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Vesicoureteral reflux in boys with hypospadias
VESICOURETERAL WITH
REFLUX
IN BOYS
HYPOSPADIAS
R. SHAFIR,
M.D.
H. TSUR,
M.D.
M. ALADJEM, M.D. P. JONAS, M.D.
M. HERTZ, M.D. H. BOICHIS, M.D.
From the Departments of Plastic Surgery, Diagnostic Radiology, Pediatrics and Urology, The Chaim Sheba Medical Center, Tel-Hashomer, afhliated with the Tel-Aviv University Sackler School of Medicine, Israel
ABSTRACT -- Hypospadias is a congenital anomaly which in most cases has to be corrected surgically. We include micturition cystourethrography (MCU) in the preoperative workup of all these children as well as three months postoperatively. Meatal stenosis and miillerian duct remnants are known to occur in this condition, but vesicoureteral refEux (VUR) was an unexpectedfinding in many boys who were asymptomatic and had no evidence of urinary tract infection. Fifty-eight of 305 hypospadiacs, examined by MCU, proved to have reflux, most of them grade Il. In 37, VUR was found before surgery and in the remaining 21 after surgical correction, many of them with meatal stenosis. In 10 patients refux appeared in the postoperative period where there had been none in the preoperative study; 8 of the 10 had a postoperative stricture of the distal urethra, and VUR subsided in 4 after adequate dilatation. We conclude that vesicoureteral re$ux is not uncommonly fozlnd in patients with hypospadias, even in those who are completely asymptomatic. We believe this is an additional incentive to include an MCU in the pre- and postoperative evaluation of patients with this anomaly.
Hypospadias is an anomaly which may be associated with other congenital defects in the urinary tract. l-3 ;Radiologic studies performed to define these anomalies have been limited mainly to excretory urogram, ‘3’ and even this examination has been considered redundant by several investigators. 4,:i Only one group has reported on the necessity of obtaining routine micturitional cystourethrography (MCU) in patients with hypospadias. 6 We have been performing this study routinely in the preoperative workup of these children and have found it useful in demonstrating other defects such as miillerian duct remnants including rudimentary vagina and functionally significant meatal stenosis.’ We began performing an additional MCU after correction of the hypospadias to evaluate the outcome of the surgical procedure.* In both the
UROLOGY
/
JULY
1982
/
VOLUME
XX,
NUMBER
1
pre- and postoperative studies a fairly high incidence of vesicoureteral reflux (VUR) was found. This was an unexpected finding since VUR is usually not present in asymptomatic children.’ The significance of this finding regarding the possible origin of VUR and its treatment will be discussed. Material
and Methods
Micturition cystourethrograms of 305 patients with hypospadias were reviewed. These studies were performed from 1969 to 1980 in our Medical Center. Fifty-eight patients who were found to have vesicoureteral reflux are included in the present report. Reflux was graded according to the International Study Classification i.e., grade I, ureter only; grade II, ureter, ( 29
TABLE I. Age of 218 patients with hypospadias a\ regards VlrR on preoperative MCI! C’UR
o-2
-
Without With
Age (Years) 2-4 l-6
7s
35
__17
___ 14
92
69
TOTALS
(Group Rl) and those in whom a preoperati\ <’ MCl_’ was not available because the operation had first been done ilr another hospital iGroup B2). The ago of the patients at the time of the preoperative M
6- 1:3 ‘I’d
22
29
181
0
6
28
3:
29
Kesults
218
VUR was found in 37 of a total of 218 patients examined prior to surgical repair of the hypospadias. The grades of reflux and the presence of meatal stenosis in these children is given in Table II. Thirty-two had grade I or grade II reflux. In 12 of the 37 patients the reflux was bilateral. Excretory urogram performed on patients with marked reflux showed dilated upper collecting system in 2 and reflux nephropathy in 4 others. Clinical findings and results of treatment are shown in Table III. In 10 patients (Group Al) urinary tract infection and dysuria and/or voiding difficulties were recorded. Eight of the 10 had meatal stenosis and underwent meatotomy, after which the VUR disappeared in 5. Three patients, 2 with grade III and 1 with grade IV reflux, had a successful antireflux operation, and 2 more recent cases with grade II reflux and a normal meatus are under conservative treatment with continuous low-dose chemoprophylaxis. In none of the other 27 patients (Group ,42) was there evidence of UTI. Six boys had definite meatal stenosis, and VUR disappeared in all of them following meatotomy. With respect to the other 21 patients in Group A2, VUR disappeared after conservative treatment in 10 and after ureteral reimplantation in 2 others with grades III and IV reflux, respectively. VUR has persisted so f:dr in 9 more recent patients treated conservatively.
