Blackwell Science, LtdOxford, UK
BJUBJU International1464-4096BJU International
90
3004
UROLOGICAL COMPLICATIONS OF RENAL TRANSPLANTATION
E.H. STREETER
et al.
10.1046/j.1464-4096.2002.03004.x
Original Article627634BEES SGML
BJU International (2002), 90, 627–634
The urological complications of renal transplantation: a series
of 1535 patients
E.H. STREETER*, D.M. LITTLE†, D.W. CRANSTON*† and P.J. MOR RIS†
*Department of Urology, and †Oxford Transplant Centre, Churchill Hospital, Oxford, UK
Objective To determine the incidence of urological com-
plications of renal transplantation at one institution,
and relate this to donor and recipient factors.
Patients and methods A consecutive series of 1535 renal
transplants were audited, and a database of donor and
recipient characteristics created for risk-factor analy-
sis. An unstented Leadbetter-Politano anastomosis was
the preferred method of ureteric reimplantation.
Results There were 45 urinary leaks, 54 primary ureteric
obstructions, nine cases of ureteric calculi, three blad-
der stones and 19 cases of bladder outlet obstruction at
some time after transplantation. The overall incidence
of urological complications was 9.2%, with that for uri-
nary leak or primary ureteric obstruction being 6.5%.
One graft was lost because of complications, and there
Introduction
Major advances have been made over the last two decades
in renal transplantation. While formal research pro-
grammes concentrate on the associated immunology
technical issues concerning the procedure have almost
been obscured. Despite this, early graft failure is often for
technical reasons, and urological complications remain a
major source of morbidity and occasional mortality. The
incidence of these complications is discussed, and causes
in their development evaluated. Recent advances in surgi-
cal technique are noted with speculation about their
possible effect for the future.
Patients and methods
All cases of renal transplantation from the inception of our
unit in January 1975 to May 1998 were included in the
study; the series comprised 1535 consecutive renal trans-
plants, in 1292 patients (mean age 43.0 years at surgery,
range 11–75; male : female ratio of procedures 1.52 : 1,
with 1386 cadaveric transplants and 149 living-related or
Accepted for publication 26 July 2002
© 2002 BJU International
doi:10.1046/j.1464-4096.2002.03004.x
were three deaths associated directly or indirectly with
urological complications. There was no association
with recipient age, cadaveric vs living-donor trans-
plants, or cold ischaemic times before organ reimplan-
tation, although the donor age was slightly higher in
cases of urinary leak. There was no association with
kidneys imported via the UK national organ-sharing
scheme vs the use of local kidneys. The management of
these complications is discussed.
Conclusion The incidence of urological complications in
this series has remained essentially unchanged for
20 years. The causes of these complications and tech-
niques for their prevention are discussed.
Keywords renal transplantation, complications, aeti-
ology
unrelated donor transplants). All patients were followed
up at the centre for at least 1 year after surgery. Data on
the incidence and nature of urological complications were
accumulated by retrospective case-note analysis.
Several operating surgeons were involved, of consultant
or specialist registrar grade. In all but three procedures
a Leadbetter-Politano ureteroneocystostomy was used,
involving the passage of the ureter through a submucosal
tunnel fashioned via a separate anterior cystostomy. Two
cases required primary uretero-ureterostomy for a short
donor ureter. In one procedure the ureter was implanted
into a bladder caecoplasty. Ureteric stents were used
rarely. A Foley catheter was used to drain the bladders of
all patients for at least 5 days after surgery. Daily serum
biochemistry was combined with careful clinical observa-
tion to monitor graft function. In recent years it has
become standard practice to image all grafts by ultra-
sonography soon after surgery, usually in the first or
second day, to detect early signs of vascular or urological
complications. This succeeds the former practice of imag-
ing only in those with suspected graft dysfunction. All
patients since 1982 have been treated with cyclosporin-
based immunosuppressive regimens. The 273 cases before
this were treated with a combination of azathioprine and
prednisolone, with high-dose prednisolone giving way to
the current low-dose schedule in 1978.
627
628 E.H. STREETER et al.

