Reflux is Dangerous but Not Always Disastrous: Conservative Treatment Often Effective

T:!!E JOURNAL OF UROLOGY

Vol. 82, No. 3, September 1959 Printed in U.S.A.

REFLUX IS DANGEROUS BUT NOT ALWAYS DISASTROUS: CONSERVATIVE TREATMENT OFTEN EFFECTIVE DONN E. LEUZINGER, JOHN K. LATTIMER

AND

CORNELIA B. McCOY

From the Babies Hospital Service of the Squier Urological Clinic, Columbia University and Presbyterian Hospital, New York 32, N. Y., and the U.S. Public Health Service Hospital, Staten Island, N. Y.

On the pediatric urological service of the Babies Hospital a detailed study was made of 148 children with ureteral reflux. One hundred and two had a mechanical obstruction or stricture of the bladder outlet, 22 were due to unknown causes, and 24 had obvious neurogenic bladders. All of those classified as having neurogenic bladders also showed other neurological defects and the majority had meningoceles. Forty-two additional cases were reviewed, but were not included in this study because of brief or insufficient followup data. The incidence of ureteral reflux among all children admitted for urological disorders at this clinic was 4.6 per cent (190 cases out of 4,093 new pediatric urological admissions, from 1937 to 1957). It should be noted that many of these 4,093 admissions were for circumcision or other nonurinary symptoms, thus accounting for this low incidence. This incidence of 4.6 per cent is the same as that reported by Gibson in 1948 when he found 2 cases of ureteral reflux in a series of 43 apparently normal infants and children. Gibson's study was designed to determine the incidence of reflux in children with normal urinary tracts. Cystoscopy was not performed in either of his cases with reflux, however, and there was no followup examination to determine whether or not these patients' urinary tracts were truly "normal." St. Martin found reflux in 13.5 per cent of 74 consecutive children admitted for urological complaints, and Campbell mentions that he found ureteral reflux in 12 per cent of 722 children with urological complaints who had cystograms. It was his opinion that vesicoureteral reflux does not occur in the normal patient. Gruber stated that excised human urinary bladder could be "filled to the bursting point without a drop flowing back into the ureters." Whether this would be true of the bladder in a live patient remains a matter of conjecture. Talbot has proposed that reflux m Accepted for publication March 6, 1959. 294

the adult paraplegic patient results from distortion and perhaps rigidity, of the ureterovesical orifice. He feels that its occurrence is related to the chronic cystitis and periureteritis so frequently found in neurogenic bladders. This mechanism has also been proposed to account for the reflux which occurs in ureters and bladders which have been scarred by tuberculosis. Reflux also has been related to the length and obliquity of the intravesical portion of the ureter. This theory is the basis for the surgical techniques proposed by Hutch, Leadbetter, Politano and others for attempting to correct vesicoureteral reflux. Considering the above evidence, it appears safe to assume that reflux rarely occurs in the normal urinary tract. The present study was undertaken in an effort to answer certain questions by means of a retrospective review of the records and x-rays of our 190 pediatric patients with vesicoureteral reflux (tables 1 to 6, figs. 1-4). An attempt was made to answer the following questions: 1) Is reflux always deleterious to the affected kidney? 2) Can severe reflux ever be corrected by nonoperative measures? 3) Which therapeutic measures used in the past were most effective? 4) Did a dilated bladder serve as a "cushion" to protect the ureters and kidneys? 5) What symptoms and signs were most reliable for indicating reflux? 6) Were there any unsuspected factors which could be revealed by statistical study? Of the 190 cases of ureteral reflux which were studied, only 148 were followed long enough and well enough to evaluate the results of treatment. These patients were divided into four categories: 1) those with marked improvement, 2) moderate improvement, 3) slight or no improvement, and 4) those who had expired. An attempt was made to specify the type of therapy employed for each case and to evaluate it in the

REFLUX IS NOT ALWAYS DISASTROUS TABLE

295

1. Sex, race and findings in 190 cases of vesicoureteral reflux ~

No. of Patients

Sex and Race

Symptoms

Per cent of Total

Laboratory Findings

--Male (white) Male (negro) Total male

84 4

Female (white) Female (negro) Total female

99

88

3 102

Total white Total negro Total cases

TABLE

183 7 190

Anorexia Chills Failure to develop Fever Nausea Vomiting Pain Dribbling Dysuria Frequency Hematuria

2. Associated anomalies in 190 cases of

vesicoureteral reflux Anomaly

Male

Female

Total

---

---

per cent per cent

Lumbosacral defects .. Spina bifida occulta ... Absent sacrum ....... Deficiency of abdominal musculature ... Meningocele ..

per cent

2.6 6.8 1.0

4.2 6.3 .52

6.8 13.1 .15

3 .1 2.6

.52 5.2

3.6 7.8

------------- --- --Total. ....

