- Email: [email protected]
Surgical treatment of reflux in neurologically impaired child
SURGICAL TREATMENT OF REFLUX IN NEUROLOGICALLY ROBERT
J. EVANS, M.D.
DAVID M. RAEZER, STANLEY
IMPAIRED CHILD
H. SHROM,
M.D. M.D.
From the Departments of Urology, University of Virginia Medical Center, Charlottesville, Virginia, and Mercy Catholic Medical Center, Philadelphia, Pennsylvania
ABSTRACT-Ninety-three consecutive patients with neurologically impaired bladders were evaluated for vesicoureteral reflux. Of 22 patients found to have reflux, 3 had spontaneous remission of reflur, 8 were maintained on suppressive antibiotic therapy, and 11 required ureteral reimplantation. A total of 14 refluxing renal units underwent ureteroneocystostomies. Twelve of 14 have had no postoperative reflur. The remaining two renal units are now free of reflux following augmentation cystoplasty. The modified Hutch ureteroneocystostomy is particularly suited for use in patients with neuropathic bladders, in that no submucosal tunnel is necessary. The operative technique is described.
The positive association between vesicoureteral reflux and upper tract deterioration has been well-documented since it was first noted by Hodgson and Edwards.1,2 The current international reflux study3 endeavors to determine the role of medical management in the treatment of reflux and to establish guidelines for reconstruction of the ureterovesical junction. This study does not, however, address itself to the unsolved problems in treating reflux in the neurologically impaired child. Due to a number of unique problems, treatment of vesicoureteral reflux becomes more difficult in patients with neurocommon to pathic bladders. Characteristics neuropathic bladders include diminished bladder volume, chronic infection and inflammation, incomplete bladder emptying, and increased intravesical pressure at rest or during voiding. Each of these characteristics can complicate pre-existing reflux and, without successful therapy, can lead to early and increased renal scarring, hypertension, impaired renal growth, and diminished renal function.
UROLOGY
i
JULY 1986
i
VOLUME
XXVIII,
NUMBER
The anatomic basis of vesicoureteral reflux in otherwise normal lower urinary tracts has been described at length. 4.5Numerous surgical procedures have been developed to correct reflux.e-lo All ureteroneocystostomy procedures are based on common anatomic principles directed at the structural deformities responsible for reflux. The ureter is repositioned so that adequate submucosal ureteral length is obtained against a firm muscular backing. The distal ureteral anastomosis is fixed, and entry into the bladder is at an oblique angle. The ability to maintain an infection-free state, the degree of reflux, and the desire to preserve renal function and maintain normal renal growth are factors in determining the need for surgical intervention. McRae, Shannon, and Otley” have shown accelerated renal growth following correction of reflux. A decrease in pyelonephritic episodes has been reported by Willscher and associates12 after surgical correction of reflux. Hutch6 was the first to consider the effect of vesicoureteral reflux on renal function in
1
31
paraplegics and to advocate surgical treatment in selected cases. Using a modification of the Hutch technique, Hackle+ reported an 85 per cent success rate in eliminating reflux in paraplegics. In those patients in whom surgery was successful, deterioration of the upper tract was eliminated. Using the Glenn-Anderson, Politano-Leadbetter, and Cohen techniques, Belloli and associates14 report the elimination of reflux in 85 per cent of children with neurologically injured bladders. This report relates our experience with the modified Hutch I ureteroneocystostomy in the treatment of children with vesicoureteral reflux and neuropathic bladders. Material and Methods Ninety-three consecutive patients (aged 6-18 years) with bladders which were impaired neurologically as a result of myelodysplasia, sacral agenesis, or traumatic injury were seen between 1975 and 1979. The initial assessment consisted of urinalysis, urine culture and sensitivity studies, excretory urogram, and voiding cystourethrogram. The primary clinical goals were the maintenance of an infection-free state and the