TABLE II. Grades of reflux prior to correction of hypospadias in 37 patients including those with meatal stenosis No. of Grade
Patients*
.~~ ~ ~~--.
I II III IV
*Numbers
9 (3) 23 (9) 3 (1) __in parentheses
2 (li indicate
patients
with
meatal
stenosis.
pelvis, and calyces filled without dilatation; grade III, mild or moderate dilatation of pelvis and calyces; grade IV, moderate to marked dilatation; and grade V, gross dilatation.’ The patients’ hospital and outpatient records were reviewed for such details as evidence of urinary tract infection (UTI), voiding difficulties, and outcome of treatment. The patient material was divided into two main groups: patients in whom the preoperative MCU revealed vesicoureteral reflux (Group A) and those in whom VUR was detected first in the postoperative study (Group B). Group A was subdivided into patients with urinary tract infection (Group Al) and those without (Group A2). Patients in Group B were subdivided into patients who had had a preoperative study
TABLE
Status Preoperative Postoperative VUR subsided After meatotomy After conservative treatment After reimplantation VUR persists ..____*M.S. = meatal stenosis.
30
III. Clinicalfindings and results of treatment in 37 patients with VUR demonstrated preoperatively -..-.__-~-~ ~Group A2 (Sterile Urine) With ?vl.S. Without M.S.
Group Al (Infected Urine) With M.S.* Without M.S. 8
2
8 5
6
21
37
6 6
12
26 11
10 2 9
3 ~- ~~
2
UROLOGY
/
Totals
JULY
1982
/
VOLUME
10 5 11
XX,
NUMBER
1
Group
Ai
Normal Preoprr;rti\~e
(h~up B2 No Pwoperative \I(;C
11(X
Status
M’ith Stricturr
Postoperative VUR Outcome \‘UR subsided After dilatation After reimplantation VUR improved VUR persists
1 3
Vesicoureteral reflux is a condition in which the bladder contents enter the ureters retrogradely through an incompetent ureterovesical junction. Continued vesicoureteral reflux disturbs ureteral peristalsis, increases pressure in the pyelocalyceal system, and brings about residual urine. An association with infection will cause chronic pyelonephritis (reflux nephropathy). lo Vesicoureteral reflux may be primary 01 secondary. Primary or congenital reflux is thought to be caused by defective musculature at the ureterovesical junction without evidence of distal outflow obstruction. I1 Secondary reflux is associated with bladder outflow obstruction, such as posterior urethral valve or meatal stenosis. I2313
/ VOLUMEXX,NUMBERl
2
8
.\\~ailablt~ LYithout Strictllre
Totals
3 3
Comment
/ JULY1982
with Stricture
8
In 21 patients (Group B) VUR was first detected after surgical repair of the hypospadias. In 10, the preoperative MCU had been normal (Group Bl) (Table IV). In 8 of these 10 the study showed in addition to VUR some postoperative bladder outflow obstruction. This took the form of either stenosis of the new meatus or a distal stricture of the newly formed urethra. VUR disappeared after urethral dilatation in 3 of 8, and improved in 1. In the other 4 it has persisted so far. Eleven additional patients with postoperative VUR (Group B2) had not had a preoperative MCU. In 7, the postoperative study revealed, in addition to VUR, urethral or meatal strictures. In 1 patient VUR disappeared after surgical repair of the stricture, 2 more underwent ureterovesical reimplantation because of persistent infection, and 8 are still under conservative treatment after urethral dilatation.
