Vol. 115, April Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
Pediatric Articles SURGICAL CORRECTION OF VESICOURETERAL REFLUX IN CHILDREN WITH NEUROGENIC BLADDER ROBERT D. JEFFS,* PAUL JONAS
AND
JOHN F. SCHILLINGER
From the Division of Urology, Department of Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
ABSTRACT
The ··~-~~-,,~ success rate for correction of vesicoureteral reflux in the bladder has been low. Reflux was corrected in 33 of 37 ureters in 23 selected children with neurogenic bladder treated reimplantation. Selection was based on good bladder capacity, little or no trabeculation and the expectation that the bladder would be useful in future management of the patient. Preoperative preparation and surgical technique are emphasized. The preservation of renal function is the urologist's first concern in the care of patients with neurogenic bladders. Pyelonephritis associated with vesicoureteral reflux remains the chief cause of progressive renal deterioration in this condition. 1 -• The incidence of vesicoureteral reflux in neurogenic bladders varies between 15 and 50 per cent in different series. Reflux will occur with apparently equal frequency in flaccid or spastic bladders.,_, Once established reflux can be difficult to control conservatively and the means of surgical correction remain somewhat controversial. Herein we report our experience with ureteral reimplantation in children with neurogenic bladders. CLINICAL MATERIAL
From 1960 to 1973, 11 boys and 12 girls with neurogenic bladders underwent ureteral reimplantation for vesicoureteral reflux. The etiologies of the neurogenic bladders were: meningomyelocele, 20 cases; sacral agenesis, 2 cases and spinal trauma (gunshot), 1 case. Of these children 15 had flaccid bladders and 8 had hyperreflexic bladders. All except 2 were seen at our hospital in the early neonatal period. Urological evaluation was done at that time and was continued on a regular 6-month basis and more frequently whenever the need arose. The catheter cinecystogram was a part of this initial urological assessment only if the excretory urogram (IVP) was abnormal or if the urine became infected. Reflux was initially diagnosed in the first year of life in 7 children, at age 2 years in 3 and at age 4 years in 4. Reflux was first noted in 8 children between the ages of 8 and 12. In the 9-year-old patient who sustained spinal trauma, reflux developed 1 year after the gunshot wound. Reflux was bilateral in 14 children and unilateral in 9. When the reflux was first discovered the IVPs showed pyelonephritic changes in 7 children and dilated ureters in 5. One patient had impairII!ent of renal function as indicated by the blood urea nitrogen and serum creatinine. All of these children had recurrent pyuria and frequent episodes of acute pyelonephritis. Thirty-seven ureters were reimplanted in the 23 children. Bilateral reimplantations were done in 14 patients and unilateral in 9. A Politano-Leadbetter procedure was done on 27 renal units. 10 The procedure Accepted for publication August 29, 1975. * Requests for Division of Pediatric Urology, The James Buchanan Institute, The Johns Hopkins Hospital, Baltimore.
