Multicenter randomized clinical trial comparing surgery and collagen injections for treatment of female stress urinary incontinence.

OBJECTIVES: To compare, in a multicenter, randomized clinical trial, collagen injections versus surgery with regard to efficacy, quality of life, satisfaction, and complications. METHODS: Of 133 women with stress urinary incontinence, 66 were randomized to collagen injection and 67 to surgery (6 needle bladder neck suspensions, 19 Burch, and 29 slings). After randomization, 15 women refused their allocated treatment. "Intent-to-treat" and "per protocol" analyses were applied. Women assigned to collagen injection could receive up to three injections before it was considered a failure. A "top-up" injection was allowed within 3 months after cure. Success as the primary outcome at 12 months was defined as a dry 24-hour pad test (2.5 g or less of urine) after having received only the allocated intervention. RESULTS: The per protocol analysis showed that the success rate 12 months after collagen injections (53.1%) was much lower than that after surgery (72.2%). The difference was 19.1% (95% confidence interval -36.2% to -2%). The general and disease-specific quality-of-life scores measured by the Rand Medical Outcomes Study 36-item Health Survey and Incontinence Impact Questionnaire were similar in the two groups (P = 0.306). Women treated by surgery were, on average, more satisfied (79.6%) than those treated by collagen injection (67.2%), but the difference was not significant (P = 0.228). Finally, complications were less frequent and severe with collagen injection: 36 events in 23 subjects for collagen injection versus 84 events in 34 subjects for surgery (P = 0.03). CONCLUSIONS: One year after intervention, the success rate of collagen injection as a treatment for stress urinary incontinence was about 19% lower than that after surgery. This has to be tempered by the similar changes in quality of life and satisfaction in both groups and that the number and severity of complications were much greater after surgery than after collagen injection. The results of this study indicate that collagen injections might be a worthwhile alternative to surgery for the treatment of stress urinary incontinence.

A novel approach to endourological training: training at the Surgical Skills Center.

PURPOSE: We investigated the effects of didactic teaching and supervised hands-on practice on endourological skills using high fidelity genitourinary bench models at a surgical skills laboratory. We also validated a global rating scale and checklist designed specifically for endourological tasks. MATERIALS AND METHODS: We assessed 17 urology residents for the ability to remove a mid ureteral stone using a high fidelity genitourinary model on 3 occasions, including a pre-test at the beginning of the study to assess baseline skills, after a didactic teaching session and after a supervised practice session on high fidelity models. Performance was graded according to a global rating scale, checklist, pass rating and time needed to complete task. RESULTS: Senior residents achieved significantly higher pre-test global rating scores than junior residents (p <0.01). One-way repeated measures analysis of variance revealed a significant effect of training on the endoscopic global rating score (p <0.001). Post-hoc tests demonstrated significant improvement in the global rating scores from the pre-test to the post-didactic session (p <0.05) and from the post-didactic to the post-practice session (p <0.01). Interrater reliability using the global rating scale was high (Pearson's r = 0.82, p <0.01). Significant but less powerful results were observed in the checklist score, pass rating and time. CONCLUSIONS: There was a positive effect of training at the surgical skills laboratory on endourological skills. The global rating scale showed good construct validity and reliability for assessing endourological tasks, more so than the checklist, pass rating or time.

Urodynamic findings in adults with the tethered cord syndrome.

PURPOSE: We evaluated bladder function in adults with the tethered cord syndrome using multichannel urodynamics. MATERIALS AND METHODS: A total of 21 patients a mean 39.6 years old (range 20 to 62) with a tethered cord were evaluated. Of the patients 13 were diagnosed with a tethered cord as an adult and 8 had undergone previous spinal surgery. The tethered cord syndrome was diagnosed by magnetic resonance imaging in 20 patients and computerized tomography myelogram in 1. All patients underwent complete neurological and urological evaluation, including multichannel urodynamics. Needle electromyography and video urodynamics were performed in select cases. Microsurgical release of the tethered cord was performed in 19 patients and 2 refused surgery. Urodynamics were done before surgery in 16 of 19 patients and a median of 12.5 months (range 1 to 40) after surgery in 14. In addition, intraoperative urodynamic monitoring and nerve root stimulation were done in 14 patients to prevent nerve root injury at surgery. RESULTS: At presentation urgency (67%) and urge incontinence (50%) were the most common findings in 18 patients with urinary symptoms. Pretreatment urodynamics in 18 of 21 patients revealed hyperreflexia in 13 (72%), external detrusor-sphincter dyssynergia in 4 (22%), decreased sensation in 4 (22%), decreased compliance in 3 (17%) and hypocontractile detrusor in 2 (11%). Postoperative urodynamic findings were improved in 4 patients (29%) and unchanged in 10 (71%). Preoperative external detrusor-sphincter dyssynergia in 4 patients resolved postoperatively in 3 and was unchanged in 1. Urinary symptoms were improved in 19% of patients (4), unchanged in 76% (16) and worse in 5% (1). To date 7 patients require anticholinergics, 4 require clean intermittent catheterization and 1 is taking an alpha-blocker. CONCLUSIONS: Adults with the tethered cord syndrome are less likely to have urodynamic or symptom improvement after cord release and most often present with irreversible findings which rarely become worse after surgery. These patients need to have careful and continuous followup, including urodynamic studies, due to possible re-tethering with time.