UROLOGY
L+‘ithout Stricture
14
VUR is detected in the course of a micturitional cystourethrography, usually performed for investigation of urinary tract infection. The incidence of VUR in the noninfected population is not well known, but it appears to be low. In a compilation of 535 MCUs in apparently normal infants and children, only 7 cases with reflux were found: 3 of these had other anomalies and a fourth was thought to have bladder outflow obstruction.’ Reflux is fomld in 30 to 50 per cent of girls with UTI. 14,15Vesicoureteral reflux in boys ma> remain undetected since boys are not so apt to have urinary tract infection. even when VUR is present. Twenty-seven of the 37 patients in this study with preoperative reflux had sterile urine. Willi and Lebotitz” report 22 boys with massive primary VUR, only half of them presenting with UTI. One hvpothesis of the authors was that reflux in boys occurs earlier and with greatel severity than in girls because the normal resistance in their urethra is higher. Scott” is of the same opinion and advocates an antireflux operation in these children because the effect of reflux and infection in boys is more severe than in girls. Few reports mention the presence of VUR in children with hypospadias. This is probably because micturitional cystourethrography is not routinely performed in the evaluation of hypospadias. The incidence of VUR in most reported series of hypospadias is between 1.5 to 3.5 per cent. 1,2 This figure is probably inaccurate since the presence of VUR in these series was established by excretory urograms or retrograde cystography, and only rarely by MCU. Avellan” in a study of 148 boys with hypospadias Inelltions an incidence of 9.4 per cent on MCU. \C’e found in a previous study. VUR in 14 of 110
x31
patients examined for hypospadias. 7 In the group of boys examined preoperatively in the present series the incidence was somewhat higher - 37 of 218 (17 per cent). Fourteen of these 37 boys also had meatal stenosis. The prognosis of VUR depends, inter alia, on the d.egree of reflux. In the lower grades of reflux recovery is high, up to 80 per cent, I8 while a much smaller rate of recovery is usually observed in collecting systems demonstrating grade III reflux or more. lg Age is also a factor in the prognosis of VUR. In the very young child with grades I and II of VUR, reflux has a good chance of disappearing on treatment with antibacterial drugs. l9 Edwards et al. l8 observed that the rate at which reflux disappears remains constant throughout childhood, being 20 to 30 per cent for each two-year period. In 10 of 23 patients in this series with hypospadias and reflux, the reflux disappeared on conservative treatment after one to two years (Table III). In 11 of 14 boys with grade II VUR and meatal stenosis, the reflux disappeared after meatotomy. Mowad and Michaels13 report that in 7 of 13 boys with meatal stenosis and VUR the reflux disappeared after meatotomy. The degree of reflux was not mentioned. In our routine postoperative studies grades I or II VUR first appeared in 10 patients after surgical repair. All of them had had a normal MCU prior to operation. In 8 of these a stricture was found either at the site of the new meatus or in the distal part of the neourethra. We suggest that in these cases the bladder outflow obstruction with or without UT1 was the trigger causing incompetence of a congenitally “weak” ureterovesical junction. We did not find reports in the li.terature about reflux appearing in initially normal children who had had an operation on the lower urinary tract. In the (other 11 patients who had postoperative VUR (Group B2) no preoperative study was available. We therefore cannot elaborate on this group of patients, although most had outflow tract obstruction similar to those in Group Bl. Bladder outflow obstruction was relieved by either meatotomy or dilatation or surgical correction of the stricture. Treatment of patients who had \‘UR without bladder outflow obstruction depended on the severity of the reflux; conservative treatment was instituted in grades I or II, while reimplantation of the ureter into the bladder w.as performed when reflux was more marked or when infection could not be controlled. 2o
32
