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Between April 1985 and April 1993, 100 consecutive men underwent lower urinary tract reconstruction after cystectomy. An ileal low pressure reservoir using the Goodwin cup-patch principle was combined with an afferent ileal tubular segment. The early complication rate was 11 percent, including 2 postoperative deaths due to septicemia. After a median followup of 27 months (range 3 to 96) 14 patients required surgery for late complications (intestinal obstruction, urethral stricture or tumor recurrence, hernia or ureteral stenosis). A total of 32 patients died of metastatic bladder cancer and 7 died of other causes.The functional capacity of the bladder substitute was increased to the desired 450 to 500 ml. after 3 to 12 months, which was paralleled by improving urinary continence. After 1 year 92 percent of the patients were continent by day and after 2 years 80 percent were continent at night. Upper tract surveillance with excretory urography, renal ultrasound and serum creatinine estimation has s...

Objective To analyse the clinical and therapeutic consequences of early treatment failure after bacille Calmette-Guerin (BCG) instillation therapy for carcinoma in situ of the bladder. Patients and methods A total of 115 patients with carcinoma in situ (Tis) of the bladder were treated by intravesical instillation of living BCG vaccine (Immun BCG Pasteur F). Twenty five patients had primary Tis and 90 had secondary Tis with synchronous or prior superficial papillary tumours. All papillary tumours were resected before instillation of BCG. All patients completed one series of 6 weekly instillations of 120 mg BCG. Results Twenty-two of 25 patients (88%) with primary Tis responded completely, with negative cytology and cystoscopy findings within a median follow-up period of 44 months. Three of the 25 (12%) had cytological evidence of disease within 9 months of therapy and were considered to be early treatment failures. One patient had muscle-invasive bladder cancer, one had Tis and invasive cancer of the prostatic urethra, and the last, in whom a second BCG course also failed, had Tis of both ureters. Seventy of 90 patients (78%) with secondary Tis had a complete response after treatment with BCG, with repeated negative cytology and cystoscopy examinations within a median follow-up time of 40 months. Twenty of the 90 (22%) with secondary Tis had positive cytology within 9 months after BCG therapy and were considered early treatment failures. Five of these 20 had a cystectomy, three for persistent Tis of the bladder and two for a solid urothelial carcinoma of the prostate. The remaining 15 early failures received a second course of BCG. Four of these 15 patients responded and the remaining 11 failed the second course. The 11 failures included two patients with multifocal T1 G3 bladder cancers, four with invasive bladder cancer, two with solid urothelial carcinomas of the prostatic urethra, and three with Tis of the upper urinary tract. Conclusions According to these data, early treatment failure after 6 weekly instillations of 120 mg Immun BCG Pasteur F is an alarming signal which requires immediate re-assessment of the patient to exclude a muscle-invasive bladder cancer or an extravesical carcinoma in situ, either in the upper urinary tract or in the prostatic urethra.

Spheroidal bladder substitutes made from double-folded ileal segments, similar to Goodwin's cup-patch technique, are devoid of major coordinated wall contractions. This, together with the reservoir's direct anastomosis to the membranous urethra, prevents major intraluminal pressure peaks and assures a residue-free voiding of sterile urine. In order to determine whether, under these conditions, an afferent tubular isoperistaltic ileal segment of 20-cm length protects the upper urinary tract as efficiently as an antireflux nipple, 60 male patients who were subjected to radical cystectomy were prospectively randomised to groups in which a bladder substitute was formed together with either of these 2 antireflux devices. An analysis of the results obtained in 20 patients from each group who could be followed for more than 1 year (median observation time 30 and 36 months) showed no differences between the groups in metabolic disturbances, kidney size, reservoir capacity, diurnal and nocturnal urinary continence, the incidence of urinary tract infection or episodes of acute pyelonephritis. Later than 1 year postoperatively, intravenous urograms of the renoureteral units of 25% of the patients with antireflux nipples showed persistent but generally slight dilatation of the upper urinary tracts. This observation was significantly more frequent than it was in patients with afferent tubular segments. Urodynamic and radiographic studies showed that the competence of the antireflux nipples was secured by the raised surrounding intravesical pressure. This, however, also resulted in a transient functional obstruction, and a gradual rise of the basal pressure in the upper urinary tracts was recorded. In patients with afferent ileal tubular segments, contrast medium could be forced upwards into the renal pelvis when the bladder substitutes were overfilled. However, despite raised intravesical pressures, peristalsis in the isoperistaltic afferent tubular segment gradually returned contrast medium back to the reservoir. Our results suggest that the combination of an ileal low-pressure reservoir together with an afferent tubular isoperistaltic limb is at least as good as an antireflux nipple valve. Moreover, the use of the afferent ileal limb makes it possible to resect the distal and often diseased ureters together with the paraureteric lymphatics at a safe distance from the bladder tumor. This avoids also distal ischemic ureteric stenosis and makes possible a simple end-to-side ureterointestinal anastomosis with a small complication rate.