449
was somewhat modified with the ureters being further advanced and fixed close to the bladder neck rather than replacing the ureteral orifices at their original sites. Reimplantation of 7 ureters was done solely by an advancement technique 11 and the Paquin procedure was used on 3 ureters. 12 Two grossly dilated ureters were trimmed at the time of reimplantation. The 4 children with apparent high outflow resistance underwent a Y-V plasty of the bladder neck at the time of reimplantation. The operation was performed immediately following the diagnosis of reflux in 9 children, 1 year fol_lowing diagnosis in 7, iyears following diagnosis in 3 and 4 to 7 years -following diagnosis in 4. Prior to operation the children were managed primarily by manual expression, prophylactic antibacterial therapy and occasional periods of catheter drainage. Transurethral resection of the bladder neck was done in 2 children and external transurethral sphincterotomy was performed in 6 without any effect on the pattern or severity of the reflux. FOLLOWUP AND RESULTS
Routine followup consisted of physical examination and urinalyses on a 3 to 6-month basis and annually repeated IVPs and catheter cine-cystograms whenever any deterioration was suspected. The length of followup was 1 year in 6 cases, 2 to 3 years in 4, 4 to 5 years in 5 and 6 to 8 years in 8, with a mean of 4 years. The criteria for a good result were 1) IVP remained normal, the pyelonephritic changes present at the time of reflux remained stationary or the degree of caliceal dilatation diminished and 2) absence of reflux on at least 2 repeated cinecystograms. According to these criteria reimplantation of 33 ureters in 20 children was successful and 4 in 3 children failed. Of the 20 children successfully reimplanted 13 continued on manual expression. Seven of these patients stayed dry from 2 to 3 hours following the expressions and 3 had adequate bladder control and were dry most of the time. One girl is on intermittent catheterization and is dry between catheterizations. Another girl has had a prosthetic sphincter 13 implanted and is continent with normal upper tracts and no reflux 2 years following bilateral ureteral reimplantations and 6 months following the prosthesis placement. Another child underwent an ileal conduit diversion at age 14 years, 10 years after successful ureteral reimplantation. The diversion was done because of incontinence and a strong request the
450
JEFFS, JONAS AND SCHILLINGER
One child was referred at the age of 8 years with impaired renal function and bilateral massive reflux. Renal function improved after successful reimplantation of the ureters. However, renal failure eventually progressed although no reflux or obstruction could be detected. The patient had to be dialyzed 5 years later. Four ureteral reimplantations failed in 2 girls and 1 boy with flaccid bladders. Of these children 2 were in the first year of life at the time of operation and 1 was 8 years old. All patients had had pyelonephritic scarring and hydrocalices preoperatively and all were reimplanted by the modified Leadbetter-Politano method. All failures occurred within 1 year postoperatively. Ileal conduits were performed in 2 children because increasing hydroureter and hydronephrosis developed. Reflux recurred in the remaining child and he is managed by intermittent catheterization at the present time.
primary importance. Care must be taken to avoid the high reimplantation effect resulting in ureteral obstruction. This effect occurs when the reimplantation is too high and/or too lateral, and can be avoided by advancing the ureteral orifice onto the trigone. Better backing to the reimplanted ureter by the trigone muscle can also be obtained. Following removal of the suprapubic cystostomy tube the patients must be closely supervised to re-establish a good voiding routine. Intermittent catheterization may be necessary until a good expression routine can be established. Although a decreased incidence of positive urine cultures following reimplantation of the ureters could not be proved in the series, it was apparent that no further episodes of acute pyelonephritis occurred following successful reimplantation. CONCLUSION
DISCUSSION
The occurrence of vesicoureteral reflux in neurogenic bladders is alarming and if left untreated will result in progressive renal deterioration and ultimate death. Although it is agreed that vesicouretera] reflux demands treatment, there is controversy as to what treatment will prove most effective. Some believe that diversion is indicated while others use intense antibacterial therapy and a rigid, scheduled, voiding routine. More recently, intermittent catheterization or lowering of outflow resistance by either bladder neck or external sphincter resection is reported to be successful in as many as 50 per cent of the cases. 14 - 17 Persistence with manual expression alone in the presence of reflux has been contraindicated by some authorities. 18 • 1 • Ureteral reimplantation techniques commonly used with excellent results in non-neurogenic bladders have been somewhat controversial. Although good results have been reported, 16 • 20 • 21 many urologists have shown little enthusiasm for these techniques or believe they have no place in the management of reflux in neurogenic bladders. 