For purposes of chronological comparison, data are
subdivided into 1975–86 (transplants 1–600), 1986–91
(transplants 601–1000), and 1991–98 (transplants
1001–1535). Data relating to the early part of the series
were published previously [1,2].
Results
Urinary leak
There were 45 cases of urinary leak, with a further three
recurrent cases after a first operative repair. The median
(range) time to onset was 29 (0–275) days, with all but
two cases before 120 days. No grafts were lost, although
one death could be directly attributed to subsequent sep-
sis. A summary of the position and timing of urinary leaks,
with the subsequent management, is shown in Table 1.
Minor leaks occurred early in four cases and were
treated with re-catheterization or with observation alone.
Three cases were managed initially with nephrostomy
insertion, although two of these proceeded to ureteric
reimplantation.
Thirty-seven cases required surgery; two with direct
perforation of the ureter at procurement or implantation
were sutured over. Three cases of vesico-ureteric leakage
in the absence of necrosis were treated with open stent
insertion. The degree of ureteric vascular compromise and
necrosis dictated the use of reimplantation (eight cases),
uretero-ureterostomy (three), uretero-pyelostomy (15) or
Boari flap (two). Two cases of leakage through the anterior

Table 1 Urinary leakage and obstruction; incidence and management

Location (n) Median (range) onset, days Treatment (n)

Leakage
No site identified (1) 14 Death from cardiac arrest (1)
Upper ureter/collecting system (5) 24 (0–49) Conservative (1)
Retrograde stent (1)
Open closure of defect in renal pelvis (1)
Open closure of renal pelvis and stent (1)
Uretero-ureterostomy (1)
Lower ureter (14) 21 (0–266) Nephrostomy (1)
Open drainage (1)
Open stent insertion (3)
Reimplantation (3)
Native ureteropyelostomy (2)
Uretero-ureterostomy (3)
Boari flap (1)
Bladder (6) 47 (0–357) Prolonged catheter drainage (3)
Percutaneous drainage (1)
Repair of vesical defect (2)
Ureteric necrosis (19) 35 (7–70) Reimplantation (5)
Native ureteropyelostomy (13)
Boari flap (1)
Obstruction
Upper/PUJ (10) 350 (35–1610) Antegrade stent (4)
Ureteric dilatation (1)
Pyeloplasty (1)
Division of obstructing vessel (1)
Native ureteropyelostomy (3)
Middle (10) 56 (1–1120) Antegrade stent (3)
Retrograde stent (1)
Open exploration (1) and stent (1)
Native ureteropyelostomy (2)
Uretero-ureterostomy (2)
Lower/VUJ (33) 110 (1–2800) Nephrostomy (2)
Antegrade stent (6)
Balloon dilatation (2)
Endoscopic excision of suture (1)
Native ureteropyelostomy (2)
Reimplantation (20)