We report on the retrospective analysis of 61 traumatic lesions of the posterior urethra in a fractured pelvis. In collaboration with the orthopedic surgeons, 44 cases could be classified with regard to the nature and mechanism of the pelvic fracture. No direct relationship between the structural integrity of the dorsal ring segment and the urological pathology could be established. However, the mechanism of injury in 35/44 cases with pelvic girdle injuries and urethral pathology appears to be a predominantly lateral compression force. Ten of the 44 patients received a surgical stabilization of the fracture and open splinting of the urethra at the same time. An infection in the area of surgery developed in only one of these patients; however, this cleared up completely under antibiotic therapy and closed suction irrigation. The primarily conservative treatment of urethral lesions (27/61) is compared with primary open splinting or reanastomosis (34/61), which we prefer, with regard to the number of reoperations and late results. The joint conclusion of urologists and orthopedic surgeons concerns a primary simultaneous surgical treatment both of the urethral lesion and the pelvic fracture.

We report on 10 years of experience with an ileal low-pressure bladder substitute combined with an afferent tubular segment following cystectomy in 100 consecutive men. The median follow-up period was 30 months (range 3–108 months), with a 2.5-year minimum in survivors. A total of 42 patients died, 33 of these dying of bladder cancer. The early complication rate was 11%, including 2 deaths due to postoperative sepsis. In all, 14 patients required reoperation for late complications. The reservoir's median functional capacity increased to 500 ml at 12 months and was paralleled by improving continence: 92% by day (after 1 year) and 80% by night (after 2 years). Four ureteric strictures occurred. No coordinated, isolated pressure rise developed in the reservoir during voiding, which was accomplished by pelvic floor relaxation with abdominal straining, if necessary. Raised intraabdominal pressure acted equally on the reservoir and ureters, preventing reflux during voiding. This technique is straightforward, allows radical cancer surgery, and protects the upper tract. The favorable functional results are comparable with those achieved by similar techniques, but meticulous follow-up is essential.

To obtain a better understanding of the prognostic factors influencing treatment outcome after extracorporeal shock wave lithotripsy (ESWL), a multivariate logistic analysis of the data from 246 patients has been undertaken. All of the patients were treated with the Dornier lithotriptor HM-3 for radiopaque renal calculi. Treatment success was defined as stone-free within 3 months of one ESWL session and without adjuvant measures after ESWL. In a first analysis, 210 patients with solitary and multiple calculi without adjuvant measures before ESWL were studied. Of 210 patients, 141 (67%) were free from stones after 3 months). Significant influences on the success rate were body mass index and stone number. In a second analysis only those 160 patients with solitary calculi were considered. In this group, age, body mass index, stone location, stone burden and serum calcium significantly influenced the prognosis. When patients with adjuvant measures were added to the analysis an increasing prognostic importance of the stone burden was seen. In patients with a small to medium stone burden (< 4.0 cm3), the number of stones seemed to be more important than the stone burden. Patients appear to have the best chance for successful ESWL when their body mass index is between 20 and 28, their age is between 40 and 60 years, their stones are in the renal pelvis and solitary, the stone burden is < 1.0 cm3, and when their serum calcium is normal.

A total of 110 patients with upper ureteral calculi was admitted to a prospective trial and randomly allocated to 2 groups: 1 group treated with in situ extracorporeal shock wave lithotripsy (ESWL) and 1 group treated with ureteral manipulation before ESWL. All patients had solitary upper ureteral calculi without urinary infection. The stones had to be smaller than 1 cm. and located more than 2 cm. lateral to the spine. ESWL was performed with the Dornier HM3 lithotriptor. One patient in the in situ ESWL group had to be treated twice because disintegration of the stone was insufficient after the initial treatment session. All other patients underwent only 1 treatment session. Because 16 patients were lost to followup, 94 were evaluable for the analysis of immediate and long-term results. For disintegration of the stones in situ ESWL needed significantly more shock waves (1,844 +/- 639 versus 1,297 +/- 473, p < 0.001) and a higher voltage (19.5 +/- 1.4 versus 18.7 +/- 0.9 kv., p < 0.001). There were no severe complications in either treatment group. At 3 months 44 of 46 patients (96%) after in situ ESWL and 45 of 48 (94%) after ureteral manipulation before ESWL were free of stones. In view of these results it is suggested that uncomplicated upper ureteral calculi (as defined previously) should be treated first with in situ ESWL, thus, avoiding an invasive procedure.

