We have used a comprehensive protocol to identify secondary forms of hypertension and operated upon 77 patients with functionally significant renovascular disease. The population included 52 patients with atherosclerotic renal arterial lesions (31 unilateral and 21 bilateral) and 25 patients with fibrodysplasia (19 unilateral and 6 bilateral). In the entire population there was a 90% cured-improved rate, a 5% failure rate and a 5% postoperative mortality. The cure rate was highest in the unilateral fibrodysplasia group and lowest in those with bilateral atherosclerotic disease. The choice of initial operative approach was based on an attempt to preserve renal mass; in 11 patients vascular reconstruction was attempted and these required secondary nephrectomy because of early or late failure. All 11 patients had a good result after nephrectomy. Our observations indicate that a vigorous operative approach to renovascular hypertension is beneficial once accurate demonstration of a functionally significant lesion is made.