2 • 6 The approach in these patients has been to perform ureteral reimplantation on a selective basis when reflux develops in neurogenic bladders. A child with good bladder capacity and little or no trabeculation is considered a good candidate. These criteria are more frequently met in flaccid bladders but the hyperreflexic or upper motor neuron bladders are not automatically excluded. Patients are selected if there is expectation of good bladder control, if intermittent catheterization is expected to be a useful method of management and if prosthetic sphincter implantation is recommended. Reimplantation may also be performed to halt renal damage early in life and to give time to assess the potential of the child and the bladder. Several studies indicate that the prevalence of reflux bore little or no relationship to the type of neurologic involvement or the height of intravesical pressure. It was thought to be better related to the presence of long-standing infection, trabeculation and saccule formation or the loss of muscular backing behind the intramural ureter. 7 • 8 • 20 Long-standing reflux with infection will eventually produce ureteral dilatation and impair ureteral peristalsis. The first signs of upper tract deterioration may be difficult to detect as well as rapidly progressive. Therefore, early reimplantation is indicated in the child with recurrent bladder infection and persistent reflux. However, operation should be undertaken only when the child is free of infection. Adequate antibacterial therapy associated with intermittent catheterization preoperatively gave the best results in achieving infection-free and inflammation-free bladders. High outflow resistance can be treated at the time of or prior to ureteral reimplantation but generally does not affect the presence of reflux. Preoperative cystoscopy is necessary to assess the condition of bladder mucosa, the ureteral orifices and the degree of trabeculation. At operation careful reconstruction of the muscle layer at the old hiatus to give good support to the reimplanted ureter is of
Vesicoureteral reflux occurring in neurogenic bladders in children can be managed successfully by ureteral reimplantation. Good results require selection of patients, meticulous surgical technique and careful clearing of bladder infection preoperatively. REFERENCES
1. Donnelly, J., Hackler, R. H. and Bunts, R. C.: Present urologic status of the World War II paraplegic: 25-year followup. Comparison with status of the 20-year Korean War paraplegic and 5-vear Vietnam paraplegic. J. Urol., Hlll: 558, 1972. 2. Eckstein, H. B.: S. neuropathic bladder. In: Encyclodedia of Urology. Urology in Childhood. Edited by D. i. Williams. New York: Springer-Verlag, pp. 249-265, 1974. 3. Marchetti, L. J. and Gonick, P.: A comparison of renal function in spinal cord injury patients with and without reflux. J. Urol., 104: 365, 1970. 4. Ross, J.C., Damanski, M. and Gibbon, N.: Ureteric reflux in the paraplegic. Brit. J. Surg., 47: 636, 1960. 5. Carlson, H. E.: Urologic problems in meningomyelocele. J. Urol., 95: 245, 1966. 6. Bors, E. and Comari. A. E.: Neurological Urology. Baltimore: University Park Press, pp. 320-328, 1971. 7. Cooper, D. G. W.: Bladder studies in children with neurogenic incontinence with comments on the place of pelvic floor stimulation. Brit. J. Urol., 40: 157, 1968. 8. Ericsson, N. 0., Hellstrom, B., Nergm-dh, A. and Rudhe, U.: Micturition urethrocystography in children with myelomeningocele. A radiologic and clinical investigation. Acta Radio!. Diag., 11: 321, 1971. 9. Mihaldzic, N., Leal, J. F. and Brewer, R. D., Jr.: Incidence of vesicoureteral reflux in paraplegia as related to the level of injury and the type of urinary drainage. Proc. Ann. Clin. Spinal Cord Inj. Conf., 15: 136, 1966. 10. Politano, V. A. and Leadbetter, W. F.: An operative technique for the correction of vesico-ureteral reflux. J. Urol., 79: 932, 1958. 11. Glenn, J. F. and Anderson, E. E.: Distal tunnel ureteral reimplantation. J. Urol., 97: 623, 1962. 12. Paquin, A. J., Jr.: Ureterovesical anastomosis: the description and evaluation of a technique. J. Urol., 82: 573, 1959. 13. Scott, F. B., Bradley, W. E., Timm, G. W. and Kothari, D.: Treatment of incontinence secondary to myelodysplasia by an implantable prosthetic urinary sphincter. South. Med. J., 66: 987, 1973. 14. Pellman, C.: The neurogenic bladder in children with congenital malformations of the spine: a study of 61 patients. J. Urol., 93: 472, 1965. 15. Ross, J.C.: Vesico-ureteric reflux in the neurogenic bladder. Brit. J. Surg., 52: 164, 1965. 16. Tarabulcy, E., Morales, P.A. and Sullivan, J. F.: Vesico-ureteric reflux in paraplegia: results of various forms of management. Paraplegia, 10: 44, 1972. 17. Walsh, J. J.: Further experience with intermittent catheterisation. Paraplegia, 6: 74, 1968. 18. Miyazaki, K.: Urological problems in children with spina bifida cystica and sacral defects. Paraplegia, 10: 37, 1972. 19. Pekarovic, E., Robinson, A., Zachary, R. B. and Lister, J.: Indications for manual expression of the neurogenic bladder in children. Brit. J. Urol., 42: 191, 1970.