prevention of upper tract deterioration. To achieve these goals, each child was approached differently, depending on the age and the social concern for dryness. Vesicostomies were performed as a temporary urinary diversion in children with persistent reflux and/or recurrent infection. The vesicostomies were closed when these children reached the age of concern and wished to develop continence. Ureteral reimplantation was performed at the time of vesicostomy closure in patients in whom reflux persisted. Voiding dysfunction was treated with pharmacologic manipulation and clean intermittent catheterization. The functional approach to management was based on each patient’s inherent dysfunction, i.e., the failure to empty the bladder or the failure to store urine. 15,1e Of 93 patients evaluated, 22 (24%) were noted on initial evaluation to have reflux. In 3 patients, reflux remitted spontaneously; 8 patients were treated conservatively and maintained on suppressive antibiotic therapy. Eleven patients (12 %) required ureteral reimplantation. Eight of these 11 had unilateral reflux and 3 had bilateral reflux, thus comprising 14 refluxing renal units. Eight patients had myelodysplasia, and 3 had sacral agenesis. One pa-
32
tient had a solitary kidney, and 1 exhibited right fused ectopia. The surgical indications for ureteroneocystostomy in this population were Grade III or greater reflux in the presence of recurrent urinary tract infections despite appropriate prophylactic antibiotic therapy and reflux coexisting with a vesicostomy which required surgical closure. Voiding cystourethrograms and excretory urograms were performed six months postoperatively and at regular intervals since. Surgical technique The operative technique was based on a modification of the Hutch I technique,e as described by Duckett and Raezer15 and Hackler. l3 We chose this technique because of the impressive success rate of 83 per cent obtained in neurologically injured adult patients, but our use of the technique varied in that we stressed intravesical as opposed to extravesical mobilization of the ureter. The reimplantation essentially consists of six steps: 1. Leaving the ureteral orifice intact, a mucosal incision involving about 180 degrees is made approximately one-eighth inch superior and lateral to the ureteral orifice (Fig. 1). 2. The bladder musculature is incised intravesically, beginning just above the ureteral orifice and extending superiorly and laterally. This incision allows exposure of the ureter throughout its course and visualization of the approximately 1.5 to 2 cm of ureter which will be brought intravesically at the end of the procedure. The ureter is freed and held with hernia tape (Fig. 2). 3. With traction obtained by the use of hernia tape, maximum mobilization of the ureter is made from this intravesical approach (Fig. 3). 4. Extravesical dissection is limited to visualization and further mobilization of the ureter and visualization of the incision made previously in the bladder wall. The hernia tape is then passed extravesically (Fig. 4). 5. Extravesical dissection is limited to further mobilization of the ureter and to visualization of the opening in the bladder which was made through the intravesical approach. The opening in the bladder can be extended on the outer surface of the bladder to give an oblique course to the ureter, thus preventing a potential area of kinking (Fig. 5). 6. The ureter is returned to its intravesical position, and the bladder is closed intravesically
UROLOGY
/ JULY 1986
/ VOLUME
XXVIII,
NUMBER
1
Mucosal incision made around ureteral orifice and extended along course of intramural ureter. Orifice remains intact.
FIGURE1.
lntravesical
lntravesical
-_
2. 1.5 to 2 cm of ureter are exposed by intravesical incision. FIGURE
Extravesical lntravesical Hernia tape passed extravesically and opening in bladder visualized. FIGURE 4.
UROLOGY
/
JULY 1986
5. Limited extravesical extension of incision may be necessary to insure oblique course to ureter. FIGURE
/
VOLUME XXVIII, NUMBER 1
FIGURE 3. Exposed ureter mobilized and brought into bladder by gentle traction with hernia tape.
lntravesical Strong muscular backing for ureter obtained with twoboth layer closure utilizing intravesical and extravesical approaches. FIGURE 6.