With intensified screening and the use of new diagnostic tools for prostate cancer (prostate-specific antigen, rectal ultrasound, magnetic resonance imaging with rectal coils, etc), the number of newly diagnosed cases of prostate cancer is rising rapidly, whereas the frequency of death due to prostate cancer remains almost stable. It must therefore be assumed that the number of patients in whom a diagnosed prostate cancer will not be fatal is also increasing. Consequently, not every prostatic carcinoma requires radical treatment when diagnosed. Also, it must be concluded that not every man who is a long-term survivor after radical prostatectomy owes his survival to the treatment. Long-term survivorship may reflect the relatively benign biological potential of this disease in an individual patient. Therefore, there is an inherent risk of overtreating patients and this must be weighed against the costs, the postoperative morbidity and the, albeit low, mortality of a radical prostatectomy. Nevertheless, as long as we do not have diagnostic tools which, at an early stage of prostate cancer, enable us to determine whether a carcinoma will ultimately have a fatal outcome, we are obliged to offer radical prostatectomy to younger patients (who have a life expectancy of more than 10 years) as long as they have organ-confined disease.

When a urinary reservoir intended to replace the bladder is made from bowel, it should meet several requirements: good capacity, viscoelasticity and compliance, voluntary control of micturition without residual (infected) urine, a sensation of the filled state and urinary continence. In addition, there should be no major metabolic changes due to malabsorption after bowel resection or due to reabsorption of urinary constituents by the reservoir. In this review several conflicting aspects of bladder reconstruction are addressed: the persisting intestinal peristalsis and urinary incontinence, the volume of the reservoir and its metabolic impact, the bowel segment to be used and the amount that can be resected without the risk of long-term sequelae. Our clinical experience with ileal bladder substitutes in 80 patients underlines the theoretical aspects. After careful instruction, our patients increased the functional capacity of their reservoirs to 500 ml, a precondition for good urinary continence. Provided that the patients were regularly followed-up, the functional, clinical and metabolic results were good. The operative procedure was easy to perform, and no major metabolic sequelae occurred during a maximal observation time of 6 years. Nevertheless, continuing careful follow-up for the detection of potential long-term sequelae, such as disturbances in lipid metabolism or chronic bone demineralisation, are required before definitive statements on the role of intestinal bladder substitutes can be made.

The relationship between renal disease and hypertension has been known for over 150 years [165]. Goldblatt showed that clamping of the main renal artery leads to reversible elevation of the systemic arterial pressure [166, 167], Butler [23] reported a case of unilateral pyelonephritic kidney and severe hypertension in a young patient. Nephrectomy relieved the high blood pressure. On the basis of these results nephrectomies were carried out in many patients with small kidneys and hypertension. However, an analysis of the results showed that hypertension was cured in only 26% of cases [138].

Preoperative axial computerized tomography scans in 163 patients with renal cell carcinoma were reviewed to assess the predictive value for the diagnosis of regional lymph node metastases. Computerized tomography was falsely negative in 5 patients: 2 had metastatic lymph nodes in the renal hilus adjacent to the primary tumor measuring 2 and 2.5 cm., and 3 had micrometastases in nodes of less than 1 cm. In 43 patients enlarged lymph nodes with a diameter of 1 to 2.2 cm. (median 1.4 cm.) were diagnosed on the preoperative scan and this was confirmed at nephrectomy and pathologically. In 18 of these 43 patients (42%) histological study showed metastases of the renal cell carcinoma in the enlarged lymph nodes. In the other 25 patients (58%) the enlarged nodes showed only inflammatory changes and/or follicular hyperplasia. This finding was significantly more frequent in patients with tumor involvement of the renal vein and tumor necrosis (p = 0.0044). We conclude that the sensitivity of preoperative computerized tomography is good for the detection of enlarged lymph nodes in patients with renal cell cancer (95%). However, significant lymph node enlargement frequently may be caused by inflammatory changes, especially in the presence of tumor necrosis. This radiological finding should not be misinterpreted as metastatic disease, unless it has been proved cytologically by fine needle aspiration.

