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The vesico-psoas hitch usually has been advocated for the management of lower ureteral injuries or failed ureteroneocystostomies when there is inadequate ureteral length. Since 1966 we have used this technique in 36 children with obstructed megaureters. There has been no postoperative obstruction and reflux has been prevented in all but 1 case. The vesico-psoas hitch has proved to be an important adjunct in the repair of the obstructed megaureter, since it allows the construction of a long intravesical ureter, thus avoiding reflux, and locates the new ureteral hiatus in the bladder at a fixed point so that ureteral kinking and obstruction are prevented.

Fifty-two male patients were studied prospectively to assess the results of direct vision urethrotomy in the treatment of urethral strictures. The prognosis was found to be significantly worse in those patients who had received extensive previous treatment. A catheter is recommended for at least 3 days and for 4 weeks in patients who have had minimal previous treatment or who have impaired detrusor function. The use of a urine flowmeter is essential for determining the success of treatment and stricture recurrence. Measurement of the recurrence-free period is important for assessing progressive improvement following repeat urethrotomy and for determining which patients cannot be cured by direct vision urethrotomy.

We report a case of spontaneous intraperitoneal rupture of the bladder. Followup urodynamic studies revealed unsuspected detrusor bladder neck dyssynergia that was treated by unilateral endoscopic bladder neck incision. The pathogenesis of spontaneous bladder rupture is discussed and we recommend urodynamic evaluation in all cases of spontaneous rupture.

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There is renewed interest in the management of advanced RCC, with data supporting cytoreductive nephrectomy with systemic biological therapy. These results confirm that such patients with or without metastatic disease can survive for a considerable period with no aggressive surgical or systemic measures, and such intervention may offer no significant advantage in outcome and survival over supportive treatment alone.

Abstract. The hypothesis is advanced that the functional urethral obstruction found in neuropathic states is due, in part at least, to urethral supersensitivity following sym pathetic decentralisation.A simple postural test for this condition is described. By its use it has been shown that urethral denervation occurs not only in disorders of the central nervous system but with peripheral damage such as may result from rectal excision and hysterectomy.In some cases with functional urethral obstruction, attributable to supersensitivity of the urethra, no neurological abnormality has been found. These may be examples of localised visceral neuropathy.Key words: Neuropathic urethra; Urethral supersensitivity test; Urethral obstruction.BLADDER function reflects the relationship between intravesical pressure and urethral resistance. In disorders of the nervous system poor bladder emptying is more often due to urethral obstruction than to subnormal voiding pressures. The bladder, however, was almost exclusively the focus of attention in these cases until less than 50 years ago. Then Watkins (1936) reported finding obstruction at the level of the membranous urethra in patients with lesions of the sacral segments. Internal membranous urethrotomy (loosely called 'external sphincterotomy') was introduced for the relief of these cases (Ross et ai., 1957), and whilst it proved effective, the mechanism of the obstruction was obscure (Gibbon, 1973).About the same time Emmett et ai. (1948) noted the common occurrence of membranous urethral obstruction in spastic paraplegics and suggested its relief by subarachnoid alcohol block, sacral rhizotomy or pudendal neurectomy on the assumption that contraction of the striated muscle of the urethra or pelvic floor was responsible. Electromyography has given some support to this concept (Diokno et al., 1974). Rhizotomy, whether chemical or surgical, gave effective relief and the accompanying loss of reflex bladder activity could be compensated for, except in cervical lesions, by abdominal straining or manual compression. Unfortunately, the inevitable impotence produced by sacral rhizotomy was unacceptable to many patients, and pudendal neurectomy as an alternative therefore had a vogue. This operation proved unreliable, however, which is not surprising in view of the repeated demonstration that the internal pudendal nerves do not supply the external urethral sphincter (Gil-Vernet, 1964; Donker et ai., 1976). On the other hand, impotence was an unexpectedly common complication and one which has not even yet been adequately explained. Iilternal membranous urethrotomy, aimed at dividing the striated urethral sphincter, has now become firmly established as the procedure of choice for these cases (Ross et ai., 1976) as well as for the sacral segment cases for whom the operation was originally described.The mechanism of neuropathic urethral obstruction, particularly in conus 222PARAPLEGIA lesions, has been the subject of research at Southport for the past 30 years. An obvious clue was the trad...

Endoscopic bladder transection has been performed in 30 patients with symptoms as a result of unstable bladder activity. The symptomatic improvement produced justifies the use of this new operation which should replace the open procedure.