----
_..,..
VESICOURETERAL REFLUX IN CHILDREN WITH NEUROGENIC BLADDER
20. Hutch, J. A.: Vesico-ureteral reflux in the paraplegic: cause and correction. J. Urol., 68: 457, 1952. 21. Malkin, R. B., Schellhammer, P. F. and Hackler, R. H.: Experience with transureteroureterostomy in the paraplegic patient with irreversible vesicoureteral reflux. J. Urol., 112: 181, 197 4.
COMMENT Recently, I have been doing more reimplantations into neurogenic bladders than I used to because it is now apparent that children and
451
parents accept intermittent catheterization well, and often prefer this to a supravesical diversion. Patients with high residuals often stay dry for usable periods when so treated. In such circumstances, one likes to stop reflux when it persists in order to protect the kidney from infection. I have been using the Hutch I operation for reimplantation into thickened, trabeculated neurogenic bladders and it has worked well in 6 or 8 personal cases. Perhaps reimplantation into a neurogenic bladder is not as challenging as was once thought. After all, the operation was invented for use in paraplegics. L.R.K.
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
Pediatric Articles SURGICAL CORRECTION OF VESICOURETERAL REFLUX IN CHILDREN WITH NEUROGENIC BLADDER ROBERT D. JEFFS,* PAUL JONAS
AND
JOHN F. SCHILLINGER
From the Division of Urology, Department of Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
ABSTRACT
The ··~-~~-,,~ success rate for correction of vesicoureteral reflux in the bladder has been low. Reflux was corrected in 33 of 37 ureters in 23 selected children with neurogenic bladder treated reimplantation. Selection was based on good bladder capacity, little or no trabeculation and the expectation that the bladder would be useful in future management of the patient. Preoperative preparation and surgical technique are emphasized. The preservation of renal function is the urologist's first concern in the care of patients with neurogenic bladders. Pyelonephritis associated with vesicoureteral reflux remains the chief cause of progressive renal deterioration in this condition. 1 -• The incidence of vesicoureteral reflux in neurogenic bladders varies between 15 and 50 per cent in different series. Reflux will occur with apparently equal frequency in flaccid or spastic bladders.,_, Once established reflux can be difficult to control conservatively and the means of surgical correction remain somewhat controversial. Herein we report our experience with ureteral reimplantation in children with neurogenic bladders. CLINICAL MATERIAL
From 1960 to 1973, 11 boys and 12 girls with neurogenic bladders underwent ureteral reimplantation for vesicoureteral reflux. The etiologies of the neurogenic bladders were: meningomyelocele, 20 cases; sacral agenesis, 2 cases and spinal trauma (gunshot), 1 case. Of these children 15 had flaccid bladders and 8 had hyperreflexic bladders. All except 2 were seen at our hospital in the early neonatal period. Urological evaluation was done at that time and was continued on a regular 6-month basis and more frequently whenever the need arose. The catheter cinecystogram was a part of this initial urological assessment only if the excretory urogram (IVP) was abnormal or if the urine became infected. Reflux was initially diagnosed in the first year of life in 7 children, at age 2 years in 3 and at age 4 years in 4. Reflux was first noted in 8 children between the ages of 8 and 12. In the 9-year-old patient who sustained spinal trauma, reflux developed 1 year after the gunshot wound. Reflux was bilateral in 14 children and unilateral in 9. When the reflux was first discovered the IVPs showed pyelonephritic changes in 7 children and dilated ureters in 5. One patient had impairII!ent of renal function as indicated by the blood urea nitrogen and serum creatinine. All of these children had recurrent pyuria and frequent episodes of acute pyelonephritis. Thirty-seven ureters were reimplanted in the 23 children. Bilateral reimplantations were done in 14 patients and unilateral in 9. A Politano-Leadbetter procedure was done on 27 renal units. 10 The procedure Accepted for publication August 29, 1975. * Requests for Division of Pediatric Urology, The James Buchanan Institute, The Johns Hopkins Hospital, Baltimore.
