Long urethral strictures remain one of the hazards of modern urology. Reconstructive operations with scrotal skin suffer a high rate of recurrent stricture. To avoid complications, meshed split thickness skin graft or foreskin was used to construct a neourethra. In stage 1 split thickness skin graft is harvested and transplanted along the opened urethra. In stage 2 the neourethra is formed 8 to 12 weeks later. Since 1977 mesh graft urethroplasty has been performed in 96 patients using meshed foreskin (76) or split thickness skin grafts (23). In all but 1 patient excellent anatomical and functional results were achieved regardless of which type of graft was used. This technique was most useful in exceedingly long or problematic strictures, for example in spinal cord injury patients.

Urinary tract complications apparently resulting from radiation therapy for carcinoma of the cervix can occur as long as 30 years after cessation of such treatment. Patients generally present with urinary incontinence and often are treated by standard operative methods that usually are unsuccessful. Incontinence is related to bladder fibrosis, urethral nonfunction and vesicovaginal fistuLa formation, and may be accompanied by bilateral ureteral obstruction. Of 11 patients with late complications of radiotherapy 4 had upper tract deterioration, 4 had vesicovaginal fistulas, 5 had an incompetent urethra aNd 9 had a fibrotic, noncompliant areflexive bladder. Treatment was aimed at providing adequate low pressure storage capacity and consisted of augmentation cystoplasty in 5 patients, repair of the fistula in 4 and correction of urethral dysfunction in 5. Women who complain of incontinence and/or irritable bladder symptoms with a history of radiotherapy for cervical carcinoma should be evaluated for fistuLa formation, urethral incompetence, and detrusor areflexia and fibrosis before treatment is done.

Sphincterotomy was the treatment of choice in spinal cord injured patients with reflex bladder activity and detrusor sphincter dyssynergia after World War II. However, nowadays the conversion of a spastic bladder into a low pressure reservoir by medication or operatively has become a more favourable bladder management. Only in quadriplegic patients who are not able to perform self-catheterization, this treatment modality seemed to be an alternative. With twelve o'clock sphincterotomy, urodynamic parameters of the lower urinary tract can be brought to favourable measures (leak-point, residuals). However, the reoperation rate for the maintenance of these urodynamic results is high (57%). Laser sphincterotomy seems to be advantageous in this respect, as it reduces the need for resphincterotomy significantly. Additionally, 14% of the patients needed operations, which made condom fixation possible. Upper tract could only be preserved if sphincterotomy is done early enough. Patients who do not empty completely while in the wheelchair are at risk to develop a hydronephrosis.

One hundred eighteen patients consecutively admitted to a University Rehabilitation Program entered a protocol study of urologic management. Bladder pressures were kept below 30 cms/H,O by urologic treatment. Serial urodynamic, radiographic, bacteriologic, and endoscopic studies were performed at regular intervals. Eighteen patients have been lost to follow-up; 100 patients were followed for a mean 25.4 months with a range of 6 months to 56 months. There were 105 patients with lesions superior to thc sacral segments and 13 patients with low lesions. At discharge 11 patients were voiding normally, 105 were continent on an intermittent catheterization (1C) protocol, and 2 patients used condom catheter drainage following sphincterotomy. Bacterial cultures and urinalysis data showed little or no relationship to clinical outcome, and treatment for 387 weeks by antimicrobial agents was not associated with discernible benefit as opposed to no treatment. Five patients developed bladder calculi, and five developed unilateral epididymitis. Bladder pressure was rrlatively easy to control following spinal cord injury, a result which suggests that high bladder pressure is not a direct result of the neural injury, but rather an evolutionary change as a result of bladder and urethral interactive dysfunction.

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