We conclude that vesicoureteral reflux is a not infrequent finding in patients with hypospadias, and may occur in the absence of symptoms which would constitute an indication for MCU such as UT1 and voiding difficulties. This was the case in 27 of 37 children studied preoperatively. A routine MCU both before and after surgical correction of hypospadias therefore appears to be indicated, since VUR has a potentially damaging effect on renal parenchyma. Department of Diagnostic Radiology The Chaim Sheba Medical Center Tel-Hashomer 52621 Israel (DR. HERTZ) References 1. Fallon B, Devine CJ, and Horton CE: Congenital anomalies associated with hypospadias, J. Urol. 116: 585 (1976). 2. Shima H, et al: Developmental anomalies associated with hypospadias, ibid. 122: 619 (1979). 3. Svensson J: Male hypospadias. 625 cases, associated malformations and possible etiological factors, Acta Paediatr. &and. 68: 587 (1979). 4. Lutzker LG, Kogan SJ, and Levitt SB: Is routine intravenous urography indicated in patients with hypospadias? Pediatrics 59: 630 (1977). 5. McArdle R, and Lebowitz R: Uncomplicated hypospadias and anomalies of upper urinary tract, Need for screening? Urology 5: 712 (1975). 6. Avellan L: Micturition studies in hypospadias, &and. J. Plast. Reconstr. Surg. 14: 115 (1980). 7. Rozenman J, Hertz M, and Boichis H: Radiological findings of the urinary tract in hypospadias: a report of 110 cases, Clin. Radlol. 39: 471 (1979). 8. Shafir R, Hertz M, Bornstein LA, and Tsur H: Cystourethrography as an aid in the evaluation of hypospadia5 and its complications, Plast. Reconstr. Surg. 62: 721 (1978). 9. Levitt SB: Medical versus surgical treatment of primary vesicoureteral reflux: a prospective international reflux study in children (Report of the International Reflux Study Committee), J. Ural. 125: 277 (1981). 10. Hodson CJ, and Edwards D: Chronic pyelonephritis and vesicoureteric reflux, Clin. Radiol. 11: 219 (1960). 11. Stephens FD, and Lenaghan D: The anatomical basis and dynamics of vesicoureteral reflux, J, Urol. 87: 669 (1962j. 12. Johnston JH: Vesicoureteric reflux with urethral valves, Br. J. Ural. 51: 100 (1979). 13. Mowad JJ, and Michaels MM: Meatal stenosis associated with vesicoureteral reflux in boys: management of25 cases, J. Ural. 111: 100 11974). 14. Bairatt’TM: Urinary tract infection in, Williams, D. I.: Urology in Childhood, Berlin, Springer-Verlag, 1974, p. 88. 15. Hertz M: Cystourethrography - a Radiographic Atlas, Amsterdam, Excerpta Medica, 1973, p. 34 16. Willi UV, and Lebowitz RL: The so-called megaureter megacystis syndrome, AJR 133: 409 (1979). 17. Scott JES: The role of surgery in the management of vesicoureteric reflux. Kidnev Int. 8: 73 11975). 18. Edwards D, Nbrmand I&, Prkscod N, and Smellie JM: Disappearance of vesicoureteric reflux during long-term prophylaxis of urinary tract infection in children. Br. Med. J. 2: 285 (1977). 19. Aladjem M, et al: The conservative management of vesicoureteric reflux: a review of 12.1 children, Pediatrics 65: 78 (1980). 20. Ransley PG: Vesicoureteric reHux: continuing surgical dilemma, Urology 12: 246 (1978).
UROLOGY
i
JULY
19%
/
VOLUME
XX,
NUMBER
1
REFLUX
IN BOYS
HYPOSPADIAS
R. SHAFIR,
M.D.
H. TSUR,
M.D.
M. ALADJEM, M.D. P. JONAS, M.D.
M. HERTZ, M.D. H. BOICHIS, M.D.
From the Departments of Plastic Surgery, Diagnostic Radiology, Pediatrics and Urology, The Chaim Sheba Medical Center, Tel-Hashomer, afhliated with the Tel-Aviv University Sackler School of Medicine, Israel
ABSTRACT -- Hypospadias is a congenital anomaly which in most cases has to be corrected surgically. We include micturition cystourethrography (MCU) in the preoperative workup of all these children as well as three months postoperatively. Meatal stenosis and miillerian duct remnants are known to occur in this condition, but vesicoureteral refEux (VUR) was an unexpectedfinding in many boys who were asymptomatic and had no evidence of urinary tract infection. Fifty-eight of 305 hypospadiacs, examined by MCU, proved to have reflux, most of them grade Il. In 37, VUR was found before surgery and in the remaining 21 after surgical correction, many of them with meatal stenosis. In 10 patients refux appeared in the postoperative period where there had been none in the preoperative study; 8 of the 10 had a postoperative stricture of the distal urethra, and VUR subsided in 4 after adequate dilatation. We conclude that vesicoureteral re$ux is not uncommonly fozlnd in patients with hypospadias, even in those who are completely asymptomatic. We believe this is an additional incentive to include an MCU in the pre- and postoperative evaluation of patients with this anomaly.
