SUMMARY Seventeen patients have been treated by a new type of urethroplasty, which embodies an inverted U‐shaped flap of scrotal skin. It has certain practical advantages. It is technically easy to perform and can be used to deal with a stricture of any length from one end to the other of the urethra.

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More than 40 years have passed since the operation of transurethral resection of the prostate was first devised, yet even now its place in the treatment of benign enlargement of the prostate is disputed. In Britain today there are many urologists who limit their use of the resectoscope to annular stenoses of the neck of the bladder, or the palliative relief of an obstructing carcinoma. For a benign adenoma of any size most surgeons still prefer a retropubic or transvesical enucleative operation. There are several reasons for this. On the one hand there is a general belief that transurethral resection is necessarily incomplete in respect of removal of the adenoma, and so has to be done again in many cases; whilst on the other hand there is a widespread opinion that transurethral resection carries a very high risk of perforation, stricture and post-operative incontinence-a risk which, although not unreasonable in the hands of the experts, becomes unacceptably high when surgeons are learning how to do the operation.In the last decade the senior authors of this paper have gradually come to be performing more and more transurethral resections in gradually larger and larger glands, and their assistants have been learning and doing a substantial proportion of these operations in the course of their training. In view of the criticisms which are so often voiced, we have felt it appropriate to examine our performance and see whether we are justified in continuing to regard transurethral resection as the operation of choice for the benign prostate of all but the largest size. (Table I) 1,135 patients with a pre-operative diagnosis of benign enlargement of the prostate were admitted or transferred to our care between October 1964 and December 1971 at The London and S t Peter's Hospitals. 935 had a transurethral resection; of these, 198 underwent Millin's retropubic prostatectomy, and 19 had a transvesical procedure. These last 2 are grouped together for the purposes of this survey as "open" operations, and the former are referred to as TURs. Composition of the Series Selection of CasesIn the period covered by this survey it was our policy to offer some type of prostatectomy to virtually every patient who had retention or intolerable symptoms. If a patient was able to sit up in bed without incapacitating breathlessness he was accepted for operation, thanks to the use of epidural or spinal anaesthesia. Hardly any patients were left with an indwelling catheter or a suprapubic cystostomy. In practice only terminally ill patients or those who were completely demented were refused an operation. 1Read at the 28th Annudl Meeting of the British Association of Urological Surgeons in Newcastle upon Tyne, July 1972. 93

In a prolonged follow-up of a series of 416 patients at The London Hospital Stone Clinic it was found that recurrence could still occur even as long as 10 years after the first stone, though this risk decrease slowly year by year. Recurrence is seldom related to hypercalciuria or urinary infection except when infection is caused by or associated with B. proteus in women. Claims for the value of any form of therapy for stone disease must be evaluated against the background of the natural history of lithiasis.

Two years ago we described a method of urethroplasty using an inverted U-shaped scrota1 flap (Blandy et al., 1968) and referred to a preliminary series of 17 cases in whom the results seemed to be promising. We now report a larger series, comprising 70 patients, of whom 51 have completed both stages of the operation, and 21 have been followed for more than 3 years. During this time we have met with certain difficulties and complications as a result of which the original technique has been slightly modified. Composition of the Present Series.-The ages of the 70 patients in this series are shown in AGE OF PATIEhTS AT TIME OF URETHROPLASTY 20 NU. ui patients 10 Age 20 30 40 50 60 70 80 90 FIG. 1 Figure 1, where it will be seen that the majority are middle-aged but that the operation has been used in children and in the very old: our youngest patient was 7, the oldest 88.The zetiology of the strictures operated upon in this series is shown in Table I: the majority were the result of urethritis or injury. The length of history of these strictures varied considerably ( Table 11). Most of the inflammatory strictures belonged to an older generation whose gonorrhoea had been acquired many years previously, whilst those with short histories resulted from trauma or surgical misadventure. Only a small proportion of patients attending either The London Hospital or St Peter's Hospital with stricture were considered suitable for urethroplasty : their strictures were difficult to dilate, needed very frequent dilatation, were complicated by abscesses, infection, or fistulze, or they occurred in men too young to be condemned to a lifetime of frequently repeated instrumentation. The majority of men with urethral strictures were, and will continue to be, treated by regular bouginage (Devereux and Burfield, 1970). Figure 2 gives the time relationship between the first and second stages, and the follow-up of these patients. It will be noted that relatively large numbers of patients were operated on in 1965 and again in 1969 : these represent patients with particularly bad strictures selected from amongst those attending the outpatient clinics at The London and St. Peter's Hospitals.