33
TABLE I. I wsnl
Con~nnsl
Anomsllss
Results of ureteroneocwtostomy Fm-opVCUQ
with 3-O chromic sutures approximating the entire muscle wall. The new hiatus is now located approximately 1.5 to 2 cm superiorly and laterally to the original hiatus. The extravesical ureter is then revisualized using the extravesical approach, and the outer surface of the bladder is closed in a second layer. In this way, a strong muscular backing for the ureter is achieved, and hemostasis is assured (Fig. 6). Due to the inflamed nature of these bladders in general, submucosal tunnels are not practical, and no attempt is made to cover the ureter with a mucosal surface. The operative technique is similar to that of Raezer and Hackler, except that we use intravesical mobilization of the ureter, which we believe allows a more limited extravesical dissection. The end result is similar, however, allowing effective extravesical mobilization of the ureter and strong backing of the repositioned ureter.
34
sww
Follow-Up
VCUQ
Conclurlons
Results The degrees of reflux corrected are seen in Table I. Three patients had significant associated renal anomalies, including a single left pelvic kidney, a right fused renal ectopia, and a right complete ureteral duplication anomaly. The ectopic renal units were associated with Grade IV and Grade III ureteral reflux, while the ureteral duplication anomaly involved Grade III reflux in both the upper and the lower pole renal segments. Five patients who had ureteral reimplantation associated with closure of vesicostomies had Grade IIb or greater reflux; one had bilateral Grade III reflux. Two other patients had bilateral reflux: one Grade IIb and the other Grade III. Of 14 renal units displaying reflux, seven were Grade III or greater, and seven were Grade II. Follow-up cystourethrograms obtained six months after surgery revealed no evidence of
UROLOGY
I
JULY 1986
I
VOLUME XXVIII,
NUMBER 1
reflux in 12 of the 14 renal units undergoing reimplantation. The patient who had persistent bilateral reflux after bilateral ureteroneocystostomies stopped refluxing following augmentation cystoplasty. l7 Reflux has not recurred in any of the reimplanted renal units. In 3 patients reflux developed in the unaltered contralateral side, and in 1 patient who had minor reflux an increase in the reflux from Grade I to Grade III developed in the unaltered contralateral side. These patients have had good clinical follow-up and are symptom-free. Their reflux at this time varies between Grade II and Grade III. No renal units undergoing reimplantation have demonstrated any deterioration on follow-up excretory urograms obtained three to six years after surgery. Those patients in whom contralateral reflux developed have not displayed any significant deterioration on the refluxing side. Comment A modified Hutch reimplantation has been shown to be an effective antireflux procedure in the adult neuropathic bladder.13 Although the size of this study is small, our results seem to indicate that a modified Hutch reimplantation is also useful in the pediatric neuropathic bladder. The success of this type of reimplantation suggests that the causes of reflux are a lack of proper muscular backing and the relative shortness of the intravesical ureter. We believe that it is important to visualize these reimplantations from both intravesical and extravesical approaches not only to achieve a good backing and adequate intramural length for the repositioned ureter but also to assure hemostasis. The decision to correct reflux in the neurologically impaired child is often difficult. This is particularly true in instances when the reflux is initially low-grade, as we have seen in this group of patients. Currently many of these patients are managed with antibiotic suppression and intermittent catheterization. It is clear, however, that some patients will demonstrate upper tract deterioration and chronic pyelonephritis despite appropriate medical
UROLOGY
/ JULY 1986
I VOLUME XXVIII, NUMBER 1
