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A retrospective experience with preoperative lower tract evaluation, bladder rehabilitation and transplant outcome in patients with major abnormalities of the lower urinary tract is presented. From more than 1000 renal transplants during a 23‐year period, 11 patients required either augmentation cystoplasty (7 cases) or supravesical conduit diversion (4 cases) in preparation for transplantation. The causes of bladder abnormality were neurogenic, dysfunctional voiding, posterior urethral valves, congenital atresia, and acquired contracture in 4, 3, 2, 1 and 1 cases respectively. Lower tract evaluation began with voiding history and voiding cystourethrogram. Patients with incontinence or near zero bladder capacity were managed with supravesical diversion. Continent patients were studied further with serial cystometrograms via percutaneous suprapubic catheters during trials of bladder cycling to study bladder compliance. Continent patients with abnormally high bladder pressure (greater than 75 cm water) and/or low bladder capacity (less than 100 ml) underwent augmentation cystoplasty with intestinal segments. To date, 10 renal transplants have been performed in 8 patients with a cumulative graft survival of 70%, with follow‐up of 13 months to 3 1/2 yr. Two patients with bladder augmentation are awaiting transplantation. The final patient died of suspected pulmonary embolus following bladder augmentation and subsequent development of a bowel obstruction. Additional morbidity consisted of 8 episodes of urinary infection in 6 patients and 1 case of bleeding at the augmentation cystoplasty suture line. These results suggest that, with careful lower tract evaluation, patients with major bladder abnormalities may safely undergo renal transplantation into a rehabilitated bladder in most cases, or into a supravesical conduit when necessary, and can achieve satisfactory graft survival and low morbidity. A prospective plan for pre‐transplant lower tract evaluation is offered.

We evaluated 59 consecutive patients for obstructive voiding symptoms with physical examination, excretory urography, urethrocystoscopy, post-voiding residual volumes, uroflowmetry and transabdominal ultrasound of the prostate. Of the patients 53 underwent transurethral resection of the prostate and 6 underwent open prostatectomy. Followup uroflowmetry was done 4 weeks postoperatively. The best predictor of the actual prostatic weight was transabdominal ultrasound (r equals 0.975), and with digital rectal examination and urethrocystoscopy there was a tendency to overestimate small and underestimate large glands. Symptoms such as nocturia do not allow any conclusions about the size of the prostate. The correlation between post-void residual and specimen weight also is poor and only patients in retention (Foley catheter) have a significantly larger prostate. Preoperative uroflowmetry provides limited information about the prostatic size but, although the difference between the preoperative and postoperative flow rate index is highly significant (p less than 0.001, mean difference test), the correlation between specimen weight, and the difference between preoperative and postoperative flow rate index is not significant. We recommend transabdominal sonography of the prostate, a simple and noninvasive procedure, as a useful adjunct in the preoperative evaluation of patients with benign prostatic hypertrophy. In addition to the fact that only this method provides reliable and reproducible estimations of the weight of the prostate, further information, such as measurement of the post-void residual volume, can be obtained without additional costs or loss of time.

Hypertension is common in patients following renal transplantation. Chronic rejection, native end-stage kidneys, and transplant renal artery stenosis may all contribute to hypertension through the renin-angiotensin system. We believe renin measurements are of interest and that the renin-angiotensin system mediates hypertension associated with native end-stage kidneys and transplant renal artery stenosis. However, our ability to interpret renin levels in transplant recipients is limited. Native bilateral nephrectomy should be considered in the rare transplant recipient with medically uncontrollable hypertension and no transplant renal artery stenosis. Major transplant renal artery stenosis should be repaired. At this time, percutaneous transluminal angioplasty of the renal artery appears to be a reasonably safe and efficacious first-line therapy. Surgical repair may be reserved for failures by the percutaneous method. Longer follow-up and larger numbers are required to determine if this optimism in percutaneous angioplasty of transplant renal artery stenosis is justified.

Skinner and deKernion's datum, like ours, suffers from the fact it is retrospective and not randomized. Therefore, it provides suggestive but not conclusive evidence that lymphadenectomy enhances the chances for survival of a patient with a given stage and grade of renal cell carcinoma. In our study, lymphadenectomy was defined as removal of the regional lymph nodes from the diaphragm to the bifurcation of the common iliac artery on the homolateral side, which was the usual type of lymphadenectomy performed in this retrospective analysis. Because information may be obtained from lymphadenectomy alone which allows a more accurate estimate of the patient's prognosis in 8 per cent of the cases, and because our data suggest a statistical improvement in survival in patients with stage C and D disease if lymphadenectomy is performed, it is recommended that patients undergoing radical nephrectomy for renal cell carcinoma have a regional lymphadenectomy performed at the same time. It is also recommended that a prospective randomized study of the role of lymphadenectomy in patients with a given stage and grade of renal cell carcinoma be undertaken.