The treatment choice of elderly patients with erectile dysfunction.

The aim of this study was to determine treatment preference, commitment to choice of therapy, and the influence of physical disability on treatment choice in a geriatric group of males with erectile dysfunction (E.D.) of various etiologies. Eighty-nine patients aged 65 to 83 years (mean 69.5 years) were assessed and followed at our erectile dysfunction clinic from July 1991 to September 1996. Etiology of ED was based on clinical assessment. Available treatment options included oral medications, vacuum devices, injection therapy, penile prostheses, sex counseling and testosterone when indicated. Median follow-up since initial consultation was 9 months (range 1 to 63 months). Data was retrieved in a retrospective fashion from chart review and selective telephone follow-up. Clinical assessment yielded the following distribution of etiologies: vasculogenic (57.2%), neurogenic (7.9%), hormonal (1.1%), psychogenic (2.2%), and multifactorial (32.6%). The most popular initial treatment choices were injection therapy (30.3%), vacuum device (27.0%), and oral medication (20.2%). Of the 84 patients who chose to be treated, 34 (40.5%) elected to switch to a different form of therapy after a median time of 7.5 months (range 1 week to 63 months). Five patients tried a third form of therapy and two proceeded to a fourth. The remaining patients have continued with their original choice for a median time of 7 months (range 1 to 63 months). A greater drop-out rate (78%) amongst those who initially chose oral medication was statistically significant when compared to drop-out rates for injection therapy (48%) and vacuum devices (29%), p = 0.044 and p = 0.005, respectively. Significant physical disabilities in eight patients did not appear to influence their treatment selection. In conclusion, the elderly are a unique group of patients who are more likely to have an organic etiology to their erectile dysfunction. When they do present with erectile dysfunction, they are inclined to pursue treatment. The choices made by this group of men did not differ from impotent men in general. When unsatisfied with one form of therapy they were inclined to pursue an alternative treatment. A significant physical disability did not preclude a therapeutic choice.

Laparoscopic correction of stress urinary incontinence.

The laparoscopic correction of stress urinary incontinence continues to be evaluated. Early results have been encouraging with cure/dry rates equivalent to those with traditional suspensions, but with shorter hospitalization and no significant morbidity. The approach continues to take longer in the operating room than traditional suspensions, although new innovations and refinements have shortened the time. We are still lacking long-term outcome data and well-constructed prospective randomized trials. Cost effectiveness studies are also not consistent.

Collagen injections for genuine stress urinary incontinence: patient selection and durability.

The questions of patient selection parameters and durability of response in the use of collagen injections for genuine stress incontinence are addressed. A total of 181 women with a mean age of 64 years (range 26-94) underwent collagen injections for urethral incompetence. Treatment outcome was determined by a change in individual incontinence grades before and after injection. Of the 181 women 42 (23%) are cured, 94 (52%) are improved and 45 (25%) failed. Follow-up in the successful patients, either cured or improved, was a mean of 21 months (range 4-69) after their last collagen injection. No difference in outcome was seen in relation to patient age or pretreatment grade of incontinence. Of the 30 patients with bladder instability, 18 (60%) had a favorable outcome. No significant difference in outcome was seen in patients with or without hypermobility (P = 0.2889). Patients with type III incontinence required the largest amount of collagen for a successful outcome. The persistence of continence in 78 patients who were cured for at least 2 months were plotted on a Kaplan-Meier survival curve. The probability of remaining dry without additional collagen was 72% at 1 year, 57% at 2 years and 45% at 3 years. It was concluded that, collagen injection into the urethra is a safe and well-tolerated procedure. Pretreatment bladder instability may be an adverse factor. Patients with or without hypermobility had equal benefit. Long-term durability was seen. If deterioration occurred repeat collagen injections restored success. The current literature is reviewed and the use of collagen relative to other treatments is discussed.