management. Because many of these children have bladders that are thickened and edematous from chronic inflammation, creation of a submucosal tunnel is often impractical. The Hutch ureteroneocystostomy is a viable alternative to other methods of ureteral reimplantation and is particularly suitable for patients with neuropathic bladders. Box 182, Department of Urology University of Virginia Medical Center Charlottesville, Virginia 22908 (DR. EVANS) References 1. Hodgson CJ, and Edwards D: Chronic pyelonephritis and vesicoureteral reflux, Clin Radio1 11: 219 (1960). 2. Light K, and Van Black PJP: Causes of renal deterioration patients with meningomyelocele, Br J Ural 49: 257 (1977). 3. Report of the International Reflux Study Committee: Medical versus surgical treatment of primary vesicoureteral reflux: a prospective international reflux study in children, J Urol 125: 277 (1981). 4. Tanagho EA, et al: Primary vesicoureteral reflux: experimental studies of its etiology, ibid 93: 165 (1965). 5. Stephens FD, and Lenaghan D: The anatomic basis and dynamics of vesicoureteral reflux, ibid 87: 699 (1962). 6. Hutch ]A: Vesicoureteral reflux in the paraplegic: cause and correction, ibid 68: 457 (1952). 7. Politano VA, and Leadbetter WF: An operative technique for the correction of ureteric reflux, ibid 79: 932 (1958). 8. Glenn JF, and Anderson EE: Distal tunnel ureteral reimplantation, ibid 97: 623 (1967). 9. Paquin AJ: Ureterovesical anastomosis: the description and evaluation of a technique, ibid 82: 573 (1959). 10. Cohen J: Vesicoureteral reflux: a new surgical approach, Int Urol Pediatr 6: 20 (1975). 11. McRae CV, Shannon FT, and Otley WLF: Effect on renal growth of reimplantaton of refluxing ureters, Lancet 1: 1310 (1974). 12. Willscher MK, Bauer SB, Zammuto PJ, and Retik AB: Renal growth and urinary infection following antireflux surgery in infants and children, J Ural 115: 722 (1976). 13. Hackler RH: Modified Hutch I vesicoureteroplasty in paraplegia, ibid 118: 953 (1977). 14. Belloli GP, Musi L, Campobano P, and Cottaneo A: Ureteral reimplantation in children with neurogenic bladder, J Pediatr Surg 14: 119 (1979). 15. Duckett JW, and Raezer DM: Neuromuscular dysfunction of the lower urinary tract, in Kelalis P, King LR, and Belman AB (Eds): Pediatric Urology, Philadelphia, W.B. Saunders Co., 1976, pp 401-422. 16. Raezer DM, Benson GS, Wein AJ, and Duckett JW: Functional approach to the management of the pediatric neuropathic bladder: a clinical study, J Urol 117: 649 (1977). 17. Raezer DM, Evans RJ, and Shrom SH: Augmentation cystoplasty in neuropathic bladder, Urology 25: 26 (1985).
35
J. EVANS, M.D.
DAVID M. RAEZER, STANLEY
IMPAIRED CHILD
H. SHROM,
M.D. M.D.
From the Departments of Urology, University of Virginia Medical Center, Charlottesville, Virginia, and Mercy Catholic Medical Center, Philadelphia, Pennsylvania
ABSTRACT-Ninety-three consecutive patients with neurologically impaired bladders were evaluated for vesicoureteral reflux. Of 22 patients found to have reflux, 3 had spontaneous remission of reflur, 8 were maintained on suppressive antibiotic therapy, and 11 required ureteral reimplantation. A total of 14 refluxing renal units underwent ureteroneocystostomies. Twelve of 14 have had no postoperative reflur. The remaining two renal units are now free of reflux following augmentation cystoplasty. The modified Hutch ureteroneocystostomy is particularly suited for use in patients with neuropathic bladders, in that no submucosal tunnel is necessary. The operative technique is described.
The positive association between vesicoureteral reflux and upper tract deterioration has been well-documented since it was first noted by Hodgson and Edwards.1,2 The current international reflux study3 endeavors to determine the role of medical management in the treatment of reflux and to establish guidelines for reconstruction of the ureterovesical junction. This study does not, however, address itself to the unsolved problems in treating reflux in the neurologically impaired child. Due to a number of unique problems, treatment of vesicoureteral reflux becomes more difficult in patients with neurocommon to pathic bladders. Characteristics neuropathic bladders include diminished bladder volume, chronic infection and inflammation, incomplete bladder emptying, and increased intravesical pressure at rest or during voiding. Each of these characteristics can complicate pre-existing reflux and, without successful therapy, can lead to early and increased renal scarring, hypertension, impaired renal growth, and diminished renal function.
