POSTGRAD. MED. J. (I962), 38, 520

VESICO-URETERIC REFLUXD. INNES WILLIAMS, M.D., M.Ch., F.R.C.S.

Surgeon, St. Peter's and St. Paul's Hospitals, The Hospital for Sick Children, Great Ormond Street;Consultant Urologist, King Edward VII Hospital for Officers

ALTHOUGH in many systems of the body the intro-duction of efficient anti-bacterial agents hasieduced or eliminated, the need for surgery indiseases due to bacterial infection, the reverse hasoccurred in the urinary tract. The ordinary in-fecting organisms are susceptible to many drugsand acute episodes of infection can almost alwaysbe controlled by medical means, but recurrentinfection and chronic pyelonephritis are no lesscommon than formerly. It may yet prove that inchronic pyelonephritis there is some unrecognizedatiological factor in addition to the urinary in-fection but it is certain that the recurrent pyuria isa factor and that it is commonly associated withdisorders of function of the urinary passages: thehope is that operative correction of these disorderswill enable drug treatment to be as successful inpreventing the chronic disease as it is in controllingthe acute phase. The role of surgery in relievingthe major obstructions predisposing to infectionhas long been recognized but in recent yearsattention has also been devoted to the surgicalprevention of vesico-ureteric reflux as it has be-come increasingly apparent that chronic pyelone-phritis without major obstructive disease is oftenfound together with this abnormality. Thisassociation between reflux and the pyelonephriticcontracted kidney is therefore the main topic ofthis paper, but for clarity the incidence of reflux inother urological disorders must be brieflydiscussed.

Normal FunctionIn normal circumstances flow in the ureter is in

one direction only: downwards towards thebladder. The peristaltic activity of the ureterusually prevents any reversal of this flow, and thevalvular mechanism of the uretero-vesical junctionprecludes escape of urine from the bladder in thisdirection. The valve is formed by the obliquepassage of the intramural ureter through thebladder wall: it is not dependent upon anysphincteric activity. At post-mortem the normalbladder can be distended until the muscle coatbegins to rupture before any fluid enters theureters; indeed the greater the distension of thebladder the longer and more oblique the intra-

mural ureter becomes, and therefore the moreefficient the valvular action. Clearly the time atwhich. reflux is most likely to occur is towards theend of micturition, when the bladder is nearlyempty and the intramural ureter relatively short,while the intra-vesical pressure is high. Clinicallythis expectation is borne out by the fact that refluxis found most commonly on the micturating ratherthan on the simple filling cystogram.

Cystography for Detection of RefluxThe radiological detection of reflux requires the

passage of a catheter and the injection of opaquemedium into the bladder. This is something of adisadvantage in view of the well known danger ofcatheterization, but micturition films at the end ofthe intravenous pyelograms are useless sincefilling of the ureter may still be due%to the excretionof the medium. It need scarcely be emphasizedthat the instrumentation must be performed underconditions of strict asepsis and should be avoidedaltogether in cases of lower urinary obstructionunless all preparations have been made to secureadequate urinary drainage afterwards.The bladder should be filled to capacity with the

opaque medium, and films exposed before, duringand after micturition. If cine film can be takenusing the image intensifier, a very clear idea of thedegree of reflux can be obtained, but this is in noway essential. It is sometimes difficult or im-possible to persuade the patient to micturate whilein front of the X-ray tube, and occasionally inyoung children the investigation must be per-formed under an anesthetic: the bladder is thenemptied by manual expression. It must berecognized, however, that reflux cannot beexcluded unless micturating films have beenobtained and it is, after all, reflux occurring duringnormal micturition which interests us in relation todisease, not reflux under conditions of passiveover-distension of the bladder.

In most cases of reflux the post-micturition filmwill show the entire ureter and renal pelvis filledwith opaque medium, but in less severe cases onlythe lower ureter may be filled and this is oftenemptied rapidly so that there should be no delay inexposing this last picture.