Followup of intraurethral collagen for female stress urinary incontinence.

PURPOSE: We studied patient selection parameters and durability of response of collagen injections for female stress incontinence. MATERIALS AND METHODS: A total of 187 women 15 to 87 years old (mean age 63) underwent collagen injections for urethral incompetence. Treatment outcome was determined by a change in individual incontinence grades before and after injection. RESULTS: Of the 187 women 43 (23%) were cured and 97 (52%) improved, while injection failed in 47 (25%). Mean followup in the successful (cured or improved) group was 22 months (range 4 to 69) after the last collagen injection. No difference in outcome was noted in relation to patient age or pretreatment grade of incontinence. Of the 31 patients with bladder instability 13 (42%) had a favorable outcome. No significant difference in outcome was noted in patients with or without hypermobility (p = 0.21235). Patients with type 3 incontinence required the largest amount of collagen for a successful outcome. Persistence of continence in 80 patients who were cured for at least 2 months was plotted on a Kaplan-Meier survival curve. The probability of remaining dry without additional collagen was 71, 58 and 46% at 1 to 3 years, respectively. CONCLUSIONS: Intraurethral collagen is a safe and well tolerated procedure. Pretreatment bladder instability may be an adverse factor. Patients with or without hypermobility had equal benefit. Long-term durability was noted. If deterioration occurred, repeat collagen injections restored success.

Value of magnetic resonance imaging of the lumbosacral spinal cord in patients with voiding dysfunction.

PURPOSE: We evaluated the role of magnetic resonance imaging (MRI) of the lumbosacral spinal cord in patients with voiding complaints and abnormal urodynamic findings but normal neurological and lower spine examinations. MATERIALS AND METHODS: We studied 17 women and 13 men 17 to 50 years old (mean age 32.2) who presented with voiding complaints. All patients had a completely normal neurological examination and no evidence of prostatic enlargement. Of the 30 patients 18 had incontinence (17 urge, and 1 stress and urge), 9 frequency and urgency alone, and 3 urinary retention. Seven patients had persistent enuresis (2 primary and 5 secondary). All 30 patients underwent multichannel urodynamics and MRI of the lower spinal cord. RESULTS: On urodynamic testing, 25 patients had bladder instability, 3 a hypocontractile or weak detrusor, 1 significantly decreased sensation only and 1 stress incontinence. No patient had detrusor external sphincter dyssynergia or outflow obstruction. Only 1 patient with frequency and urgency had a significant finding on MRI (tethered cord) that required surgery. CONCLUSIONS: In young adults who have voiding complaints and abnormal urodynamic findings, with normal neurological and lower spine examinations, the value of MRI of the lumbosacral spine is limited.

Laparoscopic Burch bladder neck suspension: early results.

PURPOSE: The Burch suspension is an effective treatment for stress urinary incontinence due to hypermobility. To decrease the associated morbidity and hospital stay, we attempted the procedure laparoscopically in 46 women. MATERIALS AND METHODS: All patients had stress incontinence with bladder neck hypermobility. Preoperative testing included cystoscopy, multichannel urodynamics with pressure-flow studies and measurement of Valsalva leak point pressure. Mean patient age was 49.5 years (range 26 to 70). RESULTS: In 12 patients the laparoscopic approach could not be completed and an open operation was performed. Of the 34 laparoscopic Burch procedures 13 were performed transperitoneally and 21 extraperitoneally. Mean operative time was 196 minutes (range 130 to 300), mean blood loss 96.3 cc (range 50 to 400) and mean postoperative hospital stay 3.2 days (range 1 to 8). Five postoperative complications included hematoma/anemia in 2 patients, transient urinary retention in 1, enterocele in 1 and uterine prolapse in 1. Mean followup was 17.3 months (range 12 to 26). Of the 34 patients only 5 had persistent incontinence postoperatively (3 with stress and urge incontinence, 1 with stress incontinence only and 1 with urge incontinence only). Overall, 85% of the patients are totally dry. With experience the operative time and postoperative stay decreased. The extraperitoneal and transperitoneal approaches provide certain advantages. CONCLUSIONS: The Burch suspension performed laparoscopically appears to have a favorable morbidity profile with a successful continence outcome. However, there is a steep learning curve to the procedure as manifested by the long operative time.