UROLOGY
i
JULY 1986
i
VOLUME
XXVIII,
NUMBER
The anatomic basis of vesicoureteral reflux in otherwise normal lower urinary tracts has been described at length. 4.5Numerous surgical procedures have been developed to correct reflux.e-lo All ureteroneocystostomy procedures are based on common anatomic principles directed at the structural deformities responsible for reflux. The ureter is repositioned so that adequate submucosal ureteral length is obtained against a firm muscular backing. The distal ureteral anastomosis is fixed, and entry into the bladder is at an oblique angle. The ability to maintain an infection-free state, the degree of reflux, and the desire to preserve renal function and maintain normal renal growth are factors in determining the need for surgical intervention. McRae, Shannon, and Otley” have shown accelerated renal growth following correction of reflux. A decrease in pyelonephritic episodes has been reported by Willscher and associates12 after surgical correction of reflux. Hutch6 was the first to consider the effect of vesicoureteral reflux on renal function in
1
31
paraplegics and to advocate surgical treatment in selected cases. Using a modification of the Hutch technique, Hackle+ reported an 85 per cent success rate in eliminating reflux in paraplegics. In those patients in whom surgery was successful, deterioration of the upper tract was eliminated. Using the Glenn-Anderson, Politano-Leadbetter, and Cohen techniques, Belloli and associates14 report the elimination of reflux in 85 per cent of children with neurologically injured bladders. This report relates our experience with the modified Hutch I ureteroneocystostomy in the treatment of children with vesicoureteral reflux and neuropathic bladders. Material and Methods Ninety-three consecutive patients (aged 6-18 years) with bladders which were impaired neurologically as a result of myelodysplasia, sacral agenesis, or traumatic injury were seen between 1975 and 1979. The initial assessment consisted of urinalysis, urine culture and sensitivity studies, excretory urogram, and voiding cystourethrogram. The primary clinical goals were the maintenance of an infection-free state and the prevention of upper tract deterioration. To achieve these goals, each child was approached differently, depending on the age and the social concern for dryness. Vesicostomies were performed as a temporary urinary diversion in children with persistent reflux and/or recurrent infection. The vesicostomies were closed when these children reached the age of concern and wished to develop continence. Ureteral reimplantation was performed at the time of vesicostomy closure in patients in whom reflux persisted. Voiding dysfunction was treated with pharmacologic manipulation and clean intermittent catheterization. The functional approach to management was based on each patient’s inherent dysfunction, i.e., the failure to empty the bladder or the failure to store urine. 15,1e Of 93 patients evaluated, 22 (24%) were noted on initial evaluation to have reflux. In 3 patients, reflux remitted spontaneously; 8 patients were treated conservatively and maintained on suppressive antibiotic therapy. Eleven patients (12 %) required ureteral reimplantation. Eight of these 11 had unilateral reflux and 3 had bilateral reflux, thus comprising 14 refluxing renal units. Eight patients had myelodysplasia, and 3 had sacral agenesis. One pa-
32
tient had a solitary kidney, and 1 exhibited right fused ectopia. The surgical indications for ureteroneocystostomy in this population were Grade III or greater reflux in the presence of recurrent urinary tract infections despite appropriate prophylactic antibiotic therapy and reflux coexisting with a vesicostomy which required surgical closure. Voiding cystourethrograms and excretory urograms were performed six months postoperatively and at regular intervals since. Surgical technique The operative technique was based on a modification of the Hutch I technique,e as described by Duckett and Raezer15 and Hackler. l3 We chose this technique because of the impressive success rate of 83 per cent obtained in neurologically injured adult patients, but our use of the technique varied in that we stressed intravesical as opposed to extravesical mobilization of the ureter. The reimplantation essentially consists of six steps: 1. Leaving the ureteral orifice intact, a mucosal incision involving about 180 degrees is made approximately one-eighth inch superior and lateral to the ureteral orifice (Fig. 1). 2. The bladder musculature is incised intravesically, beginning just above the ureteral orifice and extending superiorly and laterally. This incision allows exposure of the ureter throughout its course and visualization of the approximately 1.5 to 2 cm of ureter which will be brought intravesically at the end of the procedure. The ureter is freed and held with hernia tape (Fig. 2). 3. With traction obtained by the use of hernia tape, maximum mobilization of the ureter is made from this intravesical approach (Fig. 3). 4. Extravesical dissection is limited to visualization and further mobilization of the ureter and visualization of the incision made previously in the bladder wall. The hernia tape is then passed extravesically (Fig. 4). 5. Extravesical dissection is limited to further mobilization of the ureter and to visualization of the opening in the bladder which was made through the intravesical approach. The opening in the bladder can be extended on the outer surface of the bladder to give an oblique course to the ureter, thus preventing a potential area of kinking (Fig. 5). 6. The ureter is returned to its intravesical position, and the bladder is closed intravesically
UROLOGY
/ JULY 1986
/ VOLUME
XXVIII,
NUMBER
1
Mucosal incision made around ureteral orifice and extended along course of intramural ureter. Orifice remains intact.
