Artificial Sphincter Placement Research Articles

Placement of an artificial urethral sphincter for treatment of passive urinary incontinence after inadvertent prostatectomy and balloon dilation treatment for stricture formation in a 5-month-old dog.

Describe the management of incontinence with several therapies, culminating with the apparently successful treatment utilizing artificial sphincter placement following an inadvertent prostatectomy. 5-month-old 7.5-kg male neutered Miniature Schnauzer. The patient was referred for dysuria and persistent stranguria following an iatrogenic total prostatectomy and urethrectomy. An extra pelvic urethral anastomosis was performed, followed by hospitalization for 2 weeks with a urinary catheter. The patient was further investigated for persistent stranguria, and a contrast urethrogram revealed a urethral stricture at the anastomosis site, which was treated with fluoroscopic balloon dilation. The stranguria resolved, but an acute nocturnal grade 3 passive urinary incontinence occurred, which was nonresponsive to medical management of phenylpropanolamine hydrochloride and estriol. An artificial urethral sphincter was placed, leading to continence after 5 top-ups to a total volume of 0.9 mL. The patient remained continent for 5.5 weeks before abrupt incontinence recurred, which was resolved by another 0.1-mL top-up. No further signs of incontinence occurred in the 11 months following. The placement of an artificial urethral sphincter successfully managed urinary incontinence in this patient. Continence was achieved with no significant complications other than a transient loss of continence. Long-term follow-up 14 months after sphincter placement revealed that the patient had remained continent since the final sphincter top-up. The owner reported a significant improvement in the patient's quality of life following successful incontinence management. This case highlighted the benefits of placing an artificial urethral sphincter in managing urinary incontinence after select cases of prostatectomy in dogs that are unresponsive to medical management.

A Full Bladder Is Not Needed for the Male Stress Incontinence Grading Scale.

Our objectives were to evaluate the Male Stress Incontinence Grading Scale to stratify male patients with stress urinary incontinence for either artificial urinary sphincter or sling using a standing cough test and determine if an emptier bladder at the time of assessment carries increased risk of treatment failure. Retrospective chart review of male patients undergoing sling and artificial urinary sphincter placement. The standing cough test score and bladder scan results were documented at initial evaluation. Forty patients underwent sling and 43 underwent naïve artificial sphincter placement. Median follow-up was 7.11 months. Thirty-six/forty slings had complete incontinence resolution or reduction to a safety pad vs 40/43 after sphincter (90% vs 93%, P = .62). Four sling patients (10%) had persistence or recurrence of incontinence. Cough test scores were similar between sling failure (67% grade 0, 33% grade 1) and success groups (83% grade 0, 3% grade 1, 14% grade 2). Bladder scan mean was 18.5 cc in the sling failure (SD 21.1) and 38.0 cc in the success groups (38.3), with 32% of success patients having bladder scans of 0 cc, and 63% of < 50 cc. Mean for sphincter patients was 45 cc (56.9). Ten patients with scan = 0 and 7 patients with scans < 30 cc demonstrated grade 4 incontinence. Cough test is a noninvasive, reliable tool to assess stress urinary incontinence severity. Our data suggest it is reliable even when bladders are nearly empty and can effectively stratify patients for sling vs artificial urinary sphincter with a high rate of success.

Synchronous Bladder Neck Contracture Dilation at the Time of Artificial Urinary Sphincter Placement Is Safe and Effective

To treat men with bladder neck contracture and stress urinary incontinence, neither long-term nor comparative data exist to support the superiority of simultaneous bladder neck contracture intervention at the time of artificial urinary sphincter placement (synchronous) or staged bladder neck contracture intervention followed by artificial urinary sphincter placement (asynchronous). This study aimed to compare outcomes of patients treated with synchronous and asynchronous protocols. Using a prospectively maintained quality improvement database, we identified all men between the years of 2001-2021 with a history of bladder neck contracture and artificial urinary sphincter placement. Baseline patient characteristics and outcome measures were collected. Categorical data was assessed with Pearson's Chi-square and continuous data was assessed using independent sample t-tests or Wilcoxon Rank-Sum test. In total, 112 men met inclusion criteria. Thirty-two patients were treated synchronously and 80 were treated asynchronously. There were no significant differences between groups across 15 relevant variables. Overall follow-up duration was 7.1 (2.8,13.1) years. Three (9.3%) in the synchronous group and 13 (16.2%) in the asynchronous group experienced an erosion. There were no significant differences in frequency of erosion, time to erosion, artificial sphincter revision, time to revision, or bladder neck contracture recurrence. Bladder neck contracture recurrences after artificial sphincter placement were treated with serial dilation with no early device failure or erosion. Similar outcomes are achieved following synchronous and asynchronous treatment of bladder neck contracture and stress urinary incontinence. Synchronous approaches should be considered safe and effective for men with stress urinary incontinence and bladder neck contracture.

