Clinical phenotyping in chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis: a management strategy for urologic chronic pelvic pain syndromes.

The urologic chronic pain conditions such as chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis are syndromes whose evaluation and management are controversial. Part of the difficulty in diagnosis and therapy is the heterogeneity of etiologies and symptoms. We propose a six-domain phenotype, which can classify these patients clinically and can direct the selection of therapy in the most evidence based multimodal manner. The domains are urinary, psychosocial, organ specific, infection, neurologic and tenderness of skeletal muscles. This system is flexible and responsive to new biomarkers and therapies as their utility and efficacy are proven.

The in situ anterior vaginal wall sling: predictors of success.

PURPOSE: We assessed the outcome of the in situ anterior vaginal wall sling for stress urinary incontinence, identified any predictors of success and reviewed the current literature on this topic. MATERIALS AND METHODS: We identified all patients who underwent an isolated anterior vaginal wall sling procedure in a 16-month period. Charts were reviewed and telephone interviews were performed to assess the success rate of the procedure and identify parameters that may influence outcome. The pertinent literature was identified. RESULTS: Of the 42 patients identified 39 had evaluable data available. The overall success rate was 79.5% at an average 19-month followup. Abdominal Valsalva leak point pressure 50 cm. water or greater was identified as a significant predictor of success (p = 0.002). The success rate was 93% and 40% in patients with a Valsalva leak point pressure of 50 or greater and less than 50 cm. water, respectively. The pertinent literature was reviewed. CONCLUSIONS: The anterior vaginal wall sling is effective for stress urinary incontinence. In patients with a Valsalva leak point pressure of 50 cm. water or greater the success rate is 93%. We recommend the anterior vaginal wall sling procedure in these patients but different treatment in those with Valsalva leak point pressure less than 50 cm. water.

Laparoscopic augmentation cystoplasty. Surgical technique.

Laparoscopic enterocystoplasty is technically feasible and successfully emulates the established principles of open enterocystoplasty while minimizing operative morbidity. As is true in open surgery, various bowel segments can be fashioned and anastomosed to the bladder laparoscopically. The increased costs associated with laparoscopy and with minimally invasive surgery in general have been a significant disadvantage; however, a previous report on the costs of laparoscopic procedures concluded that increased surgical experience reduces the surgical time and length of hospital stay, thereby decreasing costs. Furthermore, the increased use of reusable instruments results in considerable economic benefits. Implementation of appropriate cost-saving strategies ultimately will result in decreased expenses associated with laparoscopy. Although laparoscopic enterocystoplasty is currently a lengthy procedure lasting twice as long as open surgery, further technical modifications and increasing experience will continue to reduce the surgical time involved. For patients with complex comorbid illness who desire the improved quality of life associated with traditional augmentation cystoplasty, the reduced morbidity observed in the authors' series of patients undergoing a laparoscopic procedure makes this approach an attractive option to consider. The authors' initial experience suggests that laparoscopic enterocystoplasty has the potential to become a viable alternative to open enterocystoplasty.

Tension-free vaginal tape and percutaneous vaginal tape sling procedures.