FIGURE1.
lntravesical
lntravesical
-_
2. 1.5 to 2 cm of ureter are exposed by intravesical incision. FIGURE
Extravesical lntravesical Hernia tape passed extravesically and opening in bladder visualized. FIGURE 4.
UROLOGY
/
JULY 1986
5. Limited extravesical extension of incision may be necessary to insure oblique course to ureter. FIGURE
/
VOLUME XXVIII, NUMBER 1
FIGURE 3. Exposed ureter mobilized and brought into bladder by gentle traction with hernia tape.
lntravesical Strong muscular backing for ureter obtained with twoboth layer closure utilizing intravesical and extravesical approaches. FIGURE 6.
33
TABLE I. I wsnl
Con~nnsl
Anomsllss
Results of ureteroneocwtostomy Fm-opVCUQ
with 3-O chromic sutures approximating the entire muscle wall. The new hiatus is now located approximately 1.5 to 2 cm superiorly and laterally to the original hiatus. The extravesical ureter is then revisualized using the extravesical approach, and the outer surface of the bladder is closed in a second layer. In this way, a strong muscular backing for the ureter is achieved, and hemostasis is assured (Fig. 6). Due to the inflamed nature of these bladders in general, submucosal tunnels are not practical, and no attempt is made to cover the ureter with a mucosal surface. The operative technique is similar to that of Raezer and Hackler, except that we use intravesical mobilization of the ureter, which we believe allows a more limited extravesical dissection. The end result is similar, however, allowing effective extravesical mobilization of the ureter and strong backing of the repositioned ureter.
34
sww
Follow-Up
VCUQ
Conclurlons
Results The degrees of reflux corrected are seen in Table I. Three patients had significant associated renal anomalies, including a single left pelvic kidney, a right fused renal ectopia, and a right complete ureteral duplication anomaly. The ectopic renal units were associated with Grade IV and Grade III ureteral reflux, while the ureteral duplication anomaly involved Grade III reflux in both the upper and the lower pole renal segments. Five patients who had ureteral reimplantation associated with closure of vesicostomies had Grade IIb or greater reflux; one had bilateral Grade III reflux. Two other patients had bilateral reflux: one Grade IIb and the other Grade III. Of 14 renal units displaying reflux, seven were Grade III or greater, and seven were Grade II. Follow-up cystourethrograms obtained six months after surgery revealed no evidence of
UROLOGY
I
JULY 1986
I
VOLUME XXVIII,
NUMBER 1
reflux in 12 of the 14 renal units undergoing reimplantation. The patient who had persistent bilateral reflux after bilateral ureteroneocystostomies stopped refluxing following augmentation cystoplasty. l7 Reflux has not recurred in any of the reimplanted renal units. In 3 patients reflux developed in the unaltered contralateral side, and in 1 patient who had minor reflux an increase in the reflux from Grade I to Grade III developed in the unaltered contralateral side. These patients have had good clinical follow-up and are symptom-free. Their reflux at this time varies between Grade II and Grade III. No renal units undergoing reimplantation have demonstrated any deterioration on follow-up excretory urograms obtained three to six years after surgery. Those patients in whom contralateral reflux developed have not displayed any significant deterioration on the refluxing side. Comment A modified Hutch reimplantation has been shown to be an effective antireflux procedure in the adult neuropathic bladder.13 Although the size of this study is small, our results seem to indicate that