16.1

16.74

31.45

light of the severity of the dilatation and tortuosity of the upper urinary tract. Those patients with marked or moderate improvement were considered satisfactory therapeutic results and those patients with slight or no improvement and those who expired were considered as unsatisfactory results. A large percentage of the cystograms were performed by the standard Columbia University technique, as described by Dean, Lattimer and McCoy, which provides for the injection of contrast medium at a standard pressure of 24 inches of water. Thirty minute delayed films were always taken, and additional trapping or special films were taken according to the individual findings. EFFECT OF REFLUX

Our first question was whether or not ureteral reflux is always deleterious to the kidney affected. We have always presumed that a child with reflux up the ureter would naturally be more

12.6 6.8 8.4 62.6 .52 14.2 16.6 4.2 12.1 5.7 5.2

Per cent of Total

--Albuminuria (over 1+) Anemia Azotemia Casts (positive) Culture (positive) Hematuria Leukocytosis Pyuria Secondary hyperparathyroidism Acidosis

44.1 40.0 38.2 .52 46.3 4.2 33.1 54.2 .15 5.7

susceptible to urinary tract infections because there would always be residual urine in such a refluxing tract, especially if the child only voided once at each "sitting." This certainly appears to be true in clinical practice where it is found to be especially difficult to eradicate urinary infections in young children who have even slight ureteral reflux. In cases where there is massive dilatation of the upper urinary tract, residual urine in the renal pelvis and ureters can be easily demonstrated by x-ray techniques and chronic infection is the usual finding under such circumstances. Triple voiding techniques, as described by Lattimer and Stephens, are effective in reducing the amount of this residual urine, but are not satisfactory in children who are too young to co-operate. The results of this study clearly indicate that when ureteral reflux was present only on one side, 77 per cent of the cases showed more severe dilatation of the upper tract on the side which had reflux. There were 27 such patients, with unilateral reflux, out of the group of 102 patients with mechanical obstruction; in 21 of these patients (77 per cent), the dilatation was worse on the side with reflux. This fact indicated the tendency of regurgitation of urine up the ureter and into the renal pelvis to have a deleterious effect. Further studies are now being undertaken to determine whether reduction of bladder neck resistance will effectively reduce this hazard to the kidney. It could certainly be said that uncorrected vesicoureteral reflux tended to create more dilatation of the kidneys. Just how serious this turned out to be will be the subject of a further study.

296

D. E. LEUZINGER, J. K. LATTIMER AND C. B. MCCOY TABLE

3. Incidence and degree of dilatation and tortuosity of the upper tract in 190 cases of vesicoureteral refliix Female, Per Cent of 102 Cases

Male, Per Cent of 88 Cases

I ' Vesicoureteral .. Hydroureter Severe. Moderate. Slight. . . . . . . Hydronephrosis Severe .. .. Moderate. Slight. ........ Ureteral tortuosity Severe. Moderate. .... Slight. ......

I

Left only

Bilateral

Right only

Left only

Bilateral

14.8

14.8

70.5

18.6

24.5

57.8

3.4 6.1 7.9

1.1 7.9 1.1

3.4 9.9 1.1

3.9 2.9 5.8

5.8 2.9 2.9

24.4 14.7 6.8

3.4 1.1

9.9 2.2 1.1

55.6 10.2 7.9

5.8 2.9 4.9

l. 9 2.9 6.8

32.3 11.7 6.8

6.8

51.1 5.6 4.5

7.9 1.1 2.2

-

17.6 8.8

Right only

-

2.2 2.2 1.1

. . . . . . . . . . . .I .

.........

-

1.1 3.4

I

-

Patients with Vesicoureteral Reflux with Hydroureter Only Among 190 Cases Male

Severe ... Moderate. .. Slight. ...... Total

.

..... ..... .

.

I

Female

Right only

Left only

Bilateral

Total

Right only

Left only

Bilateral

Total

0 0 0

0 0 0

0 0 0

0 0 0

0 1 0

0 0 0

0 0 0

0 1 0

O

I

O

I

O

-i--;--

-------1

I

o

0

1

Patients with Vesicoureteral Reflux with Hydronephrosis Only Among 190 Cases Severe. Moderate. Slight.