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September 1962 WILLIAMS: Vesico-ureteric Reflux 521

Mechanism of RefluxReflux occurs when disease or injury has

rendered the intramural ureter short and wide, orwhen the presence of a saccule adjacent to theorifice leads to its displacement outwards. Tuber-culosis provides the best example of the firstcategory: the infected ureter is rigid and shortened,the bladder contracted, reflux then occurs but isreversible if the disease process is controlled bychemotherapy. The passage of a large uretericstone or a surgical ureteric meatotomy may havethe same effect. In some pyelonephritic con-tracted kidneys the ureter is shortened and rigid,so that it may be suspected that reflux is secondaryto the infective process, but as will be seen laterthis is not the usual finding and it is believed thatreflux is usually a primary abnormality in thisgroup.The detrusor coat of the bladder is made up of

many interlacing, but distinct, muscle bundles.Such a pattern is apt to leave weak points and onesuch occurs behind and lateral to the uretericorifice. Here a saccule of vesical mucosa may bepushed out between the muscle fibres duringmicturition. Saccules of this type may be seenwithout any other serious abnormality, but theyare, of course, usually associated with obstructionto the outflow from the bladder, or with a nervelesion, and therefore with a hypertrophieddetrusor. Hutch (I955) has shown how a sacculein this situation may, as it enlarges, draw theureteric orifice out with it, until the terminalureter is no longer intramural and therefore nolonger valvular (Fig. i). It is because of thissaccule formation and not because of any simpleincrease of intra-vesical pressure that refluxoccurs in some, but by no means all, cases ofurinary obstruction. The saccule may, of course,enlarge until it assumes the proportions of adiverticulum and the ureter may be permanentlydisplaced so that it opens into the diverticulumitself.

Congenital abnormalities of the ureter mayfacilitate reflux, because a short, wide intramuralureter is present. In many of the pyelonephriticcontracted kidneys this is the only local lesionwhich can be found.When reflux occurs into a ureter of normal

calibre, the refluxed urine does not pass upwardsfor more than two or three inches; it is then re-turned by active ureteric peristalsis. This seemsto be a harmless condition in the short run sinceit can be shown radiologically in cases with normalkidneys, but if it continues a change in the uretericactivity is seen. A great deal depends, however,upon the state of the bladder from which refluxoccurs.

..

Ureteric orifice pushed outthrough bladder wall.

FIG. I.-Saccule formation and reflux. Diagrams toshow the formation of a saccule causing the intra-mural ureter to be pushed outwards and thereforeto lose its valvular action.

Reflux as the Sole AbnormalityCystograms are not usually performed on

normal, symptom-free subjects, but from suchevidence as there is (see McGovern, Marshall andPaquin, I960) reflux is not found in these in-dividuals. Cystograms have been performed,however, in large numbers of enuretics, and inchildren with recurrent urinary infection who havenormal intravenous pyelograms. In the enureticgroup reflux scarcely ever occurs, if the bladder isnormal, without evidence of obstruction ortrabeculation: in the infected group, however,reflux is relatively common. Radiological de-tection of chronic pyelonephritis implies, ofcourse, that the disease has already produceddeep scars in the kidney and there seems littledoubt that in this infected group pyelonephritis ispresent in its early stages.

It may be mentioned here that reflux is veryseldom a direct cause of symptoms: the classicalcomplaint of renal pain during micturition is veryinfrequently heard, although obviously a pyelo-nephritic kidney may be painful during an acuteepisode of infection.

El

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522 POSTGRADUATE MEDICAL JOURNAL September I962

FIG. 2.-Sketches from pyelograms of contractedkidneys with reflux to show the characteristicappearance.

Reflux in the Contracted KidneyIt has already been emphasized that the pyelo-

nephritic contracted kidney is frequently asso-ciated with reflux, and in this group there is nogreat dilatation of the urinary tract (Hinman andHutch, I962). The kidney is smaller than normal,as can be seen by measuring the extent of therenal outline in the pyelographic series. Absolutelynormal dimensions are hard to establish, butusually it is possible to compare one kidney withthe other, or the same kidney in different X-raystaken over the course of years. Pyelonephritis is apatchy disease and the renal outline is irregular,showing that the loss of parenchyma has occurredin relation to the calyces showing the most distor-tion (Figs. 2 and 3). The affected calyces them-selves are blunted but do not have the smoothoutline of hydronephrotic calyces. They arecrowded together where a large part of the kidneyis diseased and approach close to the surface. Therenal pelvis is often a little larger than normal andmay at first suggest hydronephrosis, but there isno sharp cut-off at the pelvi-ureteric junction, andemptying is reasonably efficient. The pelvis andureter of the very small kidney are often disposedin one vertical line, close to the vertebral column.

a.. .......

,.:.:. .... .... ...B.B..as: .........--:.

4':'. }';'''...... ...: .''........ ......................''..'''''..............

~~~~. ............. --' .~.......... .... ...........: :.:.::.. .--:".< .........

