We treated 91 children with neuropathic bladder and 141 refluxing ureters in an attempt to eliminate or ameliorate reflux and preserve renal function. The reflux was 1 and 2 degree in 48 ureters and 3 and 4 degree in 93 according to the classification of Dwoskin and Perlmutter. In the lower degree refluxes we preferred a conservative treatment with intermittent vesical catheterization, appropriate drug use and, much less frequently, transurethral external sphincterotomy. The reflux disappeared in 11 ureters in intermittent vesical catheterization and improved in an additional 17 ureters; in these cases the presence of bacteriuria without clinical significance and renal deterioration was rather common. In the severe refluxes, often associated with recurrent serious episodes of infection and renal damage, we preferred surgical treatment. All together, we performed 49 ureteral reimplantation, 15 transuretero-ureterostomy, 9 cutaneous vesicostomy (18 ureters), 1 bladder augmentation plus sphincterotomy (2 ureters) and 4 urinary diversions (7 ureters). Our primary differentiated approach resulted in cure in 83 ureters (58.9%) and in improvement of the reflux without renal deterioration in an additional 43 ureters (30.5%); failures were present in 15 ureters (10.5%). In our opinion the approach to management of upper urinary tract dilatation without reflux should be more conservative (78 dilated ureters in 46 patients). In these cases it is very important to lower, with conservative measures, the vesical pressure. When this treatment is unsuccessful, a cutaneous vesicostomy or bladder augmentation or a transureteroureterostomy in unilateral cases should be considered.(ABSTRACT TRUNCATED AT 250 WORDS)