a modified Hutch reimplantation is also useful in the pediatric neuropathic bladder. The success of this type of reimplantation suggests that the causes of reflux are a lack of proper muscular backing and the relative shortness of the intravesical ureter. We believe that it is important to visualize these reimplantations from both intravesical and extravesical approaches not only to achieve a good backing and adequate intramural length for the repositioned ureter but also to assure hemostasis. The decision to correct reflux in the neurologically impaired child is often difficult. This is particularly true in instances when the reflux is initially low-grade, as we have seen in this group of patients. Currently many of these patients are managed with antibiotic suppression and intermittent catheterization. It is clear, however, that some patients will demonstrate upper tract deterioration and chronic pyelonephritis despite appropriate medical
UROLOGY
/ JULY 1986
I VOLUME XXVIII, NUMBER 1
management. Because many of these children have bladders that are thickened and edematous from chronic inflammation, creation of a submucosal tunnel is often impractical. The Hutch ureteroneocystostomy is a viable alternative to other methods of ureteral reimplantation and is particularly suitable for patients with neuropathic bladders. Box 182, Department of Urology University of Virginia Medical Center Charlottesville, Virginia 22908 (DR. EVANS) References 1. Hodgson CJ, and Edwards D: Chronic pyelonephritis and vesicoureteral reflux, Clin Radio1 11: 219 (1960). 2. Light K, and Van Black PJP: Causes of renal deterioration patients with meningomyelocele, Br J Ural 49: 257 (1977). 3. Report of the International Reflux Study Committee: Medical versus surgical treatment of primary vesicoureteral reflux: a prospective international reflux study in children, J Urol 125: 277 (1981). 4. Tanagho EA, et al: Primary vesicoureteral reflux: experimental studies of its etiology, ibid 93: 165 (1965). 5. Stephens FD, and Lenaghan D: The anatomic basis and dynamics of vesicoureteral reflux, ibid 87: 699 (1962). 6. Hutch ]A: Vesicoureteral reflux in the paraplegic: cause and correction, ibid 68: 457 (1952). 7. Politano VA, and Leadbetter WF: An operative technique for the correction of ureteric reflux, ibid 79: 932 (1958). 8. Glenn JF, and Anderson EE: Distal tunnel ureteral reimplantation, ibid 97: 623 (1967). 9. Paquin AJ: Ureterovesical anastomosis: the description and evaluation of a technique, ibid 82: 573 (1959). 10. Cohen J: Vesicoureteral reflux: a new surgical approach, Int Urol Pediatr 6: 20 (1975). 11. McRae CV, Shannon FT, and Otley WLF: Effect on renal growth of reimplantaton of refluxing ureters, Lancet 1: 1310 (1974). 12. Willscher MK, Bauer SB, Zammuto PJ, and Retik AB: Renal growth and urinary infection following antireflux surgery in infants and children, J Ural 115: 722 (1976). 13. Hackler RH: Modified Hutch I vesicoureteroplasty in paraplegia, ibid 118: 953 (1977). 14. Belloli GP, Musi L, Campobano P, and Cottaneo A: Ureteral reimplantation in children with neurogenic bladder, J Pediatr Surg 14: 119 (1979). 15. Duckett JW, and Raezer DM: Neuromuscular dysfunction of the lower urinary tract, in Kelalis P, King LR, and Belman AB (Eds): Pediatric Urology, Philadelphia, W.B. Saunders Co., 1976, pp 401-422. 16. Raezer DM, Benson GS, Wein AJ, and Duckett JW: Functional approach to the management of the pediatric neuropathic bladder: a clinical study, J Urol 117: 649 (1977). 17. Raezer DM, Evans RJ, and Shrom SH: Augmentation cystoplasty in neuropathic bladder, Urology 25: 26 (1985).
35