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Vesicoureteral Reflux in Women with Primary Bladder Diverticulum
0022-534 7/85/1341-0033$02.00/0 Vol. 134, July
THE JOURNAL OF UROLOGY
Copyright© 1985 by The Williams & Wilkins Co.
Printed in U.S.A.
VESICOURETERAL REFLUX IN WOMEN WITH PRIMARY BLADDER DIVERTICULUM ARJAN D. AMAR*
AND
SAKTI DAS
From the Departments of Urology, Kaiser Permanente Medical Center, Walnut Creek and the University of California School of Medicine, San Francisco, California ABSTRACT
In 22 years we treated 271 adults, including 149 women, for vesicoureteral reflux. We describe our management of vesicoureteral reflux in 12 women between 18 and 58 years old who had an associated primary vesical diverticulum. A vesical diverticulum located near the ureteral orifice caused reflux by destroying the ureterovesical valve in 11 of these 12 patients. In 1 woman a bladder diverticulum distant from the ureteral orifice acted as a reservoir of chronic infection, which perpetuated reflux in a marginally competent ureterovesical junction. The reflux disappeared after excision of the diverticulum. Reflux was bilateral in 3 and unilateral in 9 cases. Symptoms of acute pyelonephritis were noted in 3 women and radiographic changes of chronic pyelonephritis were noted in 4. Urinary infection was controlled successfully by medical management in 4 patients. Ureteral reimplantation after excision of the bladder diverticulum and repair of the bladder wall was successful in eradicating reflux in 5 patients. Each patient was followed for 3 or more years. The occurrence of a vesical diverticulum in women is not common. There are 2 theories concerning the pathogenesis of vesical diverticulum. One theory is that obstruction to the bladder outlet leads to increased residual urine in the bladder. Increased pressure generated in the bladder muscle to overcome obstruction at the bladder neck or urethra leads to back pressure, resulting in herniation of bladder mucosa between hypertrophied muscle bundles. The second theory is based on congenital weakness in an area of the vesical wall in which a diverticulum eventually develops. Perhaps both factors may contribute to the development of diverticula in some women. An area of the bladder wall that is congenitally weak and prone to diverticulum formation is the ureteral hiatus. This is the gap in the posterior bladder wall through which the ureter enters to start its approach before it eventually opens at the trigone. Weakness in this area in the early stage leads to the formation of a paraureteral saccule. As the saccule enlarges it develops into a small bladder diverticulum. As the diverticulum gets larger the ureteral hiatus enlarges further and eventually the ureteral opening is incorporated into the cavity of the diverticulum. This leads to vesicoureteral reflux and the ureterovesical valvular function is destroyed. Figure 1 is a schematic diagram showing the stages of progression from the early saccule to the formation of a paraureteral bladder diverticulum and eventual vesicoureteral reflux. If a bladder diverticulum forms in an area away from the ureteral hiatus, the valvular function of the ureterovesical junction will not be affected directly. However, the diverticulum located away from the ureteral orifice may influence indirectly vesicoureteral reflux by acting as a reservoir of chronic urinary infection. During a 22-year period a diagnosis of vesicoureteral reflux was made in 149 women. Of these women 12 between 18 and 58 years old also had 1 or more primary vesical diverticula. Our clinical experience with these 12 women is analyzed and our recommendation in regard to management is discussed. Each patient has been followed for 3 or more years.