~~~...........,. '--'s~~..'.~~~~~~~.......4e'..',.

-:~~~~~~~........ .. ............''.-':,:

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.........-.

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FIG. 3.-Intravenous pyelogram from a girl of 9 yearswith recurrent pyuria. The right kidney is severelypyelonephritic and reflux was present on this sideonly.

The refluxing ureter in this group shows acharacteristically 'flabby' dilatation (Fig. 4) andits calibre varies according to the circumstances.In intravenous pyelograms it may look completelynormal, though the upper part is often a little widewhile the compression is applied. During micturi-tion, however, when reflux is occurring the ureteris considerably dilated. After the act, the refluxedurine returns rapidly to the bladder, which there-fore contains 'false' residual urine.The ureteric orifice is cystoscopically normal in

most patients in this group, though in long-stand-ing cases it may become rigid and wide. Thecontrasting appearance of the refluxing mega-ureter is discussed below. The bladder may benormal, but in many girls with this type of pyelo-nephritic kidney there is definite trabeculationand, therefore, evidence of slight obstruction. Therole of 'bladder neck obstruction' in these girlswith recurrent pyuria is still much disputed, for itis unusual for them to progress to retention orserious upper tract dilataion, but the presence ofa hypertrophied detrusor without urethral obstruc-tion strongly suggests some hold-up at the bladderneck and often the beneficial effects of bladderneck surgery confirm this view (Williams andSturdy, I96I). On the other hand, these bladdersmay simply be irritable and the frequency andurgency may themselves lead to trabeculation.The small saccule which interferes with thevalvular action of the intramural ureter is acorollary of the trabeculation whatever its origin.

Pyelonephritis is in general bilateral but asym-metrical, and in most cases of this group reflux is

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September I962 WILLIAMS: Vesico-ureteric Reflux

a-E tv'>..'f..,ff,.. ....'.=..-......,..

l~ l.l...............- .,

xe:.:......

... .. ... ..<|,

........ ....

..

FIG. 4.-Cystogram from a girl of 9 years with recurrentpyuria: reflux into the left kidney.

bilateral, though often more marked on one sidethan the other. It has also been observed thatwhere reflux has been prevented by operation onone side, it has subsequently appeared contra-laterally.

It has been stated that the pyelonephriticcontracted kidney is commonly associated withreflux. In children this finding is almost con-stant, though exceptions do occur. An interestingexample of this is found in Fig. 5; the patientwas a girl of ii years suffering from recurrentpyuria who had, during attacks, pain in the leftloin. The intravenous pyelogram shows a con-tracted right kidney, and a large, but slightlydistorted, left kidney. On cystography reflux waspresent only on the left, the side of the symptoms,but not the side of the most advanced disease.The small kidney may, of course, be the result

of renal artery stenosis, not of pyelonephritis,and reflux is not then to be expected. It mayalso be congenitally hypoplastic, and reflux is notthen invariable, but the distinction between con-genital hypoplasia and pyelonephritic contractionis difficult or impossible to make except by thehistological finding of dysplastic elements in theformer group: moreover, infection frequentlycomplicates the anomaly.

In adults reflux is less common, and a proportion

; : :: ::::: ~~~....::...-...;...s.y...;.8 .:.............. ...

,.R.,WA ..:. i...-. '.....

,.X ...... ...... B.. ... .. ...<lg; ....., '.''. ..:........

.. ....i ... .....

,,,,

-; ~..

f- ~~.. ............-

FIG. 5.-Intravenous pyelogram from a girl of io yearswith persistent pyuria, and episodes of high feverwith left loin pain. The right kidney is con-tracted but on cystography reflux was present onlyon the left, the side of the pain.

of cases, male and female, with severely contractedpyelonephritic kidneys have been investigated bycystography on a number of occasions withoutfinding this particular disorder. In the obstructedcases, too, without infection, reflux is less likely inadults than in children; the saccule is not so aptto form. In some children reflux ceases with thepassage of time, probably due to the consolidationof the vesical muscularis associated with growth.