Hypospadias is an anomaly which may be associated with other congenital defects in the urinary tract. l-3 ;Radiologic studies performed to define these anomalies have been limited mainly to excretory urogram, ‘3’ and even this examination has been considered redundant by several investigators. 4,:i Only one group has reported on the necessity of obtaining routine micturitional cystourethrography (MCU) in patients with hypospadias. 6 We have been performing this study routinely in the preoperative workup of these children and have found it useful in demonstrating other defects such as miillerian duct remnants including rudimentary vagina and functionally significant meatal stenosis.’ We began performing an additional MCU after correction of the hypospadias to evaluate the outcome of the surgical procedure.* In both the
UROLOGY
/
JULY
1982
/
VOLUME
XX,
NUMBER
1
pre- and postoperative studies a fairly high incidence of vesicoureteral reflux (VUR) was found. This was an unexpected finding since VUR is usually not present in asymptomatic children.’ The significance of this finding regarding the possible origin of VUR and its treatment will be discussed. Material
and Methods
Micturition cystourethrograms of 305 patients with hypospadias were reviewed. These studies were performed from 1969 to 1980 in our Medical Center. Fifty-eight patients who were found to have vesicoureteral reflux are included in the present report. Reflux was graded according to the International Study Classification i.e., grade I, ureter only; grade II, ureter, ( 29
TABLE I. Age of 218 patients with hypospadias a\ regards VlrR on preoperative MCI! C’UR
o-2
-
Without With
Age (Years) 2-4 l-6
7s
35
__17
___ 14
92
69
TOTALS
(Group Rl) and those in whom a preoperati\ <’ MCl_’ was not available because the operation had first been done ilr another hospital iGroup B2). The ago of the patients at the time of the preoperative M
6- 1:3 ‘I’d
22
29
181
0
6
28
3:
29
Kesults
218
VUR was found in 37 of a total of 218 patients examined prior to surgical repair of the hypospadias. The grades of reflux and the presence of meatal stenosis in these children is given in Table II. Thirty-two had grade I or grade II reflux. In 12 of the 37 patients the reflux was bilateral. Excretory urogram performed on patients with marked reflux showed dilated upper collecting system in 2 and reflux nephropathy in 4 others. Clinical findings and results of treatment are shown in Table III. In 10 patients (Group Al) urinary tract infection and dysuria and/or voiding difficulties were recorded. Eight of the 10 had meatal stenosis and underwent meatotomy, after which the VUR disappeared in 5. Three patients, 2 with grade III and 1 with grade IV reflux, had a successful antireflux operation, and 2 more recent cases with grade II reflux and a normal meatus are under conservative treatment with continuous low-dose chemoprophylaxis. In none of the other 27 patients (Group ,42) was there evidence of UTI. Six boys had definite meatal stenosis, and VUR disappeared in all of them following meatotomy. With respect to the other 21 patients in Group A2, VUR disappeared after conservative treatment in 10 and after ureteral reimplantation in 2 others with grades III and IV reflux, respectively. VUR has persisted so f:dr in 9 more recent patients treated conservatively.
TABLE II. Grades of reflux prior to correction of hypospadias in 37 patients including those with meatal stenosis No. of Grade
Patients*
.~~ ~ ~~--.
I II III IV
*Numbers
9 (3) 23 (9) 3 (1) __in parentheses
2 (li indicate
patients
with
meatal
stenosis.
pelvis, and calyces filled without dilatation; grade III, mild or moderate dilatation of pelvis and calyces; grade IV, moderate to marked dilatation; and grade V, gross dilatation.’ The patients’ hospital and outpatient records were reviewed for such details as evidence of urinary tract infection (UTI), voiding difficulties, and outcome of treatment. The patient material was divided into two main groups: patients in whom the preoperative MCU revealed vesicoureteral reflux (Group A) and those in whom VUR was detected first in the postoperative study (Group B). Group A was subdivided into patients with urinary tract infection (Group Al) and those without (Group A2). Patients in Group B were subdivided into patients who had had a preoperative study
TABLE
Status Preoperative Postoperative VUR subsided After meatotomy After conservative treatment After reimplantation VUR persists ..____*M.S. = meatal stenosis.
30
III. Clinicalfindings and results of treatment in 37 patients with VUR demonstrated preoperatively -..-.__-~-~ ~Group A2 (Sterile Urine) With ?vl.S. Without M.S.