PURPOSE: Midurethral synthetic sling procedures for treatment of stress urinary incontinence (SUI) are gaining increased attention from surgeons specializing in female pelvic reconstructive techniques seeking successful patient outcomes through reproducible simplicity. This report describes the procedural steps and methods used to maximize the potential for successful outcomes using techniques of midurethral synthetic sling placement. Reported complications and surgical outcomes are reviewed with respect to patient selection and minimizing the potential for morbidity and mortality as long-term clinical experience is accumulated. MATERIALS AND METHODS: Tension-free vaginal or transvaginal tape (TVT) and the recently introduced percutaneous vaginal tape (PVT) are two new procedural choices for placement of synthetic sling material at the midurethra. Both procedures use sling material composed of polypropylene mesh, a nonabsorbable synthetic material, placed at the level of the midurethra via an antegrade (PVT, using a percutaneous ligature carrier) suprapubic approach or retrograde (TVT, using vaginal trocars) vaginal approach. Patient selection, procedural techniques, and methods described are based on observations obtained or reported from clinical experience. Outcomes and complications for TVT are derived from a literature review of all published articles in Index Medicus from 1996 to 2000. RESULTS: The experience with TVT for the last 5 years is encouraging. At 3-year follow-up for TVT, reported cure rates for SUI range from 80% to 95%. A multitude of worldwide reports on PVT with shorter follow-up support the findings of the TVT experience. Reproducible findings with midurethral synthetic slings are the short operative times recorded for the sling procedure, ease of technical performance, minimal patient discomfort, and a high rate of early return of normal voiding function. The rate of complications such as obstructive voiding or de novo instability (0-15%) and urinary retention necessitating a secondary procedure (2-4%) appear to be equal to the rates of contemporary competing technologies and procedures for treatment of SUI. CONCLUSIONS: Preliminary reports and the experience at our institution suggest that the techniques of midurethral synthetic sling placement of TVT and PVT are reproducible, easy to master, and minimally invasive with respect to tissue handling. Although complications with all anti-incontinence procedures exist, understanding the anatomical considerations and methodology of these unique procedures should minimize patient morbidity, avoid patient mortality, and produce a high rate of durable success.

Incidence of concomitant procedures for pelvic organ prolapse and reconstruction in women who undergo surgery for stress urinary incontinence.

OBJECTIVES: To determine the incidence of concomitant procedures performed for pelvic organ prolapse or vaginal reconstruction at the time of surgery for stress urinary incontinence in contemporary practice. METHODS: We recorded all concomitant procedures for pelvic organ prolapse or vaginal reconstruction in 264 women who underwent surgery for stress urinary incontinence at our institution from January 1995 to August 1997. RESULTS: Of 264 women, 111 (42%) had at least one concomitant procedure performed for pelvic organ prolapse or vaginal reconstruction, including 87 cystocele repairs, 31 rectocele repairs, 8 sacrospinous fixations, 5 enterocele repairs, 5 abdominal sacrocolpopexies, 4 perineoplasties, 3 urethral diverticulectomies, and 1 vaginal hysterectomy. Furthermore, 9% of patients had two or more procedures. CONCLUSIONS: We found that women who undergo surgery for stress urinary incontinence have a high incidence (42%) of associated pelvic organ prolapse requiring surgical repair. These additional repairs contribute to the overall success of surgery and should not be overlooked.

Bone anchor infections in female pelvic reconstructive procedures: a literature review of series and case reports.

PURPOSE: We determined the reported prevalence of infectious osseous complications due to the use of bone anchors for suture fixation in female pelvic reconstructive procedures. In addition, the type and method of bone anchors as well as the reported pathogens associated with osseous infections were reviewed. MATERIALS AND METHODS: Primary reported series of female pelvic reconstructive procedures involving bone anchor suture fixation referenced in Index Medicus from January 1990 to July 2000 were extracted using the MEDLINE bibliographic database on English language articles involving humans. All case reports of infectious osseous complications due to bone anchor use in female reconstructive procedures were also reviewed during this period. RESULTS: Since the inception of bone anchor suture fixation for female pelvic reconstructive procedures 10 years ago, the overall prevalence of related infectious complications has been 6 cases in 1,018 procedures (0.6%). This type of adverse event developed between followup weeks 1 and 24. The prevalence of suprapubic bone anchors has been 6 cases in 698 procedures (0.86%). For transvaginal bone anchor procedures no infectious cases have been reported in the combined series of 314 procedures and the same is true for 1 reported case of sacral bone anchor placement in 6 procedures. No statistical difference was noted in regard to the prevalence of infection in procedures involving suprapubic bone anchors and transvaginal bone anchor combined with sacral bone anchor placement (Fisher's exact test p = 0.19). The organisms reported in case reports suggest a coliform, skin or hematogenous source for contamination of the bone anchor site. CONCLUSIONS: An infectious bone anchor complication in female pelvic reconstructive procedures is an uncommon event with a reported prevalence of 0.6%. Currently there is no evidence of differences in the prevalence of osseous complications after transvaginal versus suprapubic bone anchor fixation. Preoperative broad-spectrum antibiotics are recommended to decrease the potential of infectious bone anchor complications.