© 2002 BJU International 90, 627–634

 UROLOGICAL COMPLICATIONS OF RENAL TRANSPLANTATION
Table 2 The incidence of major complications with time
Ureteric obstruction, %
Transplant Urinary Ischaemic Other
number leak, % Total stricture causes
1–600 2.80 4.33 1.83 2.50
601–1000 2.00 2.50 2.25 0.25
1001–1535 3.73 3.36 2.24 1.12
Total 2.93 3.52 2.08 1.43
cystotomy required re-suturing of the bladder. Two cases
required repeat reconstruction, with one leak persisting,
being treated with nephrostomy and antegrade stenting.
An additional operative failure was treated with ante-
grade stenting. Table 2 shows the relative incidence of
urinary leakage over the study period.
Primary ureteric obstruction
Ureteric obstruction with no external compression
occurred in 46 patients; there were two groups, i.e. those
with an ischaemic origin, becoming clinically evident
usually at 1–18 months (32; median 6 months, range
0.5–47), and those where anatomical or technical factors
were likely to have been more significant, evident in the
early recovery period (14; median 3 days, range 0–11).
There was no graft loss but there were two deaths, one
caused by nephrostomy-related haemorrhage and the
second with persistent stricturing, ureteric fistulation and
sepsis. There were seven further cases of obstruction
by lymphocoele (six) or obstructing blood vessels (one) in
the early part of the series. Table 2 shows the relative
incidence of ureteric obstruction over the study period.
The site and timing of obstruction again influenced
management (Table 1). Antegrade stenting was used
primarily in 19 cases, although five of these required sub-
sequent operative procedures. Two distal strictures were
successfully percutaneously dilated, but an attempt to
remedy a pelvi-ureteric obstruction in the same way was
unsuccessful, requiring surgery. One case of a very limited
stricture at the ureteric orifice was successfully managed
endoscopically via local excision.
An open operation was required in 33 cases. The ureter
was unkinked in two cases and an overlying blood vessel
divided in one. Proximal obstruction was treated by native
ureteropyelostomy (five) or pyeloplasty (one). Distal
obstruction favoured ureteric reimplantation in the 20
cases with a short segment stenosis, although one was
later revised to a uretero-ureterostomy. Two further
uretero-ureterostomies and one uretero-pyelostomy were
performed for longer or mid-ureteric stenoses.
© 2002 BJU International 90, 627–634
62 9
Transplant renal calculi
There were six cases of obstructive ureteric calculi, with
three further cases not associated with obstruction.
The median (range) time to presentation was 150 (56–
1280) days. In the three unobstructive cases there was no
intervention. Of those with obstruction, one was treated
with nephrostomy insertion followed by percutaneous
shock wave lithotripsy, three underwent successful percu-
taneous nephrolithotomy and one proceeded to open
nephrolithotomy having failed the percutaneous
approach. In the final case both endoscopic and percuta-
neous attempts failed to remove the calculus, with graft
function being lost, resulting in a nephrectomy.
BOO
Seventeen patients developed significant BOO during the
course of the study, about half presenting within the first
month of transplantation. The causes were bladder neck
stenosis (five), urethral strictures (four), BPH (five) and
undetermined (three). Patients were treated with bladder
neck incision (five), optical urethrotomy (two) urethral
dilatation (two), TURP (five) or observation (three). There
was one death after TURP caused by suprapubic catheter-
ization, urinary extravasation and sepsis.
Haematuria causing obstruction
Six cases were recorded; of these, four occurred within
10 days of transplantation, causing hydronephrosis in two
catheterized patients (days 2 and 3) and clot retention in
two patients (days 6 and 8). One patient with hydroneph-
rosis required cystoscopic irrigation, whilst the others
were treated conservatively.
There were two cases each of ureteric obstruction
caused by haemorrhage after percutaneous needle biopsy
at 12 and 27 days, the latter associated with clot reten-
tion. Both were treated with nephrostomy.
Neoplasia
Two patients developed TCC of the bladder, both several
years after transplantation. One had invasive disease, rap-
idly metastasising and leading to death. The other had
superficial disease managed endoscopically. There was one
case of nephrogenic adenoma at 4.5 years, excised endo-
scopically, recurring 2 years later and requiring two fur-
ther cystoscopic resections. One patient who had had
bilateral nephrectomies 3 and 4 years before transplanta-
tion for metachronous adenocarcinomas had widespread
metastatic recurrence at 6 months and died.
630 E.H. STREETER et al.

for the origin of the kidney, or cadaveric vs living donors.

Miscellaneous complications
Bladder calculi were found on three occasions, at 8
months to 4 years after surgery; in all three cases the cal-
culi were removed cystoscopically. One further patient
underwent cystoscopy for an ultrasonographically diag-
nosed bladder mass, which was found to be a protruding
suture at the ureteric orifice, and which was excised
endoscopically.
Association of complications with donor factors
The characteristics of the renal donors from the last
8 years were analysed to ascertain whether causal factors
could be identified in the development of urological com-
plications. In particular, the origin of the kidney, i.e.
locally retrieved vs imported via the UK organ-matching
scheme, the donor’s age and the cold ischaemic time were
recorded (Table 3). There were no significant differences
The donors were slightly older in cases with urinary leaks
than in the overall population. There was a paradoxically
shorter cold ischaemic time for ischaemic strictures.
Discussion
Urological complications remain a major source of mor-
bidity and occasional mortality in renal transplantation,
despite a reduction in their incidence of at least half over
the last 30 years. Table 5 [3–17] shows a comparison of
the present with contemporary series including > 400
transplants. Similarly, the graft loss and related mortality
has decreased, from 22% associated mortality and 54%
graft loss in 1981 [3] to 3.3% and < 1%, respectively,
reported here. The cause of these complications is of
course multifactorial, and comparison of internationally
published series shows wide variation among centres with
different practices. We consider possible causal factors

Table 3 Complications compared with donor factors

Variable Total (535) Leak (20), % Ischaemic stricture (12), %

Method of retrieval
Imported 149 4.7 3.4
Local 386 3.4 1.8
Donor
Cadaveric 55 5.4 1.8
Living-related 480 3.5 2.3
Mean (SD):
donor age, years 41.25 (14.7) 45.8 (11.0)* 40.3 (14.5)
cold ischaemic time, min 1517 (488) 1650 (598) 1064 (286)†

*P < 0.05; †P < 0.001.