diverticulum was located away from the ureteral orifice and acted as a reservoir of chronic bladder infection, which perpetuated reflux in a marginally competent ureterovesical junction. Reflux was bilateral in 3 and unilateral in 9 cases. Mild grade I or II reflux was noted in 7 patients and advanced grade III or IV reflux was noted in 5 patients. Symptoms of acute pyelonephritis were noted in 3 women and radiographic changes of chronic pyelonephritis were seen in 4. TREATMENT AND FOLLOWUP
Medical management was successful in controlling urinary infection in 4 patients. Of 8 patients who were treated surgically the vesical diverticulum was excised in 5 and the ureter was reimplanted by the surgical technique recently described by us. 1 This operation was successful in eradicating reflux in each of the 5 patients. In 2 patients nephrectomy was performed because the kidney was beyond salvage, including 1 in whom the refluxing ureteral stump acted as a reservoir of infection and was removed as a secondary operation after nephrectomy. In 1 patient a bladder diverticulum located away from the ureteral orifice acted as a reservoir of chronic infection. After the diverticulum was excised the reflux in a marginally competent ureter ceased. Each patient was followed for at least 3 years whether treated surgically or medically. CASE REPORTS
Case 1. A 34-year-old woman was seen with a 4-year history of recurrent bladder infections. An excretory urogram (IVP) showed changes of chronic right upper pole pyelonephritis (fig. 2, A). A bladder diverticulum was noted on the right side, which was confirmed by a cystogram (fig. 2, B). Cystoscopic examination revealed a right paraureteral diverticulum and right reflux was demonstrated by the indigo carmine cystoscopic test. 2 The patient was managed conservatively. Urinary infection was controlled, and during a 10-year period right renal function and radiographic appearance remained stable. Case 2. A 43-year-old woman was seen with a 5-year history of recurrent bladder infections as well as pain in the right flank during and after voiding. An IVP showed mild changes of caliceal clubbing in the right kidney (fig. 3, A). A voiding cystogram revealed right vesicoureteral reflux filling the right ureter and renal pelvis (fig. 3, B). Bladder diverticula were not evident on a film of the bladder filled with contrast medium. A post-void film of the bladder showed a small dog-ear type of
DIAGNOSIS
A paraureteral vesical diverticulum was considered responsible for reflux in 11 of these 12 women. In 1 woman the bladder Accepted for publication March 5, 1985. Read at annual meeting of Western Section, American Urological Association, Reno, Nevada, July 15-19, 1984. * Requests for reprints: Department of Urology, Kaiser Permanente Medical Center, 1425 S. Main St., Walnut Creek, California 94596.
33
34
A
AMAR AND DAS
B
C
D
1. Schematic diagram of stages in development of paraureteral vesical diverticulum. A, normal ureteral course through bladder wall. B, herniation of bladder mucosa in region of ureteral hiatus leading to formation of saccule. C, enlargement of saccule into diverticulum. FIG.
Ureteral orifice still has independent opening into bladder lumen and reflux is absent. D, enlargement of diverticulum with incorporation of ureteral orifice into lumen of diverticulum. Vesicoureteral reflux results.
FIG. 2. Case 1. A, 10-minute film of IVP shows changes of chronic pyelonephritis with scarring and atrophy of right renal upper pole. Note bladder diverticulum lateral to right lower ureter. B, cystogram reveals bladder diverticulum on right side. Reflux into right ureter was proved on indigo carmine cystoscopic test.
FIG. 3. Case 2. A, 10-minute film of IVP shows mild right caliceal clubbing. B, voiding cystogram reveals right ureteral reflux with filling of ureter and renal pelvis. C, post-void film of cystogram demonstrates 1 small diverticulum on each side of bladder and reflux into distal right ureter.