Impaired alpha-interferon signaling in transitional cell carcinoma: lack of p48 expression in 5637 cells.

The limited success of IFN-alpha therapy for clinical treatment of transitional cell carcinoma (TCC) has prompted us to investigate the responsiveness of TCC lines to IFN-alpha. The response to IFN-alpha in terms of 561 gene induction, an IFN-stimulated response element-containing IFN-alpha/beta-inducible gene, and IFN-stimulated gene factor 3 (ISGF3) formation was normal in primary human urothelial cells. We tested the antiproliferative effects of IFN-alpha in three TCC lines as a measure of IFN-alpha responsiveness, and variable patterns of growth inhibition were observed in three TCC lines. More than 90% growth inhibition was noted in TCCSUP cells, whereas only 40% and 10% inhibition by IFN-alpha was observed in 5637 and HT1197 cells, respectively. IFN-alpha treatment formed extremely low levels of ISGF3 in electrophoretic mobility shift assays in these later two relatively insensitive cells. In addition, expression of the 561 gene was significantly reduced in these two TCC lines by Northern blots. We have further identified a low expression level of Tyk2 in HT1197 cells compared with two other TCCs. This suggests that an extremely low ISGF3 level after IFN-alpha treatment may be due to low Tyk2 expression or other unidentified defects. In 5637 cells, p48 protein expression was undetectable. This undetectable p48 expression is not due to a deletion in the coding region because the correct size protein is detected following IFN-gamma treatment. Consequently, the ISGF3 complex formation and 561 gene induction were restored by IFN-gamma pretreatment plus IFN-alpha treatment. Introduction of p48 expressing plasmid into 5637 cells was sufficient to form the ISGF3 complex by IFN-alpha treatment, suggesting the defect lies in the expression of p48 protein in 5637 cells. Detailed mechanistic understanding of the action of IFNs in bladder cancer cell lines may explain the abrogated therapeutic response of IFN-alpha in the clinical treatment of TCCs.

Association of chronic urinary symptoms in women and Ureaplasma urealyticum.

UNLABELLED: OBJECTIVES. To determine the incidence of Ureaplasma urealyticum in women experiencing chronic urinary symptoms and to determine whether antibiotic therapy targeting these organisms is effective. METHODS: Forty-eight consecutive women referred to our academic medical center for chronic voiding symptoms and possible interstitial cystitis underwent urologic evaluation, including culture screening for U. urealyticum and Mycoplasma hominis. Patients with positive cultures were treated with a 1-g dose of azithromycin; persistent infection was treated with 7 days of doxycycline, ofloxacin, or erythromycin. Patients reported symptom severity (0, mild; 3, severe) and voiding frequency before and 6 months after treatment. RESULTS: Positive cultures were obtained in 23 (48%) of 48 patients; 22 had U. urealyticum and 1 had M. hominis. All had negative cultures after treatment. The mean symptom severity score improved with treatment (2.2 to 0.7, P <0.001), and the mean urinary frequency decreased (9.2 daily to 6.8 daily, P <0.001). Two of the 23 patients experienced no improvement; one had detrusor instability and the other had medically related urinary frequency. Of the 25 patients with negative cultures, interstitial cystitis was established in only 9 (19% of the total sample). CONCLUSIONS: Although often overlooked or improperly treated, U. urealyticum and M. hominis infections may account for a large proportion of unexplained chronic voiding symptoms. Culture and treatment should be considered before pursuing more costly and invasive tests.