Artificial Urinary Sphincter in a High-Risk Urethra: Transcorporal Gullwing Modification Description of the Technique.

In this report, we describe a modification of transcorporal artificial urinary sphincter place ment known as Gullwing modification. Using a penoscrotal approach, bilateral corpora cavernosa flaps are harvested and sutured in the midline covering the lateral and ventral surfaces of the urethra. Transcorporal cuff placement provides dorsal reinforcement, thus having extra tissue buttressing all the circumference in cases of a fragile urethra due to previous urethral cuff erosion, urethroplasty, or pelvic radiotherapy. After previous urethral cuff erosion, radiotherapy, and urethral reconstruction, our patient complained of severe stress urinary incontinence. Due to the high risk of urethral complications, we proceed to a transcorporal artificial sphincter placement with urethral reinforcement through a bilateral cavernosal flap. The surgery was successfully completed, and after 6 weeks, sphincter was activated with satisfac tory results. Two years after surgery, his continence status is stable without complications. Urethral complications associated with artificial urinary sphincter surgery remain a challenge for the reconstructive surgeon. Reinforcement of the ventral aspect of the urethra through corpora cavernosal flaps may reduce the likelihood of urethral erosion in high-risk cases.

Robot-Assisted Bladder Augmentation and Artificial Sphincter Placement

Abstract Introduction: Augmentation cystoplasty (AC) has traditionally been used in the treatment of low capacity, poorly compliant, or refractory overactive bladder (OAB). The concept of AC is to ...

WITHDRAWN: Prerectal-transperineal approach for treatment of recurrent vesico-urethral anastomotic stenosis after radical prostatectomy

Abstract Vesico-urethral anastomotic stenosis (VUAS) after radical prostatectomy is a narrowing of the vesicourethral anastomosis after radical prostatectomy. We aim to describe a safe re-anastomotic procedure for recurrent bladder neck contracture following radical prostatectomy (RP). This technique allows an easier access to the stenotic vesico-urethral anastomosis, a better mobilization of the bladder neck and a tension free re-anastomosis. Twelve patients suffering from VUAS after radical prostatectomy were enrolled between May 2014 and September 2018. We describe our approach to the disease. The evaluated outcomes were intra- and post-operative complications, stricture recurrence, and postoperative stress incontinence. Average operative time was 3 h. No major intraoperative complications or bleeding occurred. Patients were discharged after 72 h. At the time of catheter removal, 3 weeks after surgery, 9 out of twelve patients developed stress urinary incontinence, requiring 4 pads/day. Two patients with history of pelvic radiotherapy developed a surgical site abscess that required toilette and external urinary diversion. One recurrence occurred and was treated with internal urethrotomy before sphincter placement. No patient reported significant postoperative pain or fecal incontinence. Our approach allows direct access to the posterior urethra, and we demonstrate the advantages for treatment of VUAS to achieve a tension free anastomosis. All patients need to be informed of subsequent urinary incontinence to be treated with artificial sphincter placement. Patients with a history of pelvic radiotherapy show very poor preoperative conditions of the tissues and must be informed about the possibility of an external urinary diversion.

VE10 - Robotic-assisted bladder augmentation and artificial sphincter placement for neurogenic bladder dysfunction: A step-by-step procedure

VE10 - Robotic-assisted bladder augmentation and artificial sphincter placement for neurogenic bladder dysfunction: A step-by-step procedure

Impact of Radiation and Transcorporeal Artificial Sphincter Placement in Patients with Prior Urethral Cuff Erosion: Results from a Retrospective Multicenter Analysis