Table 4 Comparative large series of renal transplants (1981–2001)

Ref. Year Number of transplants Vesico-ureteric anastomosis Ureteric stents Urinary leaks, % Ureteric obstruction, %

[3] 1981 1000 L-P No 5.6 7.5

[4] 1983 505 L-P No 2.2 1.0
[5] 1984 718 L-P No 8.9 3.3
[6] 1988 808 Extravesical No 1.4 0.9
[7] 1992 505 Transvesical nipple No 3.0 7.0
[8] 1992 1000 Extravesical No 0.9 0.3
[9] 1994 1200 Extra/transvesical N/A 4.0 2.5
[10] 1994 1298 Extravesical No N/A 3.1
[11] 1994 1016 L-P No 6.2 12.4
[12] 1996 1157 Paquin/extravesical No 1.5 1.3
[13] 1997 534 Extravesical No 5.6 6.3
[14] 1997 2084 L-P No 1.0 0.5
[15] 1998 600 Extravesical Mixed 2.5 1.7
[16] 2000 400 Extravesical Yes 0 0
[17] 2001 1200 Extravesical No 3.1 1.9
Present 2002 1535 L-P No 2.93 3.52

N/A, data not available; L-P, Leadbetter-Politano.

© 2002 BJU International 90, 627–634

 UROLOGICAL COMPLICATIONS OF RENAL TRANSPLANTATION
and how changes in practice may reduce the rate of com-
plications further.
An initial dramatic reduction in urological complica-
tions at our unit (16% in the first 207 cases vs 5% in the
next 400) was attributed to the change from high- to
low-dose steroid-based immunosuppressive regimens, and
the rate has changed little since then. As will be discussed,
this may in fact mask an underlying trend towards safer
surgery.
Causal factors in urological complications
Most urological complications are a result of technical
errors at retrieval or reimplantation, or failure of tissue
healing, influenced by ischaemia, inflammation, infec-
tion, immunosuppression and antiproliferative agents,
and the nutritional state of the recipient. Four main
categories of factors are considered, i.e. donor, recipient,
technical and medical.
Donor
The donor’s age and pre-existing comorbidity will influ-
ence the potential function of the transplanted organs,
and their ability to withstand the insult of ischaemia and
reperfusion. Once a decision is made to offer organs for
transplantation, every effort must be made to preserve the
donor in an optimal state, with periods of hypotension,
inotrope support or prolonged stay in the intensive treat-
ment unit all affecting the quality of the organs in the
short- and possibly long-term. Retrieval surgery should
thus proceed at the earliest appropriate opportunity.
The increasing pressure on transplant waiting lists will
undoubtedly lead to more marginal donors being consid-
ered. The eventual effect of this tendency has yet to be
evaluated, although in the last 8 years, the donor age for
the present cases of urinary leak is slightly higher than for
the whole population over the same period. Long-term
graft survival is strongly correlated with donor-recipient
HLA mismatch, e.g. in the data from the UNOS and
UKTSSA registries [18,19]. This is of course a result of a
combination of acute and chronic rejection. Loughlin
et al. [5] reported no correlation of urological complica-
tions with HLA mismatch, but this series had an overall
rate higher (13.2%) than that of most recently published
series.
Recipient
The increasing availability of dialysis services and
improved medical management of chronic renal failure
have lead to an increase in the age of recipients of renal
transplants in the present series, from a mean of
37.8 years in 1975–1986 to 46.7 years at operation in
© 2002 BJU International 90, 627–634
631
1986–1998, although the present data showed no asso-
ciation between recipient age and complication rate.
There was no association with primary disease and
particularly no increased incidence of complications in
diabetic patients.
Surgical
Technical considerations are of the utmost importance in
the incidence of urological complications. Disruption of
the ureteric normal blood supply at retrieval dictates that
the remaining arterial and venous supply from the renal
vessels and lower polar branches must be preserved by
minimal peri-ureteric dissection, especially in the so-
called ‘golden triangle’ between the ureter, kidney and
renal artery. Even so, the distal ureter is prone to
ischaemia. In living-related kidney donation, less aggres-
sive preservation of the blood supply may be possible. In
our unit 10% of transplants in this series were from living
donors, with 12.5% of potentially ischaemic complica-
tions involved this subgroup. Thus no link is confirmed.
This is in agreement with most large series of living-donor
transplants, which report little effect on the incidence of
urological complications [5,12].
Iatrogenic injury, the cause of two leaks in the present
series, must be avoided during bench dissection. Minimiz-
ing warm ischaemic time is crucial. Dissection is carried