Surgical treatment for stress urinary incontinence associated with valsalva induced detrusor instability.

PURPOSE: Detrusor instability initiated by increased intra-abdominal pressure that results in incontinence has always been difficult to treat. This form of incontinence may be due to traction on the pelvic nerves when increased abdominal pressure is applied to already weakened pelvic supportive tissue. In most patients pharmacological attempts to correct this problem fail. We describe a pubovaginal sling designed to stabilize the urethrovesical junction during the Valsalva maneuver, which is our treatment of choice for such patients. MATERIALS AND METHODS: From 1994 to 1998 we treated 36 patients with a pubovaginal sling procedure for Valsalva induced detrusor instability diagnosed on preoperative urodynamics. The sling material was in situ vaginal wall in 20 cases, free swing vaginal wall in 6, rectus fascia in 4, cadaveric fascia in 3 and synthetic material in 3. Urodynamic evaluation was performed preoperatively in all patients. Followup of 6 months to 4 years involved subjective questions and objective examination. RESULTS: Cure was achieved in 33 of the 36 patients (92%), of whom leak point pressure was less than 50, 50 to 100 and greater than 100 cm. water in 9, 17 and 7, respectively. In the 3 failed cases leak point pressure was 50 to 100 cm water, including 2 in which cotton swab test results were less than 30 degrees. Urge incontinence resolved in 75% of the patients. CONCLUSIONS: The pubovaginal sling procedure may cure Valsalva induced detrusor instability. Leak point pressure does not determine which patients do well. Evaluation for hypermobility may help to predict the success or failure of a procedure by identifying those in whom Valsalva induced detrusor instability results from traction on the pelvic nerves.

Laparoscopic enterocystoplasty.

OBJECTIVES: To report the initial clinical experience with laparoscopic augmentation enterocystoplasty using the ileum, sigmoid, or right colon. METHODS: Three patients with functionally reduced bladder capacities due to neurogenic causes underwent laparoscopic enterocystoplasty: ileocystoplasty (n = 1), sigmoidocystoplasty (n = 1), and cystoplasty with cecum and proximal ascending colon (n = 1). In the last patient, a continent, catheterizable, ileal conduit with an umbilical stoma was also created. In all patients, bowel reanastomosis was performed by exteriorizing the bowel loop outside the abdomen through a 2-cm extension of the umbilical port site. Creation of a large cystotomy, mobilization of the appropriate bowel segment, and the circumferential enterovesical anastomosis were all performed intracorporeally by laparoscopic techniques. RESULTS: The operative times were 5.3, 8, and 7 hours. All three laparoscopic enterovesical anastomoses were watertight, without postoperative urinary extravasation. The hospital stay was 7, 5, and 4 days. CONCLUSIONS: Laparoscopic enterocystoplasty is feasible, safe, and efficacious and appears to be an attractive alternative to open enterocystoplasty. Various bowel segments can be used as with open surgery, including creation of a continent, catheterizable stoma. Although further technical refinements will undoubtedly occur, even at this early stage, it is clear that the technical steps of an enterocystoplasty can be satisfactorily and effectively performed laparoscopically.

In situ slings with concurrent cystocele repair.