-

Total . .

--1

•••••••••

0 0

0

0

0 0 0

0 0 0

0

0

0

0 0

0

1

1 1

0

0

0

1

2

1

0 3 3

3

6

0 2

----------------------------

Patients with Vesicoureteral Reflux Without Hydroureter or Hydronephrosis Male

Female

6

18

NONOPERATIVE 'l'REATMENT

Our second question was whether or not ureteral reflux could sometimes be corrected by nonoperative treatment, and in particular could severe ureteral reflux ever be corrected by nonoperative treatment. We were very much surprised to find that all 44 patients with reflux who

had been treated by nonoperative methods had shown either marked improvement (30 cases) or moderate improvement (14 cases). (See table 6.) It should be remembered, of course, that those patients selected for conservative treatment were probably those with less severe degrees of damage to the urinary tract. Even in the patients with

297

REFLUX IS NOT ALWAYS DISASTROUS TABLE

4. Average age of 148 patients with vesicoureteral reflux Satisfactory

Total No. of Patients

Markedly improved

Moderately improved

Av. age,

No. pts.

I

Unsatisfactory

Av. age,

No pts.

yrs.

I

yrs.

Slightly or not improved

Expired

Av. age,

No. pts.

I

Av. age,

No. pts.

yrs.

I

yrs.

Mechanical Male .... Female. ..... Total. ....

59 43 102

19 20 39

(3.28) (3.28)

(4.19) (4.42)

10 20 30

21 2 23

(3.1) (2.20)

69

9 1 10

(2.55) (5.)

-

(-)

33

Neurogenic Male .... Female. ....... Total. . . . . . ..

11 13 24

4 2 6

(5. 75) (3 .25)

(4.4) (4.82)

5 7 12

2 3 5

(6.5) (4. 8)

18

1 1

(8.)

6

Cause Unknown Male ....... .... Female .. ..... Total .. ......

3 19 22

5 5

(-)

-

(-)

(2.5)

14 14

(5. 9)

1

-

50

(4.9) (-)

2 3

---

148

2 -

1

19

Total. .....

(9.) (-)

---

I 106

severe dilatation and tortuosity of the upper urinary tracts, however, there were just as many successes as there were failures, and by the nonoperative methods used, improvement occurred just as often in the patients with severe dilatation as in those with moderate degrees of dilatation. The effectiveness of all methods of treatment was surprisingly good, with two-thirds of all the patients with reflux showing moderate or marked improvement by the methods employed. It should be pointed out that all of the methods used in this series were aimed exclusively at the relief of points of obstruction and no operations to prevent reflux at the ureterovesical junction were included. The philosophy behind the various methods of treatment used was that if the bladder outlet resistance and the pressure in the system were kept sufficiently low, then reflux was not so serious a threat to the kidneys.

56

29

I

13

42

THERAPEUTIC MEASURES

Table 6 correlates the results of treatment with the type of treatment used. In the group who improved satisfactorily, 35 were treated with urethral dilatations alone. Eight were treated with urethral dilatations plus triple voiding and eight were treated with dilatations plus some other type of drainage (urethral, suprapubic or nephrostomy). Surgery on the bladder neck, of one type or another (including transurethral resection), was done on 12 patients who improved satisfactorily. Thus it was apparent that the majority of patients (72 per cent) who improved satisfactorily, did so with conservative treatment. Of the 33 patients whose results were unsatisfactory, 70 per cent had surgery on the bladder neck, ureters or both. It must be recognized that the number of patients with severe changes in the upper tracts, in this group, was slightly higher than in the groups

298

D. E. LEUZINGER, J. K. LATTIMER AND C. B. McCOY

5. Improvement in reflux after treatment (all types) of hydronephrosis and hydro1,reter according to severity of change

TABLE

TABLE

Satisfactory

5.~Continued Satisfactory

Unsatisfactory

Unsatisfactory

Total No. of Patients

Total No. of Patients

Cause Unknown Mechanical

Hydr_onephros1s

Hydr_onephro- I SIS

Slight .. Moderate. Severe. None. Total.

12 14

5

5

8

70

26

12

6

3

3

102

39

7

30

1 22

11 21 61 9 102

10

23

69

H vdroureter ·s1ight Moderate. Severe .. None. Total.

10 33

4

6

11 21

9

1 1

9

21

10

3

6 30

23

10

39

69

Tortuosity Slight .. Moderate. Severe. None. Total.