Familiarity with the surgical therapy of adrenal tumors is desirable for any surgeon, regardless to what surgical discipline endocrine surgery is assigned. The basic preconditions for surgical treatment include not only mastery of technique but also knowledge regarding the biology of the individual tumor and experience in dealing with endocrine tumors. Collaboration with radiologists, endocrinologists, and anesthetists is crucial. The surgeon is the last or next to last link in the long chain from diagnosis to therapy.

Among the 153 patients who had undergone cystectomy for primary bladder cancer, the expected deterioration of survival occurred as tumor stage advanced. Of 10 patients with either solitary, small resected intraabdominal metastases or involvement of the urethral margin, none survived longer than 3 years. Another 12 patients were found to have regional lymph node metastases; in 11 of these the positive nodes were located along the iliac or obturator vessels; these individuals also died within 3 years. The 12th patient, who had microscopic metastases in a lymph node from the perivesical fat, was alive with no evidence of disease at 42 months. Among the remaining 131 patients who had no evidence of lymphatic, intraperitoneal or distant metastases, nor tumor at the urethral margin, survival rates were not significantly different for the various pT categories. Our results suggest that patients with deeply invasive bladder carcinoma, but no evidence of extravesical spread (which becomes less likely the deeper the tumor infiltrates) have the same 5-year survival rate as patients with superficially invasive cancer of comparable grade. They also show that lymph node metastases along the pelvic wall portend an unfavorable outcome. However, those who have limited microscopic lymph node metastases, particularly if located in the perivesical fat, may expect a better prognosis as suggested by our patient and the reports in the literature.

Summary 60 patients with carcinoma of the prostate of all clinical stages were investigated by lymphography. Positive lymphographic findings were present in about 50% of the cases. The more advanced tumours were found to metastasise more frequently. Lymphography is indispensable to select patients with clinically limited disease to the prostate for radical prostatectomy. The anatomical display of the iliac and aortic lymph nodes on the lymphogram facilitates the selection of the portal fields in external beam megavoltage radiotherapy.

Radiation therapy with negative pi-mesons (pions) was administered to 36 patients with bladder cancer. According to a Phase I/II study, doses varied from 3000 to 3600 pion rad. Although only two complete responses were achieved among 8 evaluable patients who had predominantly papillary bladder tumors, more promising results were obtained in 22 evaluable patients who had sessile, invasive carcinomas: 19 bladders were cystoscopically and cytologically cleared of tumor after 6 months. Although the side effects during the ambulatory treatment were minimal or tolerable, a steep dose-response curve for late side effects was observed with severe complications in 7 of 11 patients who received 3600 or more pion rad. Cancer 56: 1943-1952, 1985.

Ureteroendoscopy is used by most authors to approach distal ureteral calculi. With increasing experience extracorporeal shock wave lithotripsy (ESWL) of distal ureteral calculi has gained importance. The success rate of 96% in a large series of 264 consecutive patients treated in this manner, confirmed the results of other authors. Excluding women of child-bearing age and very large calculi (over 2 cm), ESWL is a suitable treatment modality for distal ureteral calculi.

Ten pyeloureteral systems in 8 patients (mean age 74 years) with cytologically proved ureteral carcinoma in situ (1 combined with ureteral papillary tumors) were perfused with bacillus Calmette-Guerin via a percutaneous nephrostomy tube. In 4 patients cytology results remained negative after 1 treatment course during an observation time of 18 to 28 months. In 1 patient a papillary tumor persisted while cytology results became negative for carcinoma in situ. Two patients with bilateral disease had repeated perfusion of bacillus Calmette-Guerin until cytology results became negative and they remained negative during observation for 18 months in 1. The other patient had a multifocal recurrence of carcinoma in situ, combined with a stage T1, grade 3 urothelial cancer in the bladder after 12 months and a recurrence of carcinoma in situ in 1 ureter after 24 months. In 1 patient treatment was stopped prematurely after severe septicemia. Although our short-term results are promising, percutaneous perfusion of bacillus Calmette-Guerin for carcinoma in situ of the upper urinary tract should be considered as an investigational treatment modality until long-term results are available.

Diversion and cystectomy have often been considered at length in the literature but little attention has been paid to the relevance and feasibility of these procedures performed specifically in the elderly patient. We describe here the results of urinary diversion in 45 patients of over 70 years of age. Most received an ileal conduit though ureterosigmoidostomy, cutaneous ureterostomy and transureterocutaneous ureterostomy were occasionally performed. In most patients diversion was done as part of a scheme of radical treatment of bladder cancer, but in others it was undertaken for palliative purposes or benign disease. The results of this retrospective study are sufficiently encouraging for us to continue to recommend such apparently extreme measures to patients whose life expectancy may be as much as 9 years. Furthermore diversion provides good palliation in preterminal disease. Moreover in patients with limited life expectancy ureterostomy should be seriously considered as a procedure which is quickly performed and with few early postoperative complications.