Stress urinary incontinence (SUI) is commonly associated with varying degrees of genitourinary prolapse; therefore, it is customary to perform surgical corrections of both problems simultaneously. The type of surgical correction is based on the surgeon's discretion. We present a series of patients who underwent in situ vaginal wall slings as well as anterior vaginal wall (cystocele) repairs. Eighteen patients treated between 1994 and 1998 were evaluated. The average age was 61 years (range 35 to 74). Urodynamic evaluation was performed preoperatively. Postoperatively, the patients were assessed with objective testing as well as physician-performed Medical, Epidemiologic, and Social Aspects of Aging questionnaires. Follow-up ranged from 6 months to 4 years. SUI cure was defined as a patient who is completely dry and voiding. Sixteen (89%) of 18 patients were cured of both their cystocele and SUI; 2 of 18 had recurrent SUI with no evidence of recurrent cystocele. Fifty-six percent of the patients with good results had preoperative leak point pressures (LPP) of 50 to 100, and 44% had LPP > 100. None of the patients who were cured had an LPP <50, and only one patient in the failure group had an LPP <50. Seventeen percent of the patients had de novo urgency. In situ vaginal wall slings are a good procedure to use in combination with cystocele repairs in patients with LPP >50.

Immunoregulatory potential of urothelium: characterization of NF-kappaB signal transduction.

PURPOSE: To characterize the basal and activated form of nuclear factor-kappaB (NF-kappaB) complex in normal urothelial cell cultures after stimulation with tumor necrosis factor-alpha (TNF-alpha), lipopolysaccharide (LPS), and double-stranded ribonucleic acid (dsRNA). MATERIALS AND METHODS: Human urothelial cells cultured from normal bladder specimens underwent immunohistochemical staining and cellular extracts were prepared for Electrophoretic Mobility Shift Assays (EMSA), Western blot analyses, RNA isolation and Northern Blot analyses before and after stimulation with TNF-alpha, LPS, and dsRNA. RESULTS: In normal human urothelial cells, activation of the NF-kappaB complex in response to stimulation with TNF-alpha, LPS, and dsRNA was detected by immunohistochemical methods and EMSA. Depending on the stimulus, a specific NF-kappaB complex was activated as seen by supershift experiments in EMSA. By Western blot, the inhibitor of NF-kappaB complex, IkappaB-alpha, degraded in response to stimulation. Northern blot analysis from total RNA revealed subsequent inducible interleukin-8 (IL-8) mRNA expression of normal urothelial cells when treated with TNF-alpha, LPS, and dsRNA. CONCLUSIONS: Normal human urothelial cells contain basal NF-kappaB complexes in an inactivated state. When these cells are challenged by different agents such as TNF-alpha, LPS, and dsRNA, the cells respond by activation of the NF-kappaB signal transduction pathway, degradation of its inhibitor, IkappaB-alpha, and translocation of this primary factor into the nucleus to induce specific genetic responses such as IL-8 expression.

The supine stress test: a simple method to detect intrinsic urethral sphincter dysfunction.

PURPOSE: A new clinical test for intrinsic urethral sphincter dysfunction is proposed and compared to abdominal leak point pressure determination by video urodynamics. MATERIALS AND METHODS: Patients were prospectively included in the study if they had stress urinary incontinence symptoms and were to undergo video urodynamic testing. Patients with urinary tract infection, cystocele, rectocele and vaginal vault prolapse were excluded from study. A supine stress test using cough and Valsalva's maneuvers was performed after bladder filling to 200 ml. with sterile normal saline solution by gravity. Efflux of the bladder solution from the meatus coinciding with the cough or Valsalva maneuver indicated a positive clinical test. A video urodynamic study, including abdominal leak point pressure, was performed. Intrinsic urethral sphincter dysfunction was diagnosed if abdominal leak point pressure was less than 100 cm. water. Test indexes were calculated based on the results of the supine stress test and the abdominal leak point pressure measurements. RESULTS: Results were positive in 30 of 41 consecutive patients and negative in 11. Using abdominal leak point pressure measurement, the supine stress test had 93.5% sensitivity, 90.0% specificity, 96.7% positive predictive value and 81.8% negative predictive value for detecting intrinsic urethral sphincter dysfunction. CONCLUSIONS: The supine stress test is easy, quick and inexpensive, and a positive test is a reliable predictor of intrinsic urethral sphincter dysfunction. A negative test is highly correlated with the absence of intrinsic urethral sphincter dysfunction during video urodynamic testing. This test is more reliable in diagnosing intrinsic urethral sphincter dysfunction than other nonurodynamic tests reported in the literature. The supine stress test can be a useful supplement to cotton swab testing for urethral hypermobility in determining the appropriate management for stress urinary incontinence.