Upper urinary tract videourodynamics: a more complete Whitaker test.

A modification of the Whitaker test is described using only a single nephrostomy tube for both inflow and pressure measurement. The technique also includes ureteral transit time and fluoroscopic imaging. This technique has been used in ten patients, all of whom had symptoms and/or imaging suggesting obstruction. Five patients had no obstruction on testing with true renal pelvic pressures 20cm. This technique requires only one access port into the renal pelvis. The addition of fluoroscopy and ureteral transit time considerably aided our interpretation of the test. These modifications have made the Whitaker test more complete.

Acute urinary retention in men: a comparison of voiding and nonvoiding patients after prostatectomy.

Multiple parameters were examined preoperatively to determine if any could predict successful voiding after prostatectomy in male patients who present in acute urinary retention due to benign prostatic hypertrophy. A total of 50 men 50 to 85 years old (mean age 69.5 years) who presented with this clinical picture was investigated with multichannel urodynamic studies, and completed the American Urological Association (AUA) symptom score for benign prostatic hypertrophy preoperatively and postoperatively. All patients underwent prostatectomy. Mean retention volume was 1,172 cc (range 500 to 2,100). Mean preoperative and postoperative AUA symptom scores were 15.5 and 5.0, respectively. At 3 months postoperatively 45 patients (90%) were able to void without catheterization. At 16.6 months 5 patients still required clean intermittent catheterization to empty the bladder. Postoperatively, there was a statistically significant improvement in AUA symptom score, opening voiding pressure and peak flow rate. The AUA symptom score was not predictive of either impending acute retention or normal voiding after prostatectomy. In our patients no preoperative parameters were statistically different between those voiding and those on clean intermittent catheterization. However, poor sensation, large retention volumes, lack of instability and no voluntary detrusor contractions were more common in the nonvoiding men.

Urodynamic comparison of ileum vs. sigmoid in augmentation cystoplasty for neurogenic bladder dysfunction.

We performed multichannel urodynamics before and after augmentation cystoplasty in 26 patients (11 females, 15 males) to determine which bowel segment is best to achieve a large volume and low pressure reservoir. All 26 patients had a neurogenic cause for their bladder dysfunction. Ileum was used in 14 patients and sigmoid was used in 12 patients. Detubularization was performed in all patients. Capacity improved significantly in both the ileum and the sigmoid group after surgery. When detubularized ileum was used, the maximum amplitude of uninhibited reservoir contractions was significantly improved or eliminated postoperatively. When sigmoid was used, uninhibited reservoir contractions did not significantly improve postoperatively and were, in fact, more common than preoperatively. Despite the detubularization, pressure waves were identified in 15 of the 26 patients postoperatively. There was significant improvement in end filling pressures at capacity (compliance) with both ileum and sigmoid postoperatively. However, end filling pressures were significantly higher in the sigmoid group. In conclusion, good capacity was achieved with both ileum and sigmoid postoperatively. However, ileum provided lower reservoir pressures and better compliance. We feel that urodynamically detubularized ileum is better suited than sigmoid for augmentation cystoplasty in patients with neurogenic bladder dysfunction.

Urinary undiversion in adults with myelodysplasia: long-term followup.