Treating a patient with a superficial bladder tumour has responsibilities far beyond performing a good TUR of the tumour. Choosing the optimum treatment policy for the patient depends on the urologist having a wide understanding of the disease, a sound knowledge of bladder tumour pathology and a critical appraisal of all the therapeutic modalities available. Treatment is likely to be prolonged over many years, and the follow-up is an essential part of this treatment. The urologist must set out prepared to use all the available forms of treatment, including intravesical chemotherapy and total cystectomy. If he is not, the patient should be referred on at an early stage, rather than persist with ineffective treatment for this may deny the patient the opportunity of cure.

Twelve experimentally induced blunt renal lesions in pigs were treated either with an alloplastic renal capsule made of semi-elastic Vicryl mesh or with homologous pig fibrin adhesive or with through-and-through chromic catgut sutures as controls. The Vicryl mesh capsule was made by the Ethnor Company (Paris, France) to our specifications. The postoperative isotope nephrograms, which were repeated until the Vicryl had been fully resorbed, showed good renal function in every case. However, when compared to the controls, the kidneys which had been repaired with Vicryl mesh contained considerably less scar tissue at the site of parenchymal rupture and showed neither perirenal fibrosis nor atrophy of the parenchyma in the vicinity of the capsule. Our preliminary results seem to confirm that simple and rapid surgical treatment of moderately severe blunt renal lesions is possible using the alloplastic Vicryl mesh capsule. The method may also be suitable for reconstruction of the parenchyma following multiple nephrotomies, such as for removal of staghorn calculus, and experimental investigations are under way to clarify this point.

When a bladder tumour invades into the muscle it is an ominous prognostic sign: The patient has at best little more than a 50% chance of surviving the disease. The probability of there being nodal or distant metastases at presentation is high and there is limited scope for curative therapy. Of patients presenting with bladder cancer 25%–35% have tumours that are already invading muscle. Most of these will not have clinically apparent metastases, and therefore curative treatment will be attempted. If this is to be achieved then treatment must be radical. However, in many cases there will already be microscopic metastases, and radical treatment of the primary tumour all too often turns out to be but a palliative measure. A thorough assessment of the tumour and full investigation of the patient to search for metastases (see Chap. 5) are essential before radical local therapy. At the present time only those cases that are without clinically detectable distant metastases should be considered for curative therapy.

Between 1978 and 1980, 96 patients with adrenal tumors confirmed at operation or autopsy were investigated by computer tomographic (CT) scanning (Table 1). Hormonally active adrenal tumors suspected on clinical grounds can be confirmed by biochemical investigation. Exact anatomic localization is of course mandatory if surgical treatment is to be undertaken. In our opinion whole body CT scanning is the most useful diagnostic method available. It has the obvious advantage of being noninvasive and in over 90% of cases is the key investigation providing the diagnosis at an early stage. Only in ectopic pheochromocytoma and in carcinoma of the adrenal with extension of invasive growth into surrounding tissues of a questionable degree are selective angiography and hormone measurements on venous effluent indicated.

A comparison was made of blood loss under controlled heparinization and that occurring under normal conditions during electroresection of the prostate. Mean blood loss in patients treated with heparin amounted to 429.4 +/- 524.8 ml. and in the control group it was 391.8 +/- 451.4 ml. The difference is not significant. Therefore, a transurethral operation does not require interruption of anticoagulation therapy in cardiovascular patients.

The highest degree of urinary supersaturation with respect to calcium oxalate monohydrate (COM) and brushite at which secondary nucleation and growth of small amounts of COM and hydroxyapatite (HAP) are inhibited was determined by new and simple methods. There were 39 subjects who produced 24 h-urine collections (11 idiopathic stone formers (ISF), 12 patients suffering from primary hyperparathyroidism (HPT) and 16 healthy controls (HC). These subjects had a moderate calcium and low oxalate intake. The results obtained were compared with the state of urinary saturation and with urine chemistry. The measurements of crystallization conditions with respect to COM were repeated in 26 subjects (11 ISF, 5 HPT, 10 HC) after a dietary oxalate load. In 24 h-urines of HC diluted to 2.4 1/24 h the degree of supersaturation necessary to induce crystallization of COM and HAP was 2-5 times higher than the state of urinary saturation measured under the same test conditions. ISF showed a decreased pyrophosphate concentration and a decreased inhibitory activity to HAP crystallization in their 24 h-urine. The urinary inhibitory activity towards crystallization of HAP showed a positive correlation to urinary pyrophosphate concentration. In the 24 h-urine of HPT hypercalciuria and increased saturation with respect to brushite which reached values to induce HAP crystallization were found. After a dietary oxalate load urinary supersaturation with respect to COM reached values to induce COM crystallization in ISF and HPT but not in HC.