Evaluation and management of lower urinary tract disorders in women with multiple sclerosis.

This paper outlines the evaluation and management of the lower urinary tract abnormalities related to voiding function in women with multiple sclerosis (MS). For the pelvic floor reconstructive surgeon, it is important to realize that every patient with MS may have voiding dysfunction unrelated to lower urinary tract symptoms, duration of disease or disability status. Proper evaluation and individualized management of the urinary tract reduces the morbidity and improves the quality of life of patients with this degenerative neurologic disorder.

The efficacy of urethrolysis without re-suspension for iatrogenic urethral obstruction.

PURPOSE: Urethral obstruction following surgical correction of stress urinary incontinence is not uncommon and urethrolysis is typically used to relieve symptoms. Whether one should resuspend the bladder neck concurrent with urethrolysis is controversial. We evaluate the efficacy of urethrolysis without re-suspension for the treatment of iatrogenic urethral obstruction. MATERIALS AND METHODS: From April 1994 to January 1998, 31 women 29 to 78 years old (mean age 60) underwent transvaginal urethrolysis without concomitant re-suspension. The incident procedure was transvaginal urethropexy in 15 patients (48%), retropubic urethropexy in 5 (16%) and pubovaginal sling in 11 (36%). The most common presenting complaints were urinary retention, feeling of incomplete emptying or straining to void in 22 patients (71%) and irritative voiding symptoms in 17 (55%). Mean time from index procedure to urethrolysis was 14 months (range 2 to 36) and mean followup was 7 (range 1 to 27). RESULTS: After urethrolysis 26 of 31 patients (84%) voided well or had significant improvement in symptoms. Of the 26 improved patients 6 had stress incontinence. Of these 6 patients 4 responded to periurethral collagen injection and are now dry. When individual variables were analyzed, none was found to be predictive of a successful outcome. CONCLUSIONS: Transvaginal urethrolysis without concomitant re-suspension is an effective treatment for iatrogenic urethral obstruction. While 19% of patients may have recurrent incontinence, the majority can be treated with outpatient collagen injections. Overall 77% of patients voided well without incontinence, 7% voided well but with some incontinence and 16% remained obstructed after urethrolysis.

Constitutive expression of the Wilms tumor suppressor gene (WT1) in renal cell carcinoma.

The expression of the Wilms tumor suppressor gene WT1 is largely restricted to elements of the developing urogenital system. In the fetal kidney, WT1 transcripts are present at low levels in the condensing mesenchyme and at much higher levels in differentiating glomerular epithelium and are not detected in other mesenchymal-derived epithelial structures such as the proximal and distal tubules. However, WT1 expression is observed in tubule-like elements found in some Wilms tumors. As renal cell carcinoma (RCC) of the clear cell type is one of the most prevalent adult tumors of the kidney, and is thought to originate from the epithelial cells of the proximal tubules, we studied WT1 expression in RCCs. Despite the absence of WT1 in normal primary epithelial cells derived from proximal tubules, RCC tumors and tumor-derived cell lines expressed WT1 RNA. Immunocytochemical analyses of tumor cryosections showed widespread expression throughout the poorly differentiated epithelial components of the tumor. Immunoblots of RCC samples detected a normal size WT I protein and reciprocal antibody immunoprecipitations of RCC cell extracts indicated that WT I interacts with p53 as has been demonstrated for normal human fetal kidney. The aberrant expression of functional WT1 in RCC may represent a reversion to a more de-differentiated phenotype and may contribute to the tumorigenic phenotype by inappropriately activating or repressing genes involved in growth regulation.

Urodynamic findings in postprostatectomy incontinence.