A total of 14 women and 6 men 19 to 39 years old (mean age 27 years) with myelodysplasia underwent undiversion 8 to 29 years (mean 16) after ileal conduit diversion. The main reasons for diversion were incontinence in 17 patients and failed ureteral reimplants in 3, and those for undiversion were a desire for an improved quality of life in 16, increasing hydronephrosis in 4 and stomal problems in 3. Preoperative assessment included upper and lower tract imaging, and video urodynamics. Operations on the ureters included reimplantation into an intussuscepted nipple valve in 8 patients, tunneled reimplants into a sigmoid augmentation in 3 and the ureters joined to either the bladder or lower ureter without interposing bowel in 9. All reimplantations were done with nonrefluxing techniques. A total of 18 patients underwent bladder augmentation and 2 women in whom cystectomy was performed for pyocystis underwent substitutions. Simultaneous continence procedures in 18 patients included trigonal tubularization in 2, artificial sphincter implantation in 2, a bladder neck sling in 5 or bladder neck tapering and a sling in 9. The patients were followed for a mean of 69 months (range 21 to 133). Eight patients required reintervention within 1 year for problems, such as anastomotic leak in 1, bladder neck obstruction in 1, incontinence in 1, artificial urinary sphincter revisions in 1 and bladder stones in 1. One patient had a recurrent renal calculus 10 years after undiversion. All patients experienced either persistence of normal upper tract appearance or improvement and/or stabilization of hydronephrosis. Mean bladder capacity was 77 cc preoperatively and 480 cc postoperatively, while mean pressure at capacity decreased from 50 to 14 cm. water with detubularized augmentation. Of the patients 17 are completely dry, 2 wear 1 pad per day and 1 has enuresis. All but 1 patient who voids with straining are on intermittent self-catheterization. All patients, on followup interviews, reported an improved quality of life without a stoma. We conclude that undiversion provides an improved quality of life and an acceptable morbidity rate. The choice of operation depends on the anatomy of the patient. We prefer a nonprosthetic type of incontinence procedure when intermittent self-catheterization is to be done. No long-term morbidity has yet been noted.

Topical minoxidil in the treatment of male erectile dysfunction.

Topically applied 2% minoxidil solution has been reported to increase diameter, rigidity and arterial flow to the penis. As a result it has been suggested as a possible treatment for erectile dysfunction. A total of 21 patients received 2% minoxidil for treatment of erectile dysfunction with instructions to apply 1 cc of the solution slowly over the glans penis 20 minutes before intercourse. Average patient age was 52.5 years (range 29 to 65 years). The etiology of the impotence was neurogenic in 8 patients, vascular in 7, psychogenic in 4 and other causes in 2. Two patients also had clinical evidence of venous incompetence and 4 were diabetics. One patient with psychogenic impotence noticed improvement in the duration of erection but no increase in rigidity or size after minoxidil application. One patient with impotence after excision of a Peyronie's plaque reported a rigid erection adequate for intercourse after using minoxidil. This patient subsequently was able to achieve erections without using minoxidil. The remaining 19 patients had no improvement in erectile rigidity, or the ability to obtain or maintain an erection. One patient did notice some mild burning on the glans penis after applying the minoxidil. No other side effects were noted in any patient. These results indicate that 2% topical minoxidil solution is not effective when applied to the penis in the treatment of erectile dysfunction. It is possible that a higher concentration, a different delivery medium or a different chemical composition may yield better results.

Experience with the hemi-Kock ileocystoplasty with a continent abdominal stoma.

We describe our experience with the hemi-Kock ileocystoplasty with a continent abdominal stoma as an alternative to an indwelling catheter or supravesical diversion in 14 women and 4 men with various problems who could not perform intermittent urethral self-catheterization. The aim of management was also to provide, if possible, a competent urethra for additional access. Mean patient age was 37 years (range 22 to 75) and mean followup was 26 months (range 5 to 58). Preoperative management in the 11 wheelchair dependent women with neurological disease was an indwelling catheter in 7, urethral intermittent catheterization with the patient in the supine position in 3 and diapers in 1. Two women with a nonneurogenic bladder and a grossly incompetent urethra (1 after multiple incontinence and fistula repairs, and 1 after severe obstetrical trauma) wore diapers, while 1 with urinary retention and inability to perform self-catheterization had an indwelling catheter. The 4 men included 2 wheelchair dependent incontinent spinal cord injury patients who could not be managed with condom drainage, 1 with multiple anomalies who had trouble with self-catheterization, and 1 with an impassable postoperative stricture and a suprapubic tube. Surgery included anti-incontinence procedures in 10 patients and bladder neck closure in 3. A total of 15 patients required bladder augmentation in addition to the stoma and 3 had a stoma alone. Postoperative intervention was necessary in 4 women for stomal incontinence and in 2 of these bladder stones were removed simultaneously. One of these women was later treated for recurrent stones cystoscopically through the stoma. Overall, 17 of 18 patients are dry on intermittent stomal catheterization, with 1 lost to followup. We conclude that this procedure is a good alternative in patients with an end stage urethra or who cannot perform urethral catheterization because of physical disability. Establishing urethral continence and maintaining patency leaves a safety valve should the stoma fail. Since the bladder remains as a reservoir no ureteral surgery is necessary.