1

1 6

3

3

58

19

37

17

102

39

10 16 30

19

71

31 102

28 11 39

I

10

23

69

Bladder Large. Not large. Total.

10

4

33

23 7 30

16 7

4 6 10

23

69

Hydr_onephros1s

15 2

3

24

6

Hydroureter Slight. Moderate. Severe .. None Total.

1

1

17 6 24

Tortuosity Slight ... Moderate. Severe None. Total. Bladder Large. Not large .. Total.

1 1

2

8 2

3

1

12

5

1

4

9

3

3 2

1

1 6

12

5

1

1 3

2

5

2

2

1

18

18 4

1

5

10

2 2

1 6

5 3

2

5 24

12

5

18

5

10

3

6 24

1

2

2

6

12

5

18

5

5

4 2 3 14

5

7 5

22

3 2 5

1

19

Hydroureter Slight Moderate. Severe. None. Total.

1 1

1

I

2

3

1

2 2

1

7

3

2

1

1 1

11

1

22

5

10 14

1

2

1

1 1 1

14

1

2

10

1

2

1

2

1

19

Tortuosity Slight. Moderate Severe. None Total

4

3

4 7

1

4 4

4

3

7 22

5

19

Bladder Large. Not large .. Total ...

16 6 22

~I

4

14

19

33

Neurogenic

Slight ... Moderate. Severe. None. Total.

Slight. Moderate. Severe. None Total.

1

1 1

1 1 6

who showed improvement, and there was undoubtedly some concentration of the worst cases in this group subjected to immediate surgery. However, the difference was not great and it was felt that this alone did not account for the significantly better results obtained by conservative treatment. All of the patients who expired had severe hydroureteronephrosis and severe tortuosity of the ureters, and had azotemia at the time of admission (average nonprotein nitrogen determination was 106 mg. per cent) which did not improve with treatment. Severe dilatation was also present in those patients who improved only slightly (table 5). Of the patients who improved only slightly, 90 per cent were males and the average age was not significantly different from that of the group of patients who showed considerable improvement. Among the patients whose reflux was secondary to neurological disorders, or in whom the cause was unknown, there appeared to be no correlation between the type of treatment and the results of treatment. In each of these categories, the

REFLUX IS NOT ALWAYS DISASTROUS

TABLE 6. Correlation between mode of treatment

and result8 in 148 patients with vesicoureteral reflux Results

Mode of Treatment Sa tis- [Unsatisfactory factory

Mechanical Dilatation and other nonoperative modes of therapy, i.e., temporary catheter drainage, triple voiding, etc ... Trans urethral resection ... Surgery of bladder neck . Other (i.e. partial resection of bladder, ureteroneocystostomy, resection of ureter, etc.). Subtotal.

44 8

7

4

8

13

18

69

33

15

4

Neurogenic Dilatation and other nonoperative modes of therapy. Transurethral resection. Surgery of bladder neck .. Other .. Subtotal.

1

1 1

2

18

6

19 0

3 0

0 0

0

19

3

Cause Unknown Dilatation and other nonoperative modes of therapy. Trans urethral resection. Surgery of bladder neck . Other .... Subtotal ....

0

299

fluxing ureters and kidney pelves from the higher intravesical pressures. It was indeed found to be true that fewer patients with large bladders had severe dilatation of the upper tracts and that recovery was much easier. This can be seen from table 5, where 51 patients with large bladders are listed as improved, whereas only 20 patients with large bladders failed to improve. By comparison, those who had no dilated bladder showed just as many failures as successes. These findings may well reflect the fact that when reflux up the ureters becomes very easy, due to severe dilatation of the ureters, the powerful bladder musculature causes the bladder to contract down, while the dilating ureters and kidney pelves absorb the pressure in the system. It is easy to understand that it might be difficult to recover from the dilatation suffered by the thin walled ureters once the bladder had contracted down into a thick walled sac whose muscle fibers were no longer on the stretch. This same suggestion of poor prognosis when the bladder had contracted down at the expense of the dilated ureter and kidney pelvis, was also found among the patients with neurogenic bladders, where those with a large bladder showed improvement three times as often as those whose bladder had contracted down to a relatively normal size. It was also noted, in this series, that among patients where partial resection of the bladder wall was done to reduce bladder volume, there were very few incidences of improvement in reflux. It might be presumed that reducing the size of the bladder, either by surgical excision or by contraction of the bladder, increases the intravesical pressure, which might then cause reflux to be more persistent. SYMPTOM!:' AND SIGNS

numbers of cases were small and no valid conclusions could be drawn in general; the patients with neurogenic bladders did quite well. The patient whose x-rays are shown in figure 4 is of interest in that the ureteral reflux disappeared after a neurosurgical operation to relieve traction on the lower portion of the spinal cord due to a meningocele scar. CONCEPT OF MEGALOBLADDER