Reflux in Double UretersAlthough the complications of ureteric duplica-

tion are uncommon in comparison with chronicpyelonephritis in the anatomically normal kidney,evidence from this group is helpful in assessingthe role of reflux in renal disease (Fig. 6). If theureteric duplication is partial, union of the twoducts may take place at any level between the renalpelvis and the bladder. Function appears to bewell co-ordinated as a rule and it is rare to find anyhold-up at the point of union, though urine mayflow from one branch into the other at times. If thecommon uretero-vesical junction is incompetent,refluxed urine flows more or less equally into bothureters. A number of cases has been observed inwhich this is complicated by chronic pyelo-nephritis, and in all the lesion has affected bothhalves of the kidney (Fig. 7). If the uretericduplication is complete and both ureters open uponthe trigone of the bladder, the ureter from theupper renal pelvis opens nearer the bladder neckthan its fellow and has, therefore, a longer intra-mural segment. It is perfectly possible for bothureters to have an efficient valvular mechanism,but clearly if one fails it will be the ureter from thelower (and larger) renal pelvis which opens higherup in the bladder and has the shorter intramural

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524 POSTGRADUATE MEDICAL JOURNAL September I962

I..f

2 'j

Y -@;XSk k | .

i-,,,.'.7 Z PS6 '2

FIG. 6.-Diagrams to show doubleureters complicated by reflux.

(a) The bifid ureter withreflux into both branches:pyelonephritis affects bothhalves of the kidney.

(b) The complete duplica-tion: reflux only into the lowerpelvis.

(c) The urethral ectopicureter: reflux into the upperpelvis.

.....

......

FIG. 7.-Cystogram in a 8-year-old boy showing refluxon both sides. On the left a bifid ureter withpyelonephritis of both renal elements.

course. This situation has been observed in i8examples, and, in each, the lower half of the kidneyonly has been pyelonephritic, the upper elementbeing healthy. In some the opposite single ureterhas also allowed reflux and has been associatedwith a pyelonephritic kidney, leaving only theone upper segment, with an anatomicallyanomalous ureter, protected.

If the ureteric duplication is complete, but theureter from the upper pelvis is ectopic, opening atthe bladder neck or into the posterior urethra, itsorifice is usually wide and rigid allowing reflux.In these circumstances, the upper renal pelvis ispyelonephritic, the lower normal as long as itsorifice is competent. In this group, however,dysplastic elements in the renal parenchyma arecommon, and some obstructive element may alsobe involved. The ectopic ureterocele introduces afurther complication in some, as has been discussedelsewhere (Williams, I962).The double ureters thus present something like

an experiment in the effects of reflux upon thekidney.

Reflux in the Mega-uretersThe term mega-ureter implies chronic dilatation

without organic obstruction. One group has aterminal ureteric segment of normal calibre, and acompetent uretero-vesical valve: these patientshave clearly a functional obstruction of as yetunknown origin, but are not of concern in thepresent paper. The other group has bilateral

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September I962 WILLIAMS: Vesico-ureteric Reflux 525

.... .....

...........

FIG. 8.-Cystogram in girl of 4 years with mega-ureter-megacystis syndrome. (Other films showedalso dilated right ureter.)

dilatation with free reflux, gaping ureteric orificesand a large-capacity bladder-the mega-ureter-megacystis syndrome. Mention has already beenmade of the fact that in cystograms the refluxingureter is often dilated although it appears normalin the intravenous pyelograms, and there is greatdifficulty in defining what is a mega-ureter. It is,in fact, possible that reflux alone is responsible forthe mega-ureter type of dilatation, but against thiswe have the extremely large calibre (Fig. 8) eventhough the bladder is not obstructed, the per-sistence in the ureters of powerful, althoughineffective contractions, and the characteristicappearance of the ureteric orifice at cystoscopy.At rest the orifice gapes widely, so that an endo-scope is easily introduced into it, yet it exhibitsbrief, powerful contractions which bring itmomentarily to a normal size. Although, there-fore, there is no proof, it is believed that themega-ureter-megacystis syndrome is distinct fromthe simple refluxing ureter with pyelonephritis.The effect on the kidney, however, is similar;

,:.... ...' m........... .................................. ..

:.. ']]w.......... ....... .... :.'.':X'.... ... ...:................ .. .. ... ........ .... f !.'.-

.............

S..B-f!

..... l-|.E.'.....

e. .. ... .-z

:X X-

b.. . .. .................................,|00fS,

:,e.,....:........ .. .:..'M

... .. .. ..... ....

.~~~.. ... :..:.@....x~~~~.,l:,,

... .. .. ..... .. .:....

| e.;. ...... ..

?K ............... ,,

..,... ...... ... .... -. -'SS

:.; .... .. .. .-

~. ..Bi.. ... .. ..... ..f..... ..

.9 ... ....... ......... -..