diverticulum on each side of the bladder (fig. 3, C). On cystoscopic examination the right ureteral orifice was found to open into the lumen of a paraureteral diverticulum. The right paraureteral diverticulum was excised intravesi-
cally and the defect in the bladder wall was closed. The ureter was reimplanted into the bladder using the antireflux technique of Amar and Weyrauch. 3 At 5-year followup the patient was free of infection, and the kidney and ureter on the right side appeared stable on repeated x-ray studies. The small diverticulum on the left side of the bladder had not changed and no reflux on the left side was noted. Case 3. A 24-year-old woman was seen elsewhere with symptoms of acute pain in the right flank, temperature up to 103F and a urine culture that was positive for Escherichia coli. Diagnosis was acute right pyelonephritis and the patient was treated with antimicrobial therapy. An IVP obtained soon after the acute urinary infection had been controlled showed a poorly visualized right kidney with changes of chronic pyelonephritis (fig. 4, A). The left kidney and ureter were normal. A right retrograde ureteropyelogram confirmed the absence of obstruction to the ureter and ureteropelvic junction (fig. 4, B). Blunted right renal calices again were noted. Right nephrectomy was performed to remove the poorly functioning kidney that was thought to be the site of chronic infection. A voiding cystogram apparently had not been performed before the kidney was removed. Recurrence of urinary infection after nephrectomy prompted the patient to seek additional treatment. A voiding cystogram showed reflux into the stump of the ureter (fig. 4, C). Cystoscopic examination revealed a paraureteral diverticulum. As the bladder cavity was filled the right ureteral opening became incorporated into the diverticulum. The right ureteral stump with reflux and the associated paraureteral diverticulum were considered to be a reservoir of chronic urinary infection. 4 ' 5 The dilated ureteral stump and the paraureteral diverticulum were excised. The patient was free of urinary infection and had no recurrence at 1-year followup. Case 4. A 58-year-old woman gave a history of recurrent urinary tract infection treated elsewhere with periodic urethral dilatations. A Y-V plasty of the bladder neck did not resolve the problem. A IO-minute IVP film showed a diverticulum on the right side of the bladder medial to the distal right ureter. On cystoscopic examination the diverticulum was located away from the trigone. The right ureter had a normal appearance and location on the trigone. The left ureteral orifice was slightly patulous, had a horseshoe type of configuration and was more lateral on the trigone than the right orifice. Cystography revealed reflux in the distal part of the left ureter and the right ureter was free of reflux. The diverticulum on the right side was considered to be a reservoir of chronic urinary infection and was excised. Subsequently, the reflux in the left ureter
FIG. 4. Case 3. A, 10-minute film of IVP shows atrophic right kidney with poor visualization of clubbed calices and normal left kidney. B, right retrograde urogram confirms chronic pyelonephritic atrophic right kidney. No obstruction is noted along course of right ureter. C, voiding cystogram shows reflux into distal right ureter and paraureteral vesical diverticulum filled with contrast medium. Right ureter was seen to open into diverticulum at cystoscopic examination.
VESICOURETERAL REFLUX IN WOMEN WITH PRHVIARY BLADDER DIVERTICULUM
The diverticulurn had perpetuated reflux through the marginally competent left ureter. After the source of chronic bladder infection was removed the reflux disappeared. At 10year followup the patient had no recurrence of reflux and was free of bladder infections.
of reflux in these women it is important to make adequate plans for excision of the diverticulum, in addition to ureteral reimplantation or other appropriate methods. REFERENCES
1. Amar, A. D. and Das, S.: Vesicoureteral reflux in patients with DISCUSSION