Question 4 was whether a large dilated bladder could provide a "cushion" to protect the re-

We were anxious to know whether or not there were any specific symptoms or signs which were more likely than others to indicate reflux. However, the fever from urinary infection was by far the commonest symptom (63 per cent), while pain, dysuria, anorexia and vomiting, each occurred only in about 12 per cent of the patients. Urinary frequency, dribbling, hematuria, and failure to develop were present in some 6 per cent of the patients. As to laboratory findings, pyuria occurred in 54 per cent, with 46 per cent having positive urine cultures recorded and approximately 40 per cent having albuminuria, anemia or azotemia. A more detailed breakdown of the

300

D. J
K. LATTIMER A:\"D C. B. MCCOY

FIG. 1. T. O'N., unit No. 05-40-09. Boy aged 8}2 years with bladder neck obstruction. A, post-voiding cystogram shows bilateral vesicoureteral ref1ux with moderately severe hydroureteronephrosis. B, cystogram 1 year later, after periodic urethral dilatations with sounds, shows no reflux, even though bladder is still large. Intravenous pyelogram (not shown) is also normal.

FIG. 2. M. S., unit No. 134 955. Girl aged 3 years with stricture of posterior urethra. A, cystogram shows bilateral vesicoureteral reflux with hydroureteronephrosis more severe on right. B, cystogram 4 years later, after treatment with periodic urethral dilatations, is normal. Intravenous pyelogram (not shown) is also normal.

Fm. 3. T. C., unit No. 69-25-56. Boy aged 10 ½ years with glandular hypospadias and pin hole urethral meatus. A, cystogram shows megalobladder, vesicoureteral reflux on left with hydroureteronephrosis. B, cystogram 1 year after meatotomy shows no evidence of reflux.

Fm. 4. S. K., unit No. 94-03-95. Boy aged 2 years with neurogenic bladder following repair of myelomeningocele. A, cystogram shows vesicoureteral reflux on left with moderately severe hydroureteronephrosis. B, cystogram at age 7 years, taken 1 year after lysis of sacral nerve roots and release of tension on tip of spinal cord shows no reflux. 301

302

D. E. LEUZINGER, J. K. LATTIMER AXD C. B. MCCOY

symptoms is presented in table 1. Reflux was equally common in both sexes, but we noted that a very small proportion of the negrocs had reflux. This proportion appeared to us to be far below the proportion of negroes in our patient population. It will be seen from these findings that even the most commonplace manifestations of urinary infection, mainly fever and pyuria, may very well herald the presence of ureteral reflux, which will certainly make the infection difficult to eradicate and will tend to damage the kidney, if not corrected.

patients with mechanical obstructions of the bladder neck or urethra, where 71 per cent had megalobladders. A relatively small proportion of our patients had unilateral reflux, and this was equally common on the two sides. It was strongly suspected that this represented an early stage of this disorder and that if bladder neck resistance persisted or became worse, eventually both ureterovesical junctions would break down and become incompetent, causing bilateral reflux. In the instances where reflux ceased, it sometimes ceased on one side before it ceased on the other. SUMMARY

OTHER CORRELATIONS

The most outstanding fact discovered was that conservative treatment, aimed at reducing the bladder neck resistance, was much more effective than we had expected. Even when allowance was made for the fact that the worst cases were selected for the most radical surgery, conservative methods appeared best in the overall picture. The correlation of reflux with associated anomalies was not as impressive as expected, although the children with neurogcnic bladders had a high incidence of lumbosacral defects, spina bifida occulta, absent sacrum and meningocele. There were several children with congenital deficiencies of the abdominal musculature and associated bladder neck obstruction, a syndrome well known to the pediatric urologist. It might be noted here that among our 30 patients with exstrophy of the urinary bladder, where we have replaced the bladder within the abdomen, most of the patients show urctcral reflux. Among these children, those with a low bladder neck resistance and dribbling show no dilatation of the upper urinary tracts, but among those whose bladder neck was made tight in order to achieve early urinary control, there was a high incidence of ureteral dilatation. Our male patients had a significantly higher percentage of severe dilatation of the upper urinary tracts and a higher incidence of ureteral tortuosity. Bilateral reflux was somewhat more common among the male patients. These findings probably reflect the fact that the male urethra is longer and offers more opportunities for points of obstruction than the female urethra. A large bladder was a common finding among our patients with reflux, and particularly among

