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Surgical aspects of primary vesico‐ureteric reflux

The topic of vesico-ureteric reflux remains controversial principally because key elements of information are still required. Recent clinical studies have shown that provided the child is kept free of infection there is no urgency to correct surgically the refluxing ureter.1-3 Even the fundamental importance of prophylactic antibiotics has been questioned recently.4 Therefore, given the reassurance that the child will come to no harm if surgery is delayed, many clinicians feel there is merit in adopting a non-operative approach until there is better understanding of the natural history of reflux. This will allow the development of a rational approach to the problem and perhaps the definition of subgroups where early corrective surgery may be appropriate. One essential question remaining to be answered is how many renal scars represent congenital dysmorphic renal tissue and how many are true acquired scars secondary to infection associated with vesico-ureteric reflux. It is assumed that most renal scars are acquired, but this is based on a theoretical assumption rather than clinical data.4 If the vast majority of scars are congenital then early surgery is not indicated. Alternatively, if most scars are the result of an infection in the first few months of life then early identification of reflux and intensive management aimed at preventing ascending urinary tract infections is required.