True congenital primary (nonobstructive) bladder diverticula are rare but have been reported in young men,6 boys 7 and girls. 7 No previous reports of bladder diverticula in women with associated vesicoureteral reflux have been published in the last decade. Our group of 12 patients is presented in an attempt to focus attention on bladder diverticulum as a contributing factor in the causation and perpetuation of reflux in women. Most probably, the paraureteral vesical diverticulum existed in each of these patients at childhood and continued into adult life. Discovery of the bladder diverticulum during investigation of the urological symptoms necessitated consideration of this factor during treatment of the reflux. Once the ureteral orifice is incorporated into the cavity of the bladder diverticulum it is unlikely that reflux will cease with conservative, nonoperative management. In 5 of the 12 patients excision of the paraureteral diverticulum and ureteral reimplantation by the antireflux technique resulted in cessation of reflux. 3 Of 4 women reflux ceased in 2 and it persisted in 2 but renal function remained unaltered, urinary infection was controlled and no radiographic changes of chronic pyelonephritis were observed at followup. Two of the patients had renal deterioration and unilateral nephrectomy was performed. In 1 patient the diverticulum located away from the ureteral orifice acted as a reservoir of chronic infection. Excision of the diverticulum alone was enough to stop reflux in a marginally competent ureteral orifice without antireflux surgery. 8 Discussion of causes, effects and treatment of reflux in the 137 women who did not have paraureteral bladder diverticulum is outside the scope of this presentation. In women with vesicoureteral reflux it is important to ascertain if vesical diverticula are contributory to causation or perpetuation of reflux. During consideration of the treatment
obstructive prostatic disease. J. Urol., 133: 194, 1985. 2. Amar, A. D.: Demonstration of vesicoureteral reflux without radiation exposure. J. Urol., 92: 286, 1964. 3. Amar, A. D. and Weyrauch, H. M.: Submucosal saline injection technique for ureteral reimplantation. Surg., Gynec. & Obst., 126: 552, 1968. 4. Amar, A. D.: Refluxing ureteral stump: reservoir of urinary infection. J. Urol., 91: 493, 1964. 5. Amar, A. D.: Delayed recurrence of reflux after initial success of antireflux operation. J. Urol., 119: 131, 1978. 6. Amar, A. D.: Vesicoureteral reflux associated with congenital bladder diverticulum in boys and young men. J. Urol., 107: 966, 1972. 7. Barrett, D. M., Malek, R. S. and Kelalis, P. P.: Observations on vesical diverticulum in childhood. J. Urol., 116: 234, 1976. 8. Amar, A. D.: Eradication of reflux in adults by excision of chronic infection reservoirs without antireflux operation. J. Urol., 113: 175, 1975. EDITORIAL COMMENT These investigators indicate that excision of a paraureteral diverticulum and reimplantation of the ureter result in cessation of reflux. They also indicate that in some patients with a similar, if not identical, anatomical arrangement nonoperative treatment appears to eliminate reflux, and is compatible with preservation of renal function and pyelographic appearance. These findings suggest that if infection can be eliminated an operation may be unnecessary. There is a critical point in regard to the decision to operate somewhere in the course of management of such patients as demonstrated by the loss of a kidney in 2 patients. Perhaps some of the currently available nuclear imaging techniques can guide us in making the decision regarding operative versus nonoperative management. John J. Murphy Department of Urology University of Pennsylvania Hospital Philadelphia, Pennsylvania
THE JOURNAL OF UROLOGY
Copyright© 1985 by The Williams & Wilkins Co.
Printed in U.S.A.
VESICOURETERAL REFLUX IN WOMEN WITH PRIMARY BLADDER DIVERTICULUM ARJAN D. AMAR*
AND
SAKTI DAS
From the Departments of Urology, Kaiser Permanente Medical Center, Walnut Creek and the University of California School of Medicine, San Francisco, California ABSTRACT
In 22 years we treated 271 adults, including 149 women, for vesicoureteral reflux. We describe our management of vesicoureteral reflux in 12 women between 18 and 58 years old who had an associated primary vesical diverticulum. A vesical diverticulum located near the ureteral orifice caused reflux by destroying the ureterovesical valve in 11 of these 12 patients. In 1 woman a bladder diverticulum distant from the ureteral orifice acted as a reservoir of chronic infection, which perpetuated reflux in a marginally competent ureterovesical junction. The reflux disappeared after excision of the diverticulum. Reflux was bilateral in 3 and unilateral in 9 cases. Symptoms of acute pyelonephritis were noted in 3 women and radiographic changes of chronic pyelonephritis were noted in 4. Urinary infection was controlled successfully by medical management in 4 patients. Ureteral reimplantation after excision of the bladder diverticulum and repair of the bladder wall was successful in eradicating reflux in 5 patients. Each patient was followed for 3 or more years. The occurrence of a vesical diverticulum in women is not common. There are 2 theories concerning the pathogenesis of vesical diverticulum. One theory is that obstruction to the bladder outlet leads to increased residual urine in the bladder. Increased pressure generated in