in the iatrogenic group developed reflux after incision of ureterocoelc. In 5 patients a degree of bladder Table 1 Grading of Vesico-Ureteric Reflux Grade I
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Table 2 Aetiology of Vesico-Ureteric Reflux
(15.6%) (15.6%) (9.3%) (9.3%) (3%)
ureteric reimplantation was carried out at the same time as a bladder neck incision and a diverticulectomy; in another patient a transurethral resection of bladder neck as well as reimplantation was carried out and finally 1 other patient had the reimplantation combined with a ureteric tailoring. Double ureters were reimplanted separately but using the same submucosal tunnel. In all cases the technique of ureteric reimplantation used was as described by Politano and Leadbetter (1958).
outlet obstruction was considered to be the cause of reflux. Two of the 3 patients with lithiasis developed reflux after diagnosis of stone and in the third patient the reflux and stone were diagnosed at the same time. The 1 patient with a neurogenic bladder developed reflux 12 months after excision of a caudal tumour. The presenting symptoms were variable (Table 3). Loin pain was invariably associated with urinary infection. When infection was present the causative organism was a coliform in every patient with the exception of I who had a Proteus. Pyrexia was rarely seen and in no case did a pyonephrosis develop. In 7 patients there was a mild degree of renal failure and 1 patient had severe uraemia. Hypertension was noticed in 4 patients. Excretion urography demonstrated pyelonephritic changes varying from slight distortion of the c a k e s to multiple scars in 26 patients. In 19 patients urography demonstrated varying degrees of upper tract dilatation. Cystoscopy was carried out on all patients and usually showed the presence of a patulous ureteric orifice. Twenty-six patients had ureteric reimplantation alone; 3 had reimplantation and a V-Y plasty of the bladder neck and of these 2 had the reimplantation carried out at the same time whilst in the third patient a V-Y plasty was carried out several years before reimplantation. In 1 patient
Results Post-operative information was not sufficiently detailed in 2 patients who had ureteric reimplantation for primary reflux and 2 patients who had reimplantation for secondary reflux; all 4 were therefore excluded, leaving 28 patients for postoperative review. The follow-up period ranged from 1 to 11 years (mean 4.5 years). In no patient was persistent or recurrent reflux detected. Eighteen patients (65%) were symptom free, whilst 10 (35%) had persistent symptoms (Table 4). Hypertension persisted in the 4 patients after ureteric reimplantation but 1 patient did become normotensive after a later nephrectomy. One patient with mild renal failure improved following reimplantation and the other 6 remained unchanged but no worse. One patient developed ureteric stenosis and a secondary stone in the lower ureter; a ureterolithotomy and a repeat reimplantation were performed with success. One patient with severe hydronephrosis showed no improvement following ureteric reimplantation and a subsequent nephrectomy was performed. Recurrent infection was seen post-operatively in 9 patients, 8 of whom presented with loin pain. Three female patients became pregnant 1 or
Table 3 Presenting Symptoms
Table 4 Post-OperativeSymptoms
Primary Secondary Iatrogenic Bladder neck obstruction Calculi Double ureter Neurogenic bladder
Urinary tract infection Loin pain Dysuria Renal colic Renal failure Hypertension Pyrexia Enuresis Residual urine Urinary incontinence
5 5 3 3 1
23 (72%) 23 (72%) 18 (56%) 8 (25%) 7 (22%) 4 (13%) 3 (9qo) 3 (9qo) 2 (6W) 1 (3%)
Urinary tract infection Loin pain Dysuria Renal failure Hypertension Renal colic Enuresis Pyrexia Residual urine (Mean follow-up 4.5 years)
9 (28%) 8 (25%) 8 (25010) 6 (19%) 4 (13%) 2 (6Vo)
I (3%) 1 (3%) 1 (3%)
URETERIC REIMPLANTATION FOR VESICO-URETERIC REFLUX IN THE ADULT
more times after ureteric reimplantation. One of these patients had a moderate degree of renal failure which did not worsen during the pregnancy; another had hypertension which remained unchanged. The third patient had a hydronephrosis which became marginally worse during pregnancy. It was thought that this was due to her pregnancy rather than recurrent reflux. Postnatal micturating cystourethrography confirmed the absence of any reflux in each of these 3 patients.
Discussion The occurrence of vesico-ureteric reflux in infancy and childhood is well recognised. The natural history in children would seem to be that reflux will often disappear spontaneously as the child grows and the infection is controlled. Baker et al. (1966) suggested that there was a spontaneous cure rate of 80%. The disappearance of reflux is generally believed to be due to lengthening of the intravesical ureter and/or the development of the musculature of the uretero-vesical junction (Hutch, 1961; Stephens and Lenaghan, 1962). Primary reflux in the adult has been recorded in several studies but no precise figures for the incidence are available (Hodson and Edwards, 1960; Zingg, 1967; Ambrose, 1969; McGovern and Marshall, 1969). Lipsky and Chisholm (1971) suggested that the incidence may be higher than that recorded in the literature. Fifteen (47%) of the patients in this series undergoing ureteric reimplantation had primary vesico-ureteric reflux. Nine were under 30 years of age. Pyelonephritic scarring was seen on excretion urography in 13 (87%). The length of history was significantly longer in patients with primary reflux than those whose reflux was secondary. The majority of these patients had recurrent urinary infections dating back to childhood, which would seem to support the view of the importance of infection on the continuation of childhood reflux or on the recurrence of reflux (Estes and Brooks, 1970). Five (16%) of the patients in this series developed vesico-ureteric reflux following instrumentation to the ureteric orifice. This compares with the 23% reported by Estes and Brooks (1 970).