Many providers elect to use a transcorporeal approach for artificial urinary sphincter placement in an attempt to minimize risks, given the increased risk of complications in revision cases. We present outcomes in a multicenter retrospective analysis of artificial urinary sphincter cuff reimplantation in patients with prior cuff erosion with special consideration given to the transcorporeal approach. We compiled a multi-institutional database of patients who underwent artificial urinary sphincter reimplantation after prior urethral erosion. Of the 34 identified patients 24 underwent transcorporeal cuff replacement. Patients with transcorporeal cuff replacement were further analyzed with specific stratification for radiation therapy. The rate of subsequent complications after eroded cuff reimplantation was 32.4% (11 of 34 patients). The most frequent complication was recurrent erosion, which developed in 9 of the 34 patients (26.4%). Repeat artificial urinary sphincter complications developed more frequently in patients with history of radiation compared to nonirradiated patients (8 of 16 or 50% vs 3 of 18 or 16.7%). However, this difference was not statistically significant (p = 0.066). The transcorporeal technique was applied in 24 of 33 patients (70.5%) and relative to the nontranscorporeal group there was no difference in the complication rate (p= 0.438). On subgroup analysis of the transcorporeal group there was a higher rate of repeat complications in irradiated patients (p = 0.006). These data suggest that transcorporeal cuff reimplantation may not decrease the incidence of repeat complications after prior cuff erosion. However, radiation therapy is associated with a worse outcome even when transcorporeal cuff placement is performed.

A two staged treatment procedure for the difficult to treat bladder neck contractures with concomitant incontinence. In the search of a solution to a complex problem.

To examine the efficacy of a two staged treating strategy with the use of a non-permanent urethral ALLIUM(®) stent for the management of recurrent bladder neck stenosis and subsequently the use of an artificial sphincter AUS800(®) by AMS for the management of the incontinence. We progressively identified patients eligible for the study creating a population of cases with recurrent bladder neck stenosis and concomitant incontinence occurring after the last intervention for the stenosis. Efficacy for the treatment of the stenosis was defined as no recurrence both prior and post to the sphincter placement and efficacy for the treatment of the incontinence was defined as continence (0-1pads) after the sphincter placement. 14 white males with a mean age of 66.21, ranging from 59 to 73 years consisted the population of the study. All patients had severe stress incontinence following the last transurethral resection. The efficacy of the treatment of the bladder neck stenosis was 93% (13/14) while the efficacy for the treatment of the incontinence was 100%. A single patient had a recurrent bladder neck stenosis after the artificial sphincter placement and was treated with transurethral resection using a long pediatric 13 F resectoscope at 12 months. Our limitations is the absence of a control group and the small number of patients enrolled, with a relatively short time of follow up. In our series we propose the use of a non-permanent urethral ALLIUM(®) stent for 6 months in order to control the growth of fibrotic scar tissue, a further 6 months follow up for recurrence, and then placement of an artificial sphincter. The results are very promising both on stabilizing the vesicourethral stenosis, and on patient safety and tolerability.

Management of Stress Urinary Incontinence in the Neobladder Patient

Considering the intent for provision of near-normal urinary function with an orthotopic diversion, issues with voiding dysfunction and urinary incontinence manifest substantial impact on quality of life for neobladder patients. Following appropriate functional and anatomic evaluation, often employing cystoscopy and urodynamics, multiple treatment strategies are available for treatment of stress incontinence in this complex patient population. Conservative modalities including pelvic floor physical therapy, behavioral therapies, and general education regarding neobladder diversion are foremost. Pharmacologic therapies may be suitable in select circumstances. Minimally invasive treatments such as transurethral bulking agents can provide improvement for women with stress incontinence following orthotopic diversion; however the risk profile may preclude use in many patients. Midurethral tape technologies, including transobturator and single incision slings, represent a comparatively recent iteration of implements to be considered. The pitfalls of fascial pubovaginal sling include navigation of complex anatomy combined with a high rate of urinary retention. In men, artificial urinary sphincter continues to exemplify an effective continence procedure following neobladder diversion with only a modestly elevated complication profile in these high risk patients. Male sling technologies are additionally gaining appreciation as an option for treatment of sphincteric dysfunction following orthotopic neobladder and forgo several drawbacks associated with artificial sphincter placement.

Long-Term Device Outcomes of Artificial Urinary Sphincter Reimplantation Following Prior Explantation for Erosion or Infection

We evaluated clinical outcomes in patients treated with artificial urinary sphincter reimplantation after artificial urinary sphincter explantation for erosion or infection. We identified 704 consecutive artificial urinary sphincter implantation procedures performed at our institution from 1998 to 2012, including 497 (71%) as primary implantation and 138 (20%) as revision surgery for device malfunction. A total of 69 patients (10%) had undergone at least 1 prior artificial urinary sphincter explantation secondary to urethral erosion and/or device infection, of whom 36 (52%) were treated with 2 to 5 prior reimplantation procedures. Patient followup was performed through office examination, or written or telephone correspondence. Patients treated with artificial urinary sphincter reimplantation had a median age of 78 years (IQR 72, 80) and a median followup of 34 months (IQR 5, 61). Artificial urinary sphincter