the bladder muscle to overcome obstruction at the bladder neck or urethra leads to back pressure, resulting in herniation of bladder mucosa between hypertrophied muscle bundles. The second theory is based on congenital weakness in an area of the vesical wall in which a diverticulum eventually develops. Perhaps both factors may contribute to the development of diverticula in some women. An area of the bladder wall that is congenitally weak and prone to diverticulum formation is the ureteral hiatus. This is the gap in the posterior bladder wall through which the ureter enters to start its approach before it eventually opens at the trigone. Weakness in this area in the early stage leads to the formation of a paraureteral saccule. As the saccule enlarges it develops into a small bladder diverticulum. As the diverticulum gets larger the ureteral hiatus enlarges further and eventually the ureteral opening is incorporated into the cavity of the diverticulum. This leads to vesicoureteral reflux and the ureterovesical valvular function is destroyed. Figure 1 is a schematic diagram showing the stages of progression from the early saccule to the formation of a paraureteral bladder diverticulum and eventual vesicoureteral reflux. If a bladder diverticulum forms in an area away from the ureteral hiatus, the valvular function of the ureterovesical junction will not be affected directly. However, the diverticulum located away from the ureteral orifice may influence indirectly vesicoureteral reflux by acting as a reservoir of chronic urinary infection. During a 22-year period a diagnosis of vesicoureteral reflux was made in 149 women. Of these women 12 between 18 and 58 years old also had 1 or more primary vesical diverticula. Our clinical experience with these 12 women is analyzed and our recommendation in regard to management is discussed. Each patient has been followed for 3 or more years.
diverticulum was located away from the ureteral orifice and acted as a reservoir of chronic bladder infection, which perpetuated reflux in a marginally competent ureterovesical junction. Reflux was bilateral in 3 and unilateral in 9 cases. Mild grade I or II reflux was noted in 7 patients and advanced grade III or IV reflux was noted in 5 patients. Symptoms of acute pyelonephritis were noted in 3 women and radiographic changes of chronic pyelonephritis were seen in 4. TREATMENT AND FOLLOWUP
Medical management was successful in controlling urinary infection in 4 patients. Of 8 patients who were treated surgically the vesical diverticulum was excised in 5 and the ureter was reimplanted by the surgical technique recently described by us. 1 This operation was successful in eradicating reflux in each of the 5 patients. In 2 patients nephrectomy was performed because the kidney was beyond salvage, including 1 in whom the refluxing ureteral stump acted as a reservoir of infection and was removed as a secondary operation after nephrectomy. In 1 patient a bladder diverticulum located away from the ureteral orifice acted as a reservoir of chronic infection. After the diverticulum was excised the reflux in a marginally competent ureter ceased. Each patient was followed for at least 3 years whether treated surgically or medically. CASE REPORTS
Case 1. A 34-year-old woman was seen with a 4-year history of recurrent bladder infections. An excretory urogram (IVP) showed changes of chronic right upper pole pyelonephritis (fig. 2, A). A bladder diverticulum was noted on the right side, which was confirmed by a cystogram (fig. 2, B). Cystoscopic examination revealed a right paraureteral diverticulum and right reflux was demonstrated by the indigo carmine cystoscopic test. 2 The patient was managed conservatively. Urinary infection was controlled, and during a 10-year period right renal function and radiographic appearance remained stable. Case 2. A 43-year-old woman was seen with a 5-year history of recurrent bladder infections as well as pain in the right flank during and after voiding. An IVP showed mild changes of caliceal clubbing in the right kidney (fig. 3, A). A voiding cystogram revealed right vesicoureteral reflux filling the right ureter and renal pelvis (fig. 3, B). Bladder diverticula were not evident on a film of the bladder filled with contrast medium. A post-void film of the bladder showed a small dog-ear type of
DIAGNOSIS
A paraureteral vesical diverticulum was considered responsible for reflux in 11 of these 12 women. In 1 woman the bladder Accepted for publication March 5, 1985. Read at annual meeting of Western Section, American Urological Association, Reno, Nevada, July 15-19, 1984. * Requests for reprints: Department of Urology, Kaiser Permanente Medical Center, 1425 S. Main St., Walnut Creek, California 94596.