449
was somewhat modified with the ureters being further advanced and fixed close to the bladder neck rather than replacing the ureteral orifices at their original sites. Reimplantation of 7 ureters was done solely by an advancement technique 11 and the Paquin procedure was used on 3 ureters. 12 Two grossly dilated ureters were trimmed at the time of reimplantation. The 4 children with apparent high outflow resistance underwent a Y-V plasty of the bladder neck at the time of reimplantation. The operation was performed immediately following the diagnosis of reflux in 9 children, 1 year fol_lowing diagnosis in 7, iyears following diagnosis in 3 and 4 to 7 years -following diagnosis in 4. Prior to operation the children were managed primarily by manual expression, prophylactic antibacterial therapy and occasional periods of catheter drainage. Transurethral resection of the bladder neck was done in 2 children and external transurethral sphincterotomy was performed in 6 without any effect on the pattern or severity of the reflux. FOLLOWUP AND RESULTS
Routine followup consisted of physical examination and urinalyses on a 3 to 6-month basis and annually repeated IVPs and catheter cine-cystograms whenever any deterioration was suspected. The length of followup was 1 year in 6 cases, 2 to 3 years in 4, 4 to 5 years in 5 and 6 to 8 years in 8, with a mean of 4 years. The criteria for a good result were 1) IVP remained normal, the pyelonephritic changes present at the time of reflux remained stationary or the degree of caliceal dilatation diminished and 2) absence of reflux on at least 2 repeated cinecystograms. According to these criteria reimplantation of 33 ureters in 20 children was successful and 4 in 3 children failed. Of the 20 children successfully reimplanted 13 continued on manual expression. Seven of these patients stayed dry from 2 to 3 hours following the expressions and 3 had adequate bladder control and were dry most of the time. One girl is on intermittent catheterization and is dry between catheterizations. Another girl has had a prosthetic sphincter 13 implanted and is continent with normal upper tracts and no reflux 2 years following bilateral ureteral reimplantations and 6 months following the prosthesis placement. Another child underwent an ileal conduit diversion at age 14 years, 10 years after successful ureteral reimplantation. The diversion was done because of incontinence and a strong request the
450
JEFFS, JONAS AND SCHILLINGER
One child was referred at the age of 8 years with impaired renal function and bilateral massive reflux. Renal function improved after successful reimplantation of the ureters. However, renal failure eventually progressed although no reflux or obstruction could be detected. The patient had to be dialyzed 5 years later. Four ureteral reimplantations failed in 2 girls and 1 boy with flaccid bladders. Of these children 2 were in the first year of life at the time of operation and 1 was 8 years old. All patients had had pyelonephritic scarring and hydrocalices preoperatively and all were reimplanted by the modified Leadbetter-Politano method. All failures occurred within 1 year postoperatively. Ileal conduits were performed in 2 children because increasing hydroureter and hydronephrosis developed. Reflux recurred in the remaining child and he is managed by intermittent catheterization at the present time.