Group Al (Infected Urine) With M.S.* Without M.S. 8
2
8 5
6
21
37
6 6
12
26 11
10 2 9
3 ~- ~~
2
UROLOGY
/
Totals
JULY
1982
/
VOLUME
10 5 11
XX,
NUMBER
1
Group
Ai
Normal Preoprr;rti\~e
(h~up B2 No Pwoperative \I(;C
11(X
Status
M’ith Stricturr
Postoperative VUR Outcome \‘UR subsided After dilatation After reimplantation VUR improved VUR persists
1 3
Vesicoureteral reflux is a condition in which the bladder contents enter the ureters retrogradely through an incompetent ureterovesical junction. Continued vesicoureteral reflux disturbs ureteral peristalsis, increases pressure in the pyelocalyceal system, and brings about residual urine. An association with infection will cause chronic pyelonephritis (reflux nephropathy). lo Vesicoureteral reflux may be primary 01 secondary. Primary or congenital reflux is thought to be caused by defective musculature at the ureterovesical junction without evidence of distal outflow obstruction. I1 Secondary reflux is associated with bladder outflow obstruction, such as posterior urethral valve or meatal stenosis. I2313
/ VOLUMEXX,NUMBERl
2
8
.\\~ailablt~ LYithout Strictllre
Totals
3 3
Comment
/ JULY1982
with Stricture
8
In 21 patients (Group B) VUR was first detected after surgical repair of the hypospadias. In 10, the preoperative MCU had been normal (Group Bl) (Table IV). In 8 of these 10 the study showed in addition to VUR some postoperative bladder outflow obstruction. This took the form of either stenosis of the new meatus or a distal stricture of the newly formed urethra. VUR disappeared after urethral dilatation in 3 of 8, and improved in 1. In the other 4 it has persisted so far. Eleven additional patients with postoperative VUR (Group B2) had not had a preoperative MCU. In 7, the postoperative study revealed, in addition to VUR, urethral or meatal strictures. In 1 patient VUR disappeared after surgical repair of the stricture, 2 more underwent ureterovesical reimplantation because of persistent infection, and 8 are still under conservative treatment after urethral dilatation.
UROLOGY
L+‘ithout Stricture
14
VUR is detected in the course of a micturitional cystourethrography, usually performed for investigation of urinary tract infection. The incidence of VUR in the noninfected population is not well known, but it appears to be low. In a compilation of 535 MCUs in apparently normal infants and children, only 7 cases with reflux were found: 3 of these had other anomalies and a fourth was thought to have bladder outflow obstruction.’ Reflux is fomld in 30 to 50 per cent of girls with UTI. 14,15Vesicoureteral reflux in boys ma> remain undetected since boys are not so apt to have urinary tract infection. even when VUR is present. Twenty-seven of the 37 patients in this study with preoperative reflux had sterile urine. Willi and Lebotitz” report 22 boys with massive primary VUR, only half of them presenting with UTI. One hvpothesis of the authors was that reflux in boys occurs earlier and with greatel severity than in girls because the normal resistance in their urethra is higher. Scott” is of the same opinion and advocates an antireflux operation in these children because the effect of reflux and infection in boys is more severe than in girls. Few reports mention the presence of VUR in children with hypospadias. This is probably because micturitional cystourethrography is not routinely performed in the evaluation of hypospadias. The incidence of VUR in most reported series of hypospadias is between 1.5 to 3.5 per cent. 1,2 This figure is probably inaccurate since the presence of VUR in these series was established by excretory urograms or retrograde cystography, and only rarely by MCU. Avellan” in a study of 148 boys with hypospadias Inelltions an incidence of 9.4 per cent on MCU. \C’e found in a previous study. VUR in 14 of 110
x31
patients examined for hypospadias. 7 In the group of boys examined preoperatively in the present series the incidence was somewhat higher - 37 of 218 (17 per cent). Fourteen of these 37 boys also had meatal stenosis. The prognosis of VUR depends, inter alia, on the d.egree of reflux. In the lower grades of reflux recovery is high, up to 80 per cent, I8 while a much smaller rate of recovery is usually observed in collecting systems demonstrating grade III reflux or more. lg Age is also a factor in the prognosis of VUR. In the very young child with grades I and II of VUR, reflux has a good chance of disappearing on treatment with antibacterial drugs. l9 Edwards et al. l8 observed that the rate at which reflux disappears remains constant throughout childhood, being 20 to 30 per cent for each two-year period. In 10 of 23 patients in this series with hypospadias and reflux, the reflux disappeared