33
34
A
AMAR AND DAS
B
C
D
1. Schematic diagram of stages in development of paraureteral vesical diverticulum. A, normal ureteral course through bladder wall. B, herniation of bladder mucosa in region of ureteral hiatus leading to formation of saccule. C, enlargement of saccule into diverticulum. FIG.
Ureteral orifice still has independent opening into bladder lumen and reflux is absent. D, enlargement of diverticulum with incorporation of ureteral orifice into lumen of diverticulum. Vesicoureteral reflux results.
FIG. 2. Case 1. A, 10-minute film of IVP shows changes of chronic pyelonephritis with scarring and atrophy of right renal upper pole. Note bladder diverticulum lateral to right lower ureter. B, cystogram reveals bladder diverticulum on right side. Reflux into right ureter was proved on indigo carmine cystoscopic test.
FIG. 3. Case 2. A, 10-minute film of IVP shows mild right caliceal clubbing. B, voiding cystogram reveals right ureteral reflux with filling of ureter and renal pelvis. C, post-void film of cystogram demonstrates 1 small diverticulum on each side of bladder and reflux into distal right ureter.
diverticulum on each side of the bladder (fig. 3, C). On cystoscopic examination the right ureteral orifice was found to open into the lumen of a paraureteral diverticulum. The right paraureteral diverticulum was excised intravesi-
cally and the defect in the bladder wall was closed. The ureter was reimplanted into the bladder using the antireflux technique of Amar and Weyrauch. 3 At 5-year followup the patient was free of infection, and the kidney and ureter on the right side appeared stable on repeated x-ray studies. The small diverticulum on the left side of the bladder had not changed and no reflux on the left side was noted. Case 3. A 24-year-old woman was seen elsewhere with symptoms of acute pain in the right flank, temperature up to 103F and a urine culture that was positive for Escherichia coli. Diagnosis was acute right pyelonephritis and the patient was treated with antimicrobial therapy. An IVP obtained soon after the acute urinary infection had been controlled showed a poorly visualized right kidney with changes of chronic pyelonephritis (fig. 4, A). The left kidney and ureter were normal. A right retrograde ureteropyelogram confirmed the absence of obstruction to the ureter and ureteropelvic junction (fig. 4, B). Blunted right renal calices again were noted. Right nephrectomy was performed to remove the poorly functioning kidney that was thought to be the site of chronic infection. A voiding cystogram apparently had not been performed before the kidney was removed. Recurrence of urinary infection after nephrectomy prompted the patient to seek additional treatment. A voiding cystogram showed reflux into the stump of the ureter (fig. 4, C). Cystoscopic examination revealed a paraureteral diverticulum. As the bladder cavity was filled the right ureteral opening became incorporated into the diverticulum. The right ureteral stump with reflux and the associated paraureteral diverticulum were considered to be a reservoir of chronic urinary infection. 4 ' 5 The dilated ureteral stump and the paraureteral diverticulum were excised. The patient was free of urinary infection and had no recurrence at 1-year followup. Case 4. A 58-year-old woman gave a history of recurrent urinary tract infection treated elsewhere with periodic urethral dilatations. A Y-V plasty of the bladder neck did not resolve the problem. A IO-minute IVP film showed a diverticulum on the right side of the bladder medial to the distal right ureter. On cystoscopic examination the diverticulum was located away from the trigone. The right ureter had a normal appearance and location on the trigone. The left ureteral orifice was slightly patulous, had a horseshoe type of configuration and was more lateral on the trigone than the right orifice. Cystography revealed reflux in the distal part of the left ureter and the right ureter was free of reflux. The diverticulum on the right side was considered to be a reservoir of chronic urinary infection and was excised. Subsequently, the reflux in the left ureter
FIG. 4. Case 3. A, 10-minute film of IVP shows atrophic right kidney with poor visualization of clubbed calices and normal left kidney. B, right retrograde urogram confirms chronic pyelonephritic atrophic right kidney. No obstruction is noted along course of right ureter. C, voiding cystogram shows reflux into distal right ureter and paraureteral vesical diverticulum filled with contrast medium. Right ureter was seen to open into diverticulum at cystoscopic examination.