primary importance. Care must be taken to avoid the high reimplantation effect resulting in ureteral obstruction. This effect occurs when the reimplantation is too high and/or too lateral, and can be avoided by advancing the ureteral orifice onto the trigone. Better backing to the reimplanted ureter by the trigone muscle can also be obtained. Following removal of the suprapubic cystostomy tube the patients must be closely supervised to re-establish a good voiding routine. Intermittent catheterization may be necessary until a good expression routine can be established. Although a decreased incidence of positive urine cultures following reimplantation of the ureters could not be proved in the series, it was apparent that no further episodes of acute pyelonephritis occurred following successful reimplantation. CONCLUSION
DISCUSSION
The occurrence of vesicoureteral reflux in neurogenic bladders is alarming and if left untreated will result in progressive renal deterioration and ultimate death. Although it is agreed that vesicouretera] reflux demands treatment, there is controversy as to what treatment will prove most effective. Some believe that diversion is indicated while others use intense antibacterial therapy and a rigid, scheduled, voiding routine. More recently, intermittent catheterization or lowering of outflow resistance by either bladder neck or external sphincter resection is reported to be successful in as many as 50 per cent of the cases. 14 - 17 Persistence with manual expression alone in the presence of reflux has been contraindicated by some authorities. 18 • 1 • Ureteral reimplantation techniques commonly used with excellent results in non-neurogenic bladders have been somewhat controversial. Although good results have been reported, 16 • 20 • 21 many urologists have shown little enthusiasm for these techniques or believe they have no place in the management of reflux in neurogenic bladders. 2 • 6 The approach in these patients has been to perform ureteral reimplantation on a selective basis when reflux develops in neurogenic bladders. A child with good bladder capacity and little or no trabeculation is considered a good candidate. These criteria are more frequently met in flaccid bladders but the hyperreflexic or upper motor neuron bladders are not automatically excluded. Patients are selected if there is expectation of good bladder control, if intermittent catheterization is expected to be a useful method of management and if prosthetic sphincter implantation is recommended. Reimplantation may also be performed to halt renal damage early in life and to give time to assess the potential of the child and the bladder. Several studies indicate that the prevalence of reflux bore little or no relationship to the type of neurologic involvement or the height of intravesical pressure. It was thought to be better related to the presence of long-standing infection, trabeculation and saccule formation or the loss of muscular backing behind the intramural ureter. 7 • 8 • 20 Long-standing reflux with infection will eventually produce ureteral dilatation and impair ureteral peristalsis. The first signs of upper tract deterioration may be difficult to detect as well as rapidly progressive. Therefore, early reimplantation is indicated in the child with recurrent bladder infection and persistent reflux. However, operation should be undertaken only when the child is free of infection. Adequate antibacterial therapy associated with intermittent catheterization preoperatively gave the best results in achieving infection-free and inflammation-free bladders. High outflow resistance can be treated at the time of or prior to ureteral reimplantation but generally does not affect the presence of reflux. Preoperative cystoscopy is necessary to assess the condition of bladder mucosa, the ureteral orifices and the degree of trabeculation. At operation careful reconstruction of the muscle layer at the old hiatus to give good support to the reimplanted ureter is of