Of 505 consecutive renal transplants urologic complications occurred in 4.1 per cent of cadaver, 2.6 per cent of living related, 1.9 per cent of diabetic and 3.8 per cent of nondiabetic allografts. Over-all, patient survival and graft salvage rates were 94 and 83 per cent, respectively. Principles of prevention, diagnosis and management of these complications are discussed. In contrast to prior standards the bladder catheter was removed within 36 hours postoperatively in nearly all cases without any increase in morbidity.

Serum from 59 men with testicular masses was examined for the presence of human chorionic gonadotropin-beta. Results indicate: 1) In patients with testicular tumor human chorionic gonadotropin-beta serves as a sensitive and specific marker of tumor activity with an incidence of 28 per cent. 2) Because human chorionic gonadotropin-beta levels correlate with response to therapy this test will be useful in selecting men for adjunctive irradiation or chemotherapy. 3) Radioimmunoassay for human chorionic gonadotropin-beta is far more sensitive and specific than conventional methods for detecting human chorionic gonadotropin production. 4) After unilateral orchiectomy for carcinoma of the testis elevated serum luteinizing hormone levels are common and may be unrelated to the presence or activity of residual tumor. 5) Human chorionic gonadotropin-beta-producing tumors were associated with increased estradiol and testosterone levels and significantly depressed serum follicle stimulating hormone levels in this series. 6) The prognostic implications of the presence of human chorionic gonadotropin-beta are not yet fully understood.

To document more clearly the effect of selective medical treatment on the course of nephrolithiasis, we surveyed 103 consecutive patients being followed in our stone clinic. Of the patients who initially had existing stones within the kidneys 69 per cent experienced no symptoms while undergoing medical therapy, compared to 96 per cent of those who had no existing stones. In all subjects studied new stone formation was reduced in more than 95 per cent and no new stones were formed in more than 75 per cent. An operation for newly formed calculi was necessary in only 2 per cent of the patients on medical therapy, whereas 58 to 69 per cent of the patients required an operation for new stones before beginning medical treatment.

To evaluate the impact of the percutaneous removal of renal calculi we compared 41 patients who had undergone open renal surgery to 88 patients who had a one- or two-stage percutaneous nephrostolithotomy for symptomatic urolithiasis. The two groups were similar with regard to stone size, stone location, treatment success, and complication rates. However, for patients with calculi 2.5 cm or smaller in diameter, the percutaneous procedure resulted in lower postoperative morbidity, more rapid convalescence, less hospital cost, and greater patient satisfaction. For patients with calculi larger than 2.5 cm in diameter, the percutaneous approach was slightly more expensive than open surgery but resulted in a markedly shortened convalescent period. In our experience, percutaneous nephrostolithotomy performed in a single stage under assisted local anesthesia was the most efficacious and least expensive of the percutaneous approaches.(JAMA 1985;254:1054-1058)

Any patient with gross hematuria or pelvic fracture should be evaluated by a cystogram after urethral injury has been ruled out. A knowledge of the high incidence of associated injuries is mandatory to the complete care of these patients. Surgical repair, drainage, and urinary diversion should be performed in the vast majority of patients. Nonoperative management should only be considered in the female patient with a small extra-peritoneal rupture and no other indications for surgery.

A prospective, single-blinded study was done to determine the ability of serial 99mtechnetium-diethylenetriaminepentaacetic acid scans to diagnose renal allograft rejection. Among 28 transplant recipients 111 renal scans were obtained 1 day postoperatively and every 3 to 4 days thereafter for 3 weeks in all patients retaining an allograft. Computer-generated time-activity blood flow curves were analyzed semiquantitatively for the 1) interval between curve peaks of the allograft and iliac artery, 2) renal transit time and 3) renal washout of radionuclide. Excretory function was assessed by degree and interval to appearance of radionuclide in the calices and bladder. Deterioration of renal blood flow and excretion compared to the initial scan was considered rejection. Of 52 scans performed during clinical rejection 47 (90.4 per cent) were interpreted as showing rejection (sensitivity). Of 53 scans interpreted as showing rejection 47 (88.7 per cent) were positive for clinical rejection. The remaining 6 patients (initial false positive results) suffered clinical rejection within 24 to 72 hours. We conclude that 99mtechnetium-diethylenetriaminepentaacetic acid renal scans are useful in the differential diagnosis of renal allograft dysfunction.