F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
401
be remembered (see page 356) that the incidence of vesico-ureteric reflux of the 476
patients admitted to Stoke Mandeville immediately or within the early days after injury
and treated with intermittent catheterization was only 4-4 per cent (21 patients), 15 had
unilateral and 6 bilateral reflux (Guttmann & Frankel, 1966). All these patients had been
infected before the cystogram at which reflux was demonstrated, and in 6 of them the
reflux was associated with hydronephrosis. Table 21 demonstrates the lapse of time
between cord injury and first diagnosis of the reflux.
These findings show contrary to my previous observations described in 1963, that
reflux can, in fact, develop already in the early months in the presence of bladder dysfunc
tion as a result of ascending infection of the vesico-ureteric junction and the ureter itself,
associated with alterations of shape and size of the bladder. Although reflux may occur
in bladders of any shape or capacity, this was found particularly as a result of long
standing suprapubic or urethral drainage, leading to fibrous contracture of the bladder
(Fig. 161).
Treatment
The treatment of vesico-ureteric reflux is still a matter of discussion. It can be divided
into conservative and surgical procedures. From all the experiences gained it can be
concluded that there is no procedure employed for the treatment of this complication
which has proved consistently or permanently successful. This applies in particular to
the various anti-reflux surgical procedures advocated, be they corrective procedures at
the vesico-ureteric junction such as introduced by Hutch (1952, 1963), Politano &
Leadbetter (1958), Bischoff (1962), Winter (1966), or neurosurgical procedures such as
posterior or anterior rhizotomies (Brendler
et
a/., 1953), sacral nerves neurectomy
(Scheibert, 1954), resection of the nerves at the vesico-ureteric junction (Bors, 1955;
Ivatsu, 1961), intrathecal alcohol block or urinary diversions such as cutaneous ureteros-
tomy, ileal conduit (Bricker, 1950) or colonic loop. Walsh (1967) reported about our
experience in 10 patients with ileal conduits most of them done elsewhere. None was free
of troubles, the commonest one being skin trouble. One patient who had an ileal conduit
done at Stoke Mandeville Centre died afterwards from ileus and peritonitis, another
with an ileal conduit done elsewhere, a man of 67, had to be operated upon because of
bowel obstruction due to adhesions around the operated site. There is by no means
general agreement amongst urologists themselves as to the most suitable method of
urinary diversion. Cosbie Ross (1967) considered diversion of urine by ileal loop to be
indicated only in stage III of ureteric reflux with progressive renal deterioration. Alter
natively, he recommended a segregated colonic loop, especially when only the left kidney
was functioning. In favour of this operation he considered the fact that a prolonged
dissection of the mesocolon was unnecessary, furthermore the anastomosis between the
iliac colon and upper rectum gave less rise to the development of postoperative ileus than
following ileal loop diversion. However, he condemned uretereo-colonic anastomosis
in the presence of associated defects in the control of defaecation. Retief & Key (1967)
in accordance with observations of Cibert
et al.
(1958), Pelot & Voestlin (1961), Pelot
(1963)5 Vernet
el al.
(1960) and True
et al.
(1962), preferred in their few cases of urinary