The effects of ureteric torsion on the upper urinary tract were studied in 8 pigs. With 5 pigs the distal ureter was mobilised, torted 1 to 5 times and reimplanted into the bladder. With three pigs the proximal ureter was torted 1 to 3 times and re-anastomosed to the renal pelvis. It was shown that a torsion of 1 or 2 times in the distal ureter does not result in ureteral obstruction. However, as little as 360 degrees torsion in the proximal ureter may lead to dysfunction secondary to mechanical obstruction. Histological examination of the ureter showed ischaemic changes only after multiple torsions.

In recent years interest has become focussed once more on the controversy concerning the best method of supravesical urinary diversion. Indeed, it has become almost impossible to remain familiar with the abundant literature on the subject. In this paper it is unnecessary to deal with the individual basic principles underlying the different types of urinary diversion, since it can be assumed that the members of this audience are already familiar with the concepts involved.

Summary— Seventy-seven patients with carcinoma of the urinary bladder were investigated by computed tomography (CT) and the results compared with those of pathological staging. The overall accuracy rate was 81 % for the estimation of local tumour extension. Perivesical tumour extension was overestimated by CT owing to previous bladder surgery or radiotherapy in about half of the cases. Nevertheless, CT gives unrivalled diagnostic information in advanced tumour invasion. The diagnostic accuracy rate of CT in the detection of lymph node metastases was 89%, compared with 73% for lymphography.

A continent cecoileal conduit to improve rehabilitation after external urinary diversion is described. The isolated cecum functions as a reservoir. The continence mechanism is constructed by intussuscepting the terminal ileum into the isolated cecum to form a nipple, preventing leakage of urine. The kidneys are protected from cecoureterorenal reflux by ureterocecostomies with submucous tunnels. We have used this technique on 4 patients, 2 of whom need no external urinary pouch since the urostoma is absolutely continent. One patient became incontinent 3 months postoperatively and is wearing a conventional bag and 1 patient died. There is no reflux into the kidneys. The upper urinary tract, which is dilated slightly 4 weeks postoperatively, tends to become normal after a few months.

At the beginning of this century it was realised that peristalsis would cause incontinence if bowel was used for augmentation or substitution of the bladder. Trans-section of the antimesenteric border and cross-folding of the intestinal segments (Goodwin's cup-patch technique) is an efficient means of solving this problem and has been successfully used in the Kock pouch. We anastomosed the ileal low pressure reservoir to the membranous urethra in 22 male patients following radical cystoprostatectomy for bladder cancer. The mean observation time was 16 months (range 3-36). The capacity of the bladder substitute increased with time, the average being 450 ml after 6 months. In the first 4 patients with a short (2-5 cm) intestinal segment between the pouch and the urethra, micturition was prolonged, residual urine varied from 50 to 300 ml and bacteriuria was found. Occasional expulsions of several ml of urine were caused by peristalsis within this short tubular segment. In the following 18 patients, the low pressure reservoir was anastomosed directly to the membranous urethra. Micturition was good, with no notable residual urine, no bacteriuria and no paroxysmal urinary incontinence. However, a safety pad is used by half of the patients because once or twice a week, mainly at night, a few ml of urine may be lost. No significant changes in serum electrolytes, bicarbonate or creatinine were noted. With the three different antireflux techniques used, no obstructive or inflammatory changes in the upper urinary tracts were found, although no long-term antibiotic prophylaxis was given.

29 patients with biochemically proven hyperparathyroidism underwent a 201Tl/99mTc subtraction scanning before neck exploration was done. The scanning technique seems not to be reliable for hyperplastic glands in secondary hyperparathyroidism, but in 19 of 21 patients with primary hyperparathyroidism a solitary adenoma was correctly located. This accuracy of 90.5% justifies to investigate all patients with primary hyperparathyroidism with this noninvasive double tracer technique prior to any surgery.