on conservative treatment after one to two years (Table III). In 11 of 14 boys with grade II VUR and meatal stenosis, the reflux disappeared after meatotomy. Mowad and Michaels13 report that in 7 of 13 boys with meatal stenosis and VUR the reflux disappeared after meatotomy. The degree of reflux was not mentioned. In our routine postoperative studies grades I or II VUR first appeared in 10 patients after surgical repair. All of them had had a normal MCU prior to operation. In 8 of these a stricture was found either at the site of the new meatus or in the distal part of the neourethra. We suggest that in these cases the bladder outflow obstruction with or without UT1 was the trigger causing incompetence of a congenitally “weak” ureterovesical junction. We did not find reports in the li.terature about reflux appearing in initially normal children who had had an operation on the lower urinary tract. In the (other 11 patients who had postoperative VUR (Group B2) no preoperative study was available. We therefore cannot elaborate on this group of patients, although most had outflow tract obstruction similar to those in Group Bl. Bladder outflow obstruction was relieved by either meatotomy or dilatation or surgical correction of the stricture. Treatment of patients who had \‘UR without bladder outflow obstruction depended on the severity of the reflux; conservative treatment was instituted in grades I or II, while reimplantation of the ureter into the bladder w.as performed when reflux was more marked or when infection could not be controlled. 2o
32
We conclude that vesicoureteral reflux is a not infrequent finding in patients with hypospadias, and may occur in the absence of symptoms which would constitute an indication for MCU such as UT1 and voiding difficulties. This was the case in 27 of 37 children studied preoperatively. A routine MCU both before and after surgical correction of hypospadias therefore appears to be indicated, since VUR has a potentially damaging effect on renal parenchyma. Department of Diagnostic Radiology The Chaim Sheba Medical Center Tel-Hashomer 52621 Israel (DR. HERTZ) References 1. Fallon B, Devine CJ, and Horton CE: Congenital anomalies associated with hypospadias, J. Urol. 116: 585 (1976). 2. Shima H, et al: Developmental anomalies associated with hypospadias, ibid. 122: 619 (1979). 3. Svensson J: Male hypospadias. 625 cases, associated malformations and possible etiological factors, Acta Paediatr. &and. 68: 587 (1979). 4. Lutzker LG, Kogan SJ, and Levitt SB: Is routine intravenous urography indicated in patients with hypospadias? Pediatrics 59: 630 (1977). 5. McArdle R, and Lebowitz R: Uncomplicated hypospadias and anomalies of upper urinary tract, Need for screening? Urology 5: 712 (1975). 6. Avellan L: Micturition studies in hypospadias, &and. J. Plast. Reconstr. Surg. 14: 115 (1980). 7. Rozenman J, Hertz M, and Boichis H: Radiological findings of the urinary tract in hypospadias: a report of 110 cases, Clin. Radlol. 39: 471 (1979). 8. Shafir R, Hertz M, Bornstein LA, and Tsur H: Cystourethrography as an aid in the evaluation of hypospadia5 and its complications, Plast. Reconstr. Surg. 62: 721 (1978). 9. Levitt SB: Medical versus surgical treatment of primary vesicoureteral reflux: a prospective international reflux study in children (Report of the International Reflux Study Committee), J. Ural. 125: 277 (1981). 10. Hodson CJ, and Edwards D: Chronic pyelonephritis and vesicoureteric reflux, Clin. Radiol. 11: 219 (1960). 11. Stephens FD, and Lenaghan D: The anatomical basis and dynamics of vesicoureteral reflux, J, Urol. 87: 669 (1962j. 12. Johnston JH: Vesicoureteric reflux with urethral valves, Br. J. Ural. 51: 100 (1979). 13. Mowad JJ, and Michaels MM: Meatal stenosis associated with vesicoureteral reflux in boys: management of25 cases, J. Ural. 111: 100 11974). 14. Bairatt’TM: Urinary tract infection in, Williams, D. I.: Urology in Childhood, Berlin, Springer-Verlag, 1974, p. 88. 15. Hertz M: Cystourethrography - a Radiographic Atlas, Amsterdam, Excerpta Medica, 1973, p. 34 16. Willi UV, and Lebowitz RL: The so-called megaureter megacystis syndrome, AJR 133: 409 (1979). 17. Scott JES: The role of surgery in the management of vesicoureteric reflux. Kidnev Int. 8: 73 11975). 18. Edwards D, Nbrmand I&, Prkscod N, and Smellie JM: Disappearance of vesicoureteric reflux during long-term prophylaxis of urinary tract infection in children. Br. Med. J. 2: 285 (1977). 19. Aladjem M, et al: The conservative management of vesicoureteric reflux: a review of 12.1 children, Pediatrics 65: 78 (1980). 20. Ransley PG: Vesicoureteric reHux: continuing surgical dilemma, Urology 12: 246 (1978).
UROLOGY
i
JULY
19%
/
VOLUME
XX,
NUMBER
1