out on ice and the organ may be contained in an ice-filled
receptacle, e.g. a rubber glove, during the vascular anas-
tomosis. This has been shown to maintain the core tem-
perature of the kidney at < 10°C for protracted periods
[20]. There was no association between cold ischaemic
time or origin of the kidney (local vs from the national
organ-sharing scheme) and the incidence of urological
complication.
Ureteric reimplantation is where most interest has been
focused in recent years, particularly for the type of vesico-
ureteric anastomosis constructed and the use of prophy-
lactic ureteric stents. In nearly all cases in the present
series a Leadbetter-Politano submucosal tunnelled anas-
tomosis was used [21]. This has been suggested to lower
the incidence of ureteric reflux over conventional extra-
vesical procedures [21,22], particularly important if the
patient has recurrent UTIs. In the present series one case
of symptomatic reflux was identified in a patient with
recurrent pyelonephritis, successfully treated with ure-
teric reimplantation. More recent modifications of the
extravesical approach, including a short muscular tunnel
over the ureteric tip in an attempt to prevent reflux, have
lead to the technique being shown in several series to pro-
duce fewer ureteric obstructions [6,23–25]. Ischaemic
strictures are probably reduced through the shorter
length of ureter required, and extrinsic compression from
the submucosal tunnel is also avoided. The operating time
632 E.H. STREETER et al.
is reduced and the need for an additional anterior cystot-
omy, the source of six leaks in our series, is obviated. The
effect of this technique has been shown by two retrospec-
tive series comparing major complications before and after
its adoption. Butterworth et al. [25] claimed a reduction
from 12% to 2% in a series of 248 patients, and Thrasher
et al. [24] from 9.4 to 3.7% over 320 cases.
Two retrospective series showed remarkable reductions
in major urological complications by using prophylactic
ureteric stents (15% to 2.6%, and 13.6% to none, respec-
tively) [26,27]. Several prospective randomized series
have since confirmed this [16,28–30]. The stents are
prone to breakage, especially if left for > 3 months, and
may also migrate. The material used in the manufacture
of the stent has been suggested to affect its lithogenicity
[31], although the incidence of stent-associated calcifica-
tion may be reduced by their early removal at 2 weeks
after surgery [16]. The current policy in our unit (adopted
after the conclusion of this series) is to use stents in cases
where there is concern about ureteric ischaemia, com-
bined with an extravesical anastomosis; it is too early to
assess the effects of this recent change of practice.
In the last 535 patients the incidence of significant hae-
maturia after transplantation, causing bladder outlet or
ureteric obstruction, is low, with four cases within the first
10 days after surgery. Whether the source of the bleeding
is from the cystotomy or elsewhere is unknown. All were
managed conservatively with re-catheterization, one re-
quiring cystoscopic irrigation. Two cases of obstructing
haematuria secondary to allograft biopsy required neph-
rostomy insertion. All patients in our centre with cadav-
eric grafts undergo biopsies at 7 and 28 days, according to
protocol or at any sign of deterioration of renal function.
Living-related transplant recipients do not undergo rou-
tine biopsy because of the lower incidence of acute rejec-
tion in this group. These two cases thus represent a very
low overall rate of urological complication, but of course
do not include other cases of significant haemorrhage.
The incidence of lower urinary tract obstruction requir-
ing a procedure within 6 months of transplantation was
2%. Whether to evaluate the lower urinary tract of asymp-
tomatic patients before surgery, with the aim of reducing
symptomatic outlet problems afterward, is an area of con-
tention [32]. Again, whether to intervene beforehand,
with the risk of stricturing of the urethra after instrumen-
tation, without the regular passage of urine, is controver-
sial [32]. Intermittent self-catheterization and instillation
of antibiotic solution with normal voiding is suggested to
circumvent this problem. Many investigators suggest
waiting until after transplantation, with an early planned
urological procedure. In the case of a noncompliant blad-
der requiring reconstruction or augmentation, enterocys-
toplasty is recommended before transplantation and the
risk of immunosuppression [32].
Medical management
Of major importance was the change to low-dose steroid
immunosuppression in the late 1970s, with the major