.............. , : .,..,,,,--

FIG. 9.-Cystogram showing reflux from a neurogenicbladder due to myelo-meningocele.

there may be some progressive hydronephrosis,but ultimately failure is more likely to be due tothe complicating infection.

Reflux in Severe ObstructionsWhen reflux occurs from a severely obstructed

and hypertrophied bladder, as for instance in thecongenital urethral or bladder-neck obstructions,the full force of the detrusor contraction is broughtto bear upon the comparatively thin-walled ureter,and a rapidly increasing dilatation of the ureterand renal pelvis follows. This effect is welldemonstrated in unilateral cases of reflux, whenthe affected kidney is always the more hydro-nephrotic and functionally the poorer. The sameeffect may be seen in the hypertrophied, neuro-pathic bladder and again increasing hydronephrosisis the usual effect (Fig. 9).

Reflux: Cause or Effect of Renal Disease?Our therapeutic attitude towards reflux must

obviously depend on whether we regard it as aninteresting but innocuous side-effect of other dis-orders, as a dangerous complication, or as a

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POSTGRADUATE MEDICAL JOURNAL

primary factor in the disease process. The evidencefrom clinical observation is to some extent confus-ing, while animal experiments are as yet in-conclusive. Nevertheless, some assessment mustbe made as a practical guide.

In severe urethral and bladder-neck obstruc-tions, reflux is a dangerous complication accelerat-ing the renal damage: this cannot be disputed, butit may be that persistent reflux is innocuous if theobstruction has been completely removed.

In tuberculosis, renal disease leads to uretericand vesical inflammation: reflux again is a com-plication but it may not be serious if the originaldisorder is adequately treated.

In chronic pyelonephritis the ureter may bethickened and rigid, but this is exceptional. Inmany cases reflux occurs into ureters which arenormally supple and muscular. In the doubleureter 'experiment', reflux is related to the anatomyof the orifice and this appears to determine the dis-tribution of pyelonephritis. Here, then, is a strongsuggestion that reflux is a primary factor in causa-tion. If we allow it to be a cause, how does itproduce its effect? If the effect were mechanicalone might expect progressive hydronephrosis in allcases, as in the obstructed ones: this does notaccord with the clinical observations. As analternative a mechanical effect upon the renal bloodvessels adjacent to the calyces has been suggested,because in some cases chronic pyelonephritispresents in a severe form without pyuria or ahistory of infection (Hodson and Edwards, I960).Nevertheless the majority of cases have recurrentinfection and the simplest suggestion is that reflux,like obstruction, predisposes to urinary tract infec-tions, while it certainly facilitates the spread ofinfection from the loWer to the upper tract. It isobviously not the only predisposing cause ofinfection and it must be allowed that chronicpyelonephritis can occur without reflux or progressafter reflux has ceased.The issue of the direct mechanical effect versus

predisposition to infection is important in relationto surgical treatment. If the former factor isparamount, reflux-preventing operations are al-ways advisable; if the latter, operation is onlyrequired, when infections are not controlledmedically. Pending-'further evidence, the presentwriter favours the theory of predisposition and,therefore, of limited surgery.

Surgical TreatmentPatients and their diseases are so infinitely

various that it is rare for any controlled observationto establi'sh once and for all the indications for anyoperation: after wild swings of favour and dis-favour a middle course is usually reached as a

result of the imperfectly analysed experience ofmany surgeons. Reflux-preventing operations arestill in the early stages of development; there is noconsensus of opinion and very little publishedevidence of results capable of analysis.The place for operative prevention of reflux is

suggested by the clinical observations recordedabove. Most pressing is the need to prevent re-current or persistent pyuria in children fromprogressing to chronic pyelonephritis with renalfailure, and it is in this group that reflux seemslikely to be a primary factor and here, therefore,is an opportunity for prophylactic surgery. If drugtherapy is failing to control or prevent pyuria, wemay hope by operation to halt the progress of thedisease 'and to preserve what healthy tissue re-mains. Clearly there will come a point at which thedamage is so advanced that in unilateral casesnephrectomy will be better than conservation, andin bilateral cases the risk of surgery will be greaterthan any possible improvement could justify. Inhypertensive cases, no effect on the blood pressurelevels can be expected, though occasionally opera-tion may prevent further deterioration of renalfunction.

In the severe lower urinary tract obstructionsthe primary need is to establish free urinary flow:reflux may then cease spontaneously. Some casesmay have persistent symptoms justifying reflux-preventing procedures at a later gtage but theseare uncommon.