Due to the large variability in the reported contribution of bladder dysfunction to postprostatectomy incontinence and the impact this dysfunction may have on the outcome of selected treatment, we retrospectively reviewed the videourodynamic findings of bladder and sphincteric function in patients with postprostatectomy incontinence. The contributions of bladder and sphincteric causes of incontinence are determined. Ninety-two patients had multichannel videourdynamic testing performed as part of a comprehensive evaluation for incontinence at least 1 year after prostatectomy. Using a 6-French double-lumen catheter in the bladder and a 10-French catheter in the rectum, all pressures were recorded continuously while in the upright position. Valsalva leak point pressures (VLPP) were measured in the absence of a bladder contraction at a 150-ml volume and at 50-ml increments thereafter until maximum functional capacity was reached. Bladder compliance and bladder capacity were determined and the presence of detrusor instability (DI) was documented. Sixty-five patients (71%) presented after radical prostatectomy (RP) and 27 patients (29%) after transurethral resection of the prostate (TURP). The predominant urodynamic finding was sphincteric incompetence as VLPP were obtained in 85 patients (92%) and ranged from 12 to 120 cm water. DI was a common finding, occurring in 34 patients (37%), and classified as follows: a) phasic instability in 22/34, b) tonic instability in 3/34, and c) mixed phasic and tonic instability in 9/34. However, we found DI to be the sole cause of incontinence in only 3/92 patients (3.3%). There was no statistically significant difference in the incidence of sphincteric incompetence after RP or TURP; however, TURP patients had a higher incidence of DI, which was statistically significant (P=0.019). There was no correlation of incontinence severity and VLPP when comparing preoperative pad usage to VLPP < or =70 or > or =71 cm water. Although bladder dysfunction may be contributing problem in patients with postprostatectomy incontinence, it is rarely the only mechanism for this disorder. VLPP does not correlate with incontinence severity. Although sphincteric incompetence is the most common mechanism contributing to incontinence after prostatectomy, bladder dysfunction may coexist or be an isolated cause of postprostatectomy incontinence. Therefore, urodynamic studies are important to illustrate the exact cause(s) of incontinence in each individual patient after prostatectomy.

Collagen injection therapy for post-prostatectomy incontinence.

PURPOSE: Post-prostatectomy incontinence has an incidence of 5 to 12% and greatly affects quality of life. Since the approval of glutaraldehyde cross-linked collagen there is a renewed interest in injectable urethral bulking agents. We investigated the long-term efficacy and prognostic criteria for transurethral collagen injection therapy for men with post-prostatectomy incontinence. MATERIALS AND METHODS: From November 1993 to May 1995, 62 men with post-prostatectomy incontinence (54 after radical prostatectomy and 8 after transurethral resection of the prostate) were treated with collagen via a transurethral approach. Median followup was 29.0 months from the date of the last injection procedure. RESULTS: Social continence was defined as dry or minimal leakage requiring at most 1 pad daily with activity. Of 62 patients 38.7% achieved social continence and 8.1% became totally dry. The success rate was 35.2 for radical prostatectomy versus 62.5% for transurethral prostatic resection patients. Of the patients who achieved social continence with at least 1-year followup 23 (60.9%) remained so with no further treatment. At 2-year followup 21 patients (42.8%) maintained social continence. The success rate was 27.3% for those who wore a penile clamp or condom catheter before treatment (3 of 11 patients), and only 21.4% for those who underwent transurethral incision of a bladder neck contracture (3 of 14). A median of 4 injection procedures and 20.0 ml. collagen were required to achieve social continence. CONCLUSIONS: Transurethral collagen injection therapy is a reasonable treatment option for post-prostatectomy incontinence in select patients in whom more conservative therapy has failed. However, patients who have required a penile clamp, experienced continuous leakage or undergone transurethral incision of a bladder neck contracture are unlikely to respond well to this treatment.