Vesicoureteral reflux occurring in neurogenic bladders in children can be managed successfully by ureteral reimplantation. Good results require selection of patients, meticulous surgical technique and careful clearing of bladder infection preoperatively. REFERENCES
1. Donnelly, J., Hackler, R. H. and Bunts, R. C.: Present urologic status of the World War II paraplegic: 25-year followup. Comparison with status of the 20-year Korean War paraplegic and 5-vear Vietnam paraplegic. J. Urol., Hlll: 558, 1972. 2. Eckstein, H. B.: S. neuropathic bladder. In: Encyclodedia of Urology. Urology in Childhood. Edited by D. i. Williams. New York: Springer-Verlag, pp. 249-265, 1974. 3. Marchetti, L. J. and Gonick, P.: A comparison of renal function in spinal cord injury patients with and without reflux. J. Urol., 104: 365, 1970. 4. Ross, J.C., Damanski, M. and Gibbon, N.: Ureteric reflux in the paraplegic. Brit. J. Surg., 47: 636, 1960. 5. Carlson, H. E.: Urologic problems in meningomyelocele. J. Urol., 95: 245, 1966. 6. Bors, E. and Comari. A. E.: Neurological Urology. Baltimore: University Park Press, pp. 320-328, 1971. 7. Cooper, D. G. W.: Bladder studies in children with neurogenic incontinence with comments on the place of pelvic floor stimulation. Brit. J. Urol., 40: 157, 1968. 8. Ericsson, N. 0., Hellstrom, B., Nergm-dh, A. and Rudhe, U.: Micturition urethrocystography in children with myelomeningocele. A radiologic and clinical investigation. Acta Radio!. Diag., 11: 321, 1971. 9. Mihaldzic, N., Leal, J. F. and Brewer, R. D., Jr.: Incidence of vesicoureteral reflux in paraplegia as related to the level of injury and the type of urinary drainage. Proc. Ann. Clin. Spinal Cord Inj. Conf., 15: 136, 1966. 10. Politano, V. A. and Leadbetter, W. F.: An operative technique for the correction of vesico-ureteral reflux. J. Urol., 79: 932, 1958. 11. Glenn, J. F. and Anderson, E. E.: Distal tunnel ureteral reimplantation. J. Urol., 97: 623, 1962. 12. Paquin, A. J., Jr.: Ureterovesical anastomosis: the description and evaluation of a technique. J. Urol., 82: 573, 1959. 13. Scott, F. B., Bradley, W. E., Timm, G. W. and Kothari, D.: Treatment of incontinence secondary to myelodysplasia by an implantable prosthetic urinary sphincter. South. Med. J., 66: 987, 1973. 14. Pellman, C.: The neurogenic bladder in children with congenital malformations of the spine: a study of 61 patients. J. Urol., 93: 472, 1965. 15. Ross, J.C.: Vesico-ureteric reflux in the neurogenic bladder. Brit. J. Surg., 52: 164, 1965. 16. Tarabulcy, E., Morales, P.A. and Sullivan, J. F.: Vesico-ureteric reflux in paraplegia: results of various forms of management. Paraplegia, 10: 44, 1972. 17. Walsh, J. J.: Further experience with intermittent catheterisation. Paraplegia, 6: 74, 1968. 18. Miyazaki, K.: Urological problems in children with spina bifida cystica and sacral defects. Paraplegia, 10: 37, 1972. 19. Pekarovic, E., Robinson, A., Zachary, R. B. and Lister, J.: Indications for manual expression of the neurogenic bladder in children. Brit. J. Urol., 42: 191, 1970.
----
_..,..
VESICOURETERAL REFLUX IN CHILDREN WITH NEUROGENIC BLADDER
20. Hutch, J. A.: Vesico-ureteral reflux in the paraplegic: cause and correction. J. Urol., 68: 457, 1952. 21. Malkin, R. B., Schellhammer, P. F. and Hackler, R. H.: Experience with transureteroureterostomy in the paraplegic patient with irreversible vesicoureteral reflux. J. Urol., 112: 181, 197 4.
COMMENT Recently, I have been doing more reimplantations into neurogenic bladders than I used to because it is now apparent that children and
451
parents accept intermittent catheterization well, and often prefer this to a supravesical diversion. Patients with high residuals often stay dry for usable periods when so treated. In such circumstances, one likes to stop reflux when it persists in order to protect the kidney from infection. I have been using the Hutch I operation for reimplantation into thickened, trabeculated neurogenic bladders and it has worked well in 6 or 8 personal cases. Perhaps reimplantation into a neurogenic bladder is not as challenging as was once thought. After all, the operation was invented for use in paraplegics. L.R.K.