Three patients with vesico-ureteric reflux were found to have upper urinary tract calculi and in all of them there was infected urine. Amar et al.
(1968) suggest that the presence of urinary calculi, urinary tract infection, structural changes at the vesico-ureteric junction and reflux may together interact in such cases. Long-standing stone causes chronic infection and this leads in turn to changes at the vesico-ureteric junction. Reflux is known to perpetuate urinary tract infection and this may contribute to the formation of urinary tract calculi. Amar et al. (1968) stressed that infected upper urinary tract calculi, especially the staghorn variety, should always be investigated to exclude vesico-ureteric reflux. This series would give modified support to this concept. Vesico-ureteric reflux in the presence of ureteric duplication is well recognised (Ambrose and Nicholson, 1964; Amar and Hutch, 1968). In the case of complete duplication the reflux occurs most frequently into the upper or orthotopic ureter because of its less oblique and shorter intramural course. Reflux secondary to neuropathic bladder disease is well known (Bunts, 1958; Damanski, 1965). One patient in this series had a neuropathic bladder with reflux. Follow-up 8 years after reimplantation revealed no evidence of recurrent reflux. Hypertension in this series has not been influenced by successful vesico-ureteric reimplantation. Nephrectomy, in 1 patient with hypertension, was successful in returning the blood pressure to a normal value. The findings on urography revealed a significant difference between those patients who underwent reimplantation for primary reflux compared to those where this operation was performed for secondary reflux. Eighty-four per cent of patients who had primary reflux had gross pyelonephritic changes, whereas only 35% of patients with secondary reflux had such changes. Renal failure was not a contra-indication to reimplantation of the ureter. In only 1 patient did the degree of renal failure improve; however, in no patient did it get worse. It would seem that successful reimplantation may prevent progressive renal failure.
Conclusion Vesico-ureteric reflux in adults is a definite clinical entity. In the majority of patients this is a primary reflux. However, it is important to realise that there is another group where there is secondary reflux. Such secondary reflux may be
associated with a wide variety of conditions such as bladder neck obstruction, following surgery to the ureteric orifice, duplication, calculi and the neuropathic bladder. The presence of these conditions should always suggest the possibility of secondary reflux. Likewise, the possibility of primary reflux should be suspected in those patients in whom there is renal scarring or recurrent urinary sepsis in the absence of obstruction. Vesico-ureteric reflux in its mildest forms can be asymptomatic or, when symptomatic, may be managed conservatively. However, when reflux is severe or when conservative management has failed, then vesico-ureteric reimplantation should be considered.
Acknowledgements We should like to thank Professor Mitchell and Mr J. B. M. Roberts for allowing us to review their patients. We are indebted to Mrs Sylvia Huggan for typing this manuscript.
References Amar, A. D., Hutch, J. A. and Katz, 1. (1968). Co-existence of urinary calculi and vesico-ureteral reflux. Journal of the American Medical Association. 206, 23 12-2313. Amar, A. D. and Hutch, J. A. (1968). Anomalies of the ureter. la Encyclopedia of Urology. eds. Alken, C. E., Dix, V. W., Goodwin, W. E., Weyrauch, H. M. and Wildbolz, E. Vol. 7/1. New York: Springer-Verlag. Ambrose, S. S. (1969). Reflux pyelonephritis in adults secondary to congenital lesions of the ureteral orifice. Journal of Urology, 102, 302-304. Ambrose, S. S. and Nicholson, W. P. (1964). Ureteral reflux in duplicated ureters. Journal of Urology. 92, 4 3 9 4 3 . Baker, R., Maxted, W., Maylath, J. and Shuman, I. (1966). Relation of age, sex and infection to reflux. Journal of Urology, 95, 27-32. Bunts, R. C. (1Y58). Vesico-ureteral reflux in paraplegic patients. Journal of Urologu, 19, 147-750.
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The Authors A. Dounis, MD, Honorary Senior Registrar, Department of Urology, Bristol Royal Infirmary. M. Dunn, ChM. FRCS, Senior Registrar, Department of Urology, Bristol Royal Infirmary. P. J. B. Smith, ChM, FRCS, Consultant Urological Surgeon, Department of Urology, Royal United Hospital, Bath.
Requests for reprints to: Mr M. Dunn, FRCS. Department of Urology, Bristol Royal Infirmary. Marlborough Street, Bristol BS2 8HW.