The state of the upper urinary tracts has been assessed in 181 adolescents and young adults with myelomeningocele. At the age of 16 years, abnormalities were present in 75 patients (41 per cent); the risk of these complications was related to the extent of the neurological deficit and the presence of a urinary diversion. During follow-up into early adult life, fresh or further deterioration of the upper renal tracts occurred in 48 patients (27 per cent); the pattern of this deterioration was influenced by whether or not previous urinary diversion had been performed.

Management of neuropathic bladder aims to maintain renal function and to secure appliance-free continence; because of recent advances, both objectives are theoretically attainable. Our present scheme of management, based upon preliminary video-urodynamic assessment, is outlined. In the years 1984-1988 we treated 156 children suffering from neuropathic bladder. In 5 per cent of cases the upper renal tracts have deteriorated on treatment; in patients presenting with upper tract dilatation, improvement has been obtained in 68 per cent. A quarter of the patients were considered too generally disabled to achieve appliance-free continence; these have been managed by penile appliance, indwelling urethral catheter or, occasionally, urinary diversion. For three-quarters of the patients, most ambulant, appliance-free continence was the goal; 68 per cent have been managed nonsurgically and 32 per cent surgically. Reliable day-time continence has been achieved in 78 per cent of the former and 86 per cent of the latter, 80 per cent overall.

Experience in undiversion of the renal tract in thirteen patients with a neurogenic bladder is presented. All cases had what was intended to be a permanent diversion and many were grossly handicapped. Upper renal tract deterioration continued after surgery in only one patient. The commonest indication for surgery was the inability to achieve a satisfactory stoma. All were either dry or only damp postoperatively.