complication rate decreasing from 16% in the first 207
cases to ≈ 7% since. Ongoing trials of immunosuppressive
regimens are unlikely to produce this magnitude of effect.
As has been stated, no clear link has been shown between
rejection and urological complications, and as long as the
complication is corrected, long-term function is preserved
Erectile dysfunction after transplantation is markedly
less than in those with renal failure or dialysis, being
halved from 47% to 22% between dialysis-dependent and
successfully transplanted patients [33]. Ongoing problems
are experienced often by patients on antihypertensive
medication. The risk of erectile dysfunction after bilateral
internal iliac transplant anastomoses has been estimated
at 65%, vs 10% for unilateral cases [34].
Urological malignancy
Urological malignancy, like all other forms of malignancy
in the transplant population, is in part a direct result of
immunosuppression. An incidence of 1.4% (relative risk
7–11 times) was reported by Schmidt et al. [35]. However,
all but 13 of the 868 patients reported in that series
received antilymphocyte or antithymocyte globulin at
induction. This practice, thought to be of great impor-
tance to the risk of developing malignancy, is very unusual
in the present series. However, more recent data from the
Australia and New Zealand Dialysis and Transplant regis-
try confirmed a seven-fold increased risk of bladder and
renal cancer in transplant recipients [36].
There were two cases of TCC of the bladder in the
present series; invasive bladder cancer must be treated
aggressively because of its propensity for rapid progres-
sion. For patients with superficial disease, management
involving transurethral tumour resection and close
cystoscopic observation should be tailored according to
standard risk factors such as the presence of high-grade
disease, multifocal invasion of the lamina propria or car-
cinoma in situ. Conventional adjuvant therapy using BCG
is contraindicated in the immunosuppressed patient, thus
early aggressive surgical treatment should be considered.
A particular risk factor for RCC is acquired renal cystic
disease, which occurs in up to half of patients on long-
term dialysis, often causing pain through cystic haemor-
rhage, haematuria and infection. It may be associated
with a 30-fold increased risk of RCC (especially of the pap-
illary variant) in the pretransplant population. The cystic
change often regresses after successful transplantation
but the relative risk of RCC in the transplant population is
not thought to be high. There were no cases of RCC in the
present series. Two prospective series of ultrasonography
© 2002 BJU International 90, 627–634
 UROLOGICAL COMPLICATIONS OF RENAL TRANSPLANTATION
screening before transplantation reported incidences of
occult tumours of 6% and 9% in patients with acquired
renal cystic disease (1.5–2% in all patients presenting for
transplantation) [37,38], but no survival benefit has been
shown by screening. Our current practice is not to screen
for the condition but to investigate urological symptoms
according to standard practice.
The incidence of prostate cancer after renal transplan-
tation has probably been underestimated because there is
little screening. This may be of increasing importance
with an ageing transplant population and the increasing
longevity of grafts. The natural history of the disease in
this population is unknown, especially important as the
low serum testosterone levels often seen with chronic
renal failure may be returned to normal with good renal
graft function. The relative benefits of various treatment
methods are likely to remain uncertain amongst trans-
plant patients, and thus with no evidence to the contrary,
they should be treated according to standard guidelines.
Men age > 50 years, who may have no urinary symptoms
if oliguric, should be considered for a DRE and serum PSA
test before transplantation.
Conclusion
The major urological complication rate was 6.5% over the
first 1535 cases of renal transplantation at our centre, and
has remained constant for about the last 20 years. Causal
factors were identified and possible changes in practice
suggested, the results of which will be apparent over the
next decade. With increasing experience of minimally
invasive endoscopic and uroradiological techniques,
the management of complications may be set to change
simultaneously.
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Authors
E.H. Streeter, MRCS.
D.M. Little, FRCS.
D.W. Cranston, FRCS.
P.J. Morris, PRCS.
Correspondence: E. Streeter, Department of Urology, Churchill
Hospital, Oxford, OX3 7LJ, UK.
e-mail: edwardstreeter@hotmail.com
© 2002 BJU International 90, 627–634