VESICOURETERAL REFLUX IN WOMEN WITH PRHVIARY BLADDER DIVERTICULUM
The diverticulurn had perpetuated reflux through the marginally competent left ureter. After the source of chronic bladder infection was removed the reflux disappeared. At 10year followup the patient had no recurrence of reflux and was free of bladder infections.
of reflux in these women it is important to make adequate plans for excision of the diverticulum, in addition to ureteral reimplantation or other appropriate methods. REFERENCES
1. Amar, A. D. and Das, S.: Vesicoureteral reflux in patients with DISCUSSION
True congenital primary (nonobstructive) bladder diverticula are rare but have been reported in young men,6 boys 7 and girls. 7 No previous reports of bladder diverticula in women with associated vesicoureteral reflux have been published in the last decade. Our group of 12 patients is presented in an attempt to focus attention on bladder diverticulum as a contributing factor in the causation and perpetuation of reflux in women. Most probably, the paraureteral vesical diverticulum existed in each of these patients at childhood and continued into adult life. Discovery of the bladder diverticulum during investigation of the urological symptoms necessitated consideration of this factor during treatment of the reflux. Once the ureteral orifice is incorporated into the cavity of the bladder diverticulum it is unlikely that reflux will cease with conservative, nonoperative management. In 5 of the 12 patients excision of the paraureteral diverticulum and ureteral reimplantation by the antireflux technique resulted in cessation of reflux. 3 Of 4 women reflux ceased in 2 and it persisted in 2 but renal function remained unaltered, urinary infection was controlled and no radiographic changes of chronic pyelonephritis were observed at followup. Two of the patients had renal deterioration and unilateral nephrectomy was performed. In 1 patient the diverticulum located away from the ureteral orifice acted as a reservoir of chronic infection. Excision of the diverticulum alone was enough to stop reflux in a marginally competent ureteral orifice without antireflux surgery. 8 Discussion of causes, effects and treatment of reflux in the 137 women who did not have paraureteral bladder diverticulum is outside the scope of this presentation. In women with vesicoureteral reflux it is important to ascertain if vesical diverticula are contributory to causation or perpetuation of reflux. During consideration of the treatment
obstructive prostatic disease. J. Urol., 133: 194, 1985. 2. Amar, A. D.: Demonstration of vesicoureteral reflux without radiation exposure. J. Urol., 92: 286, 1964. 3. Amar, A. D. and Weyrauch, H. M.: Submucosal saline injection technique for ureteral reimplantation. Surg., Gynec. & Obst., 126: 552, 1968. 4. Amar, A. D.: Refluxing ureteral stump: reservoir of urinary infection. J. Urol., 91: 493, 1964. 5. Amar, A. D.: Delayed recurrence of reflux after initial success of antireflux operation. J. Urol., 119: 131, 1978. 6. Amar, A. D.: Vesicoureteral reflux associated with congenital bladder diverticulum in boys and young men. J. Urol., 107: 966, 1972. 7. Barrett, D. M., Malek, R. S. and Kelalis, P. P.: Observations on vesical diverticulum in childhood. J. Urol., 116: 234, 1976. 8. Amar, A. D.: Eradication of reflux in adults by excision of chronic infection reservoirs without antireflux operation. J. Urol., 113: 175, 1975. EDITORIAL COMMENT These investigators indicate that excision of a paraureteral diverticulum and reimplantation of the ureter result in cessation of reflux. They also indicate that in some patients with a similar, if not identical, anatomical arrangement nonoperative treatment appears to eliminate reflux, and is compatible with preservation of renal function and pyelographic appearance. These findings suggest that if infection can be eliminated an operation may be unnecessary. There is a critical point in regard to the decision to operate somewhere in the course of management of such patients as demonstrated by the loss of a kidney in 2 patients. Perhaps some of the currently available nuclear imaging techniques can guide us in making the decision regarding operative versus nonoperative management. John J. Murphy Department of Urology University of Pennsylvania Hospital Philadelphia, Pennsylvania