Early experience with intraurethral collagen injections for urinary incontinence.

We report on 41 patients (10 men and 31 women) who underwent collagen injections for urethral incompetence. Mean followup was 6 months (range 3 to 11 months) in men cured or improved, 8.4 months (range 3 to 15 months) in women who were cured and 4.5 months (range 2 to 10 months) in women who were improved. In women the procedure was usually performed through a periurethral approach while they were under local anesthesia and in men it was performed transurethrally while under either general or local anesthesia. Of the 31 women 28 (90.3%) were cured (15) or improved (13). Mean maximum Valsalva pressure increased from 31 cm. water before injection to 85 cm. water at 6 months after injection in women who were cured or improved. The mean amount of collagen used in the female group was 12.7 cc (range 2.5 to 47.5) and the mean number of treatments was 2 (range 1 to 7). Of the men 7 (70%) had successful results (2 cured and 5 improved). In contrast to the women, they required a mean of 51.8 cc (range 7.5 to 82.5) of collagen and a mean of 6 treatments (range 3 to 12). Of 5 patients with bladder instability 4 did not improve. One patient suffered acute bacterial prostatitis and 2 patients had post-injection urinary retention. All women with little or no bladder neck hypermobility (types 1 and 3) were either cured or improved. We conclude that intraurethral collagen injection is safe and simple to perform. The results achieved in women are acceptable. In men, while collagen does provide improvement, the cost-to-benefit ratio and effectiveness are less than those in women. Instability may obviate a good outcome.

The value of immediate or early catheterization of the traumatized posterior urethra.

A total of 16 patients with posterior urethral ruptures was treated with the aim of reestablishing urethral continuity immediately or early after injury. Followup ranged from 13 to 83 months (average 27). In all patients an emergency retrograde urethrogram demonstrated extravasation from the posterior urethra. Of the patients 13 were treated with a urethral catheter either immediately or within 1 to 5 weeks after injury. Three patients were treated with a suprapubic catheter alone after unsuccessful attempts at reestablishing urethral continuity and all 3 subsequently required urethroplasty for an obliterative stricture. These 3 patients were also impotent after injury. Of the 13 patients treated with a urethral catheter 8 had the catheter inserted either retrograde (2) in the emergency room or antegrade (6) in the operating room just after the injury, and in 5 the catheter was inserted transurethrally at cystoscopy within a mean of 3 weeks after injury. A total of 7 patients (54%) treated with urethral catheterization had a stricture during followup: 4 responded well to internal urethrotomy and 3 required simple dilation. Of 12 patients 5 (42%) became impotent after injury, while 1 was impotent before injury. No patient became incontinent. We conclude that careful urethral catheter realignment either immediately or within 5 weeks after injury is safe and obviates total urethral closure. Impotence may result from the severity of the injury and not from management with catheterization.

Fascial slings and bladder neck tapering in the treatment of male neurogenic incontinence.

Intractable incontinence in selected male patients with a neurogenic bladder has been treated by increasing bladder compliance with augmentation cystoplasty and increasing urethral resistance with the artificial urinary sphincter. However, there are a number of complications associated with the use of an artificial urinary sphincter. As an alternative, we performed bladder neck tapering and bladder neck slings in 13 men with a neurogenic bladder and an incompetent urethra (10 with spina bifida and 3 with spinal cord injury) undergoing bladder augmentation. Mean patient age was 27 years (range 17 to 40 years) and mean followup was 34.3 months (range 5.5 to 49 months). Postoperatively, there was a 113% increase in mean bladder capacity (from 260 to 550 cc) and a 62% decrease in mean bladder pressure at capacity (from 53 to 20 cm. water). The earliest 2 patients with a Marlex sling suffered erosions that were treated with transurethral excision. As a result, the 11 subsequent patients had a rectus fascial sling. Nine patients (69.2%) are completely dry on self-catheterization, 2 (15.4%) required collagen injections for improved continence and 2 failures (15.4%) required additional procedures. The complications in these patients are comparable to, if not better than, the use of an artificial urinary sphincter. We conclude that a fascial sling with bladder neck tapering is an excellent alternative to the artificial urinary sphincter in the treatment of male neurogenic bladder with an incompetent urethra.