A review of 190 children with ureteral reflux provided suggestive documentation for the following generalizations concerning this condition: 1) Untreated ureteral reflux tended to be deleterious to the kidney involved and should make it difficult to eradicate urinary infections in such a kidney. Successful treatment of urckrovesieal reflux turned out to be easier than expected, however. 2) Conservative treatment was surprisingly effective in helping this condition. Even severe degrees of ureteral reflux were often markedly improved by conservative measures to relieve obstruction and to decrease the resistance of the bladder outlet. Two-thirds of the patients treated were greatly benefited. 3) The efficacy of simple urethral dilatation with sounds was surprising. The majority of patients who improved, did so following conservative methods of increasing the caliber of the bladder neck and urethra. 4) The large dilated bladder appeared to afford a "cushion" which protected the ureter and kidney pelvis from more severe dilatation, and may have made the cure of reflux easier in these cases. 5) The ordinary signs and symptoms of urinary infection, in the form of fever and pyuria, ,vere by far the commonest symptoms in our patients with reflux. 6) Reflux and urinary tract dilatation were more severe in males than in females, although the over-all incidence of reflux was the same in both sexes. The proportion of negro childrC'n in this series was much smaller than the proportion in the ward population. All of the patients who died or failed to improve, entered the hospital

REFLUX IS NOT ALWAYS DISASTROUS

with very severe dilatation of the urinary tracts and elevation of nonprotein nitrogen. On the other hand, only 10 died out of 70 children who entered the hospital with reflux plus an elevation of the nonprotein nitrogen. Failure of the azotemia to resolve after drainage was an ominous sign. In spite of the surprising success of our conservative therapy for the over-all group, more detailed studies are now in progress in an effort to enable us to determine at the time of admission those patients who will do well and those who will require more drastic treatment. REFERENCES BORS, E. AND CoMARR, A. E.: Vesicoureteral reflux in paraplegic patients. J. Urol., 68: 691-698, 1952. CAMPBELL, M. F.: Urology. Philadelphia: W. B. Saunders Co., 1954, vol. 2, p. 1360. CAMPBELL, M. F.: Pediatric Urology. New York: The Macmillan Co., 1937, vol. 2, p. 259. DEAN, A. L., JR., LATTIMER, J. K. AND McCoY, C. B.: The standardized Columbia University cystogram. J. Urol., 78: 662-668, 1957. GrnsoN, H. M.: Ureteral reflux in the normal child. J. Urol., 62: 40-43, 1949. GRAVES, R. C. AND DAVIDOFF, L. M.: Studies on the ureter and bladder with special reference

303

to regurgitation of vesical contents. J. Urol., 10: 185, 1923.

HINMAN, F.: Principles and Practice of Urology. Philadelphia: W. B. Saunders Co., 1935, p. 232. HUTCH, J. A.: Vesicoureteral reflux in the paraplegic: Cause and correction. J. Urol., 68: 457-67, 1952. HUTCH, J. A.: Vesicoureteral reflux in children. J. Urol., 74: 607, 1955. LATTIMER, J. K., DEAN, A. L. JR. AND FUREY, C. A.: The triple voiding technique in children with dilated urinary tracts. J. Urol., 76: 656660, 1956. PASQUIER, C. M., JR., ST. MARTIN, E. C. AND CAMPBELL, J. H.: The problem of vesicoureteral reflux in children. J. Urol., 79: 41-51 1958. ' POLITANO, V. A. AND LEADBETTER, W. F.: Technique for correction of vesicoureteral reflux. J. Urol., 79: 932-942, 1958. ST. MARTIN, E. C., CAMPBELL, J. H. AND PESQUIER, C. M.: Cystography in children. J. Urol., 76: 151-159, 1956. STEPHENS, F. D.: Austral. & New Zealand J. Surg., 23: 197, 1954. TALBOT, J. S. AND BUNTS, R. C.: Late renal changes in paraplegia: Hydronephrosis due to vesicoureteral reflux. J. Urol., 61: 870-880 ' 1949. UsoN, A. C., JOHNSON, D. W., LATTIMER, J. K. AND MEucow, M. M. : A classification of the urographic patterns in children with congenital bladder neck obstruction. Am. J. of Roentgenol., in press.