Complete bilateral malignant ureteral occlusion was relieved by introduction of a nephrostomy tube, first into the right kidney and 3 weeks later into the left kidney. When the second nephrostomy tube was introduced, the right kidney had recovered sufficiently to eliminate the uremic environment and to serve as control organ. This offered the rare opportunity to study in man the function of the kidney following chronic obstruction, independent of systemic influences on tubular function, such as uremia, secondary hyperparathyroidism and the state of hydration of the patient. In the left (‘experimental’) kidney glomerular filtration (GFR) was markedly reduced and fractional and, on occasions, absolute excretion of sodium, calcium and magnesium exceeded simultaneous values in the right (‘control’) kidney. During hypotonic saline and mannitol diuresis, free water clearance relative to GFR and calculated distal delivery of sodium in the experimental kidney exceeded control values by more than twofold and more than threefold, respectively. Distal tubular function, as judged by the ability to generate free water and exchange sodium for potassium, appeared spared. These data suggest that in obstructive uropathy in man there is an intrarenal resetting of the glomerulotubular balance resulting in diminution of proximal tubular reabsorption of sodium, water and probably also divalent cations, which leads to enhanced tubular flow (‘overperfusion’) in the relatively intact distal nephrons. This change in glomerulotubular balance is brought about by an undefined mechanism, initiated by ureteral occlusion or by reduction in nephron population or their combination, and contributes to the profuse natriuresis and diuresis seen following the relief of ureteral occlusion.

An operative procedure for the repair of primary vesicoureteral reflux in 51 children (83 renal units) is described, its merits are discussed and its advantages are stressed. Reflux was prevented in 90.2 per cent of the children and 74.5 per cent of the patients remained free of infection. No obstruction has occurred in our series as compared to a 5 per cent incidence rate in cases of ureteroneocystostomy. Our procedure is not recommended for megaureters with reflux or for recurrent vesicoureteral reflux.

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