In the neurogenic bladder, where the problem ofreflux has been studied for many years, Hutch haspresented the case for operative prevention, but itis not universally accepted. In the 'spina bifida'bladder, where upper urinary tract changes seemsevere enough to justify surgery, it has been foundthat the place of such conservative measures isvery limited; most cases do better with the skindiversion of the urine by cutaneous ureter-ostomy.

In the mega-ureter-megacystis group it haslong been observed that, in the absence of pyuria,good health may be preserved for very many yearswithout pyelographic deterioration. Recurrentpyuria here, as in the simple atrophic pyelo-nephritis cases, is a good indication for reflux-preventing surgery, but technical difficulties maylimit its usefulness. When dilatation is very faradvanced any operation is hazardous: moreoverreflux prevention is more difficult to achieve, theureter must be narrowed and shortened as well, aprocess which may endanger the blood supply. Inthese advanced cases, therefore, surgery is betteravoided and a 'triple micturition' regime should beadopted to reduce the false residual urine in thebladder.

526 -September i962P

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September i962 WILLIAMS: Vesico-ureteric Reflux 527

Operative TechniqueIt is not intended to discuss the details of tech-

nique in this article and reference should be madeto the original papers. All operations to preventreflux aim essentially at producing a long andstable intramural ureter: in some the continuity ofthe ureter is preserved, in others it is cut acrossand re-implanted. In the first category, the Hutchprocedure (1955) is perhaps most widely prac-tised. After preliminary extravesical mobilization,the terminal ureter is exposed through the openbladder by an incision made upwards and out-wards from the ureteric orifice. The ureter isdrawn up into the bladder lumen and the incisionclosed behind it. The ureter lying within thebladder is quickly covered by ingrowth of mucosaand a long intravesical segment is thus produced.In the Bischoff (I957) procedure the ureter isprolonged downwards towards the bladder neck byburying a strip of mucosa in an operation analogousto the Denis Browne hypospadias operation.

In the author's hands, however, neither of theseprocedures is so reliable or free of complications asthe tunnel re-implant, using a method adaptedfrom Politano and Leadbetter (1958) and Paquin,Marshall and McGovern (I960). The ureter isdivided at its entrance into the bladder and re-

introduced through a long intramural tunnel: it isre-anastomosed with a small everted nipple toprevent stenosis.

Re-implantation is usually accompanied by abladder neck Y-V plasty or -myotomy to reducevoiding pressure.

ResultsIn this type of prophylactic surgery many years

must pass before an assessment can be made.Several different techniques have been employed,with and without bladder-neck surgery, which atpresent makes comparisons difficult or impossible.

Pyelographic changes are naturally slow toappear and for the time being the cessation ofrecurrent attacks of pyuria seems the best evidenceof success. Although figures are not yet available,current impressions are that in this respect refluxprevention is well worthwhile; there have beenfailures, but it is noticeable that these now havepyuria without the pyrexia which was previously afeature, suggesting that the kidney is now lessseverely involved.At this stage it would not be justifiable to advise

operation in all cases of reflux with pyelonephritis,but where chemotherapy fails surgery has some-thing to offer.

REFERENCESBISCHOFF, P. (1957): Mega-ureter, Brit. J. Urol., 29, 4I6.HINMAN, F., and HUTCH, J. A. (I962): Atrophic Pyelonephritis from Reflux, J. Urol., 87, 230.HODSON, C. J., and EDWARDS, D. (I960): Chronic Pyelonephritis and Vesico-ureteric Reflux, Clin. Radiol., II, 219.HUTCH, J. A. (1955): 'The Uretero-vesical Junction'. Berkeley and Los Angeles: University of California Press.MCGOVERN, J. H., MARSHALL, V. F., and PAQUIN, A. J. (I960): Vesico-ureteric Regurgitation in Children, J. Urol.,

83, 122.PAQUIN, A. J., MARSHALL, V. F., and McGOVERN, J. H. (I960): The Megacystitis Syndrome, Ibid., 83, 635.POLITANO, V. A., and LEADBETTER, N. F. (1958): Operative Technique for Correction of Vesico-ureteric Reflux, Ibid.,

79, 932.WILLIAMS, D. I., and STURDY, E. (I96I): Recurrent Urinary Infection in Girls, Arch. Dis. Child., 36, 130.- (1962): Vesico-ureteric Reflux, Proc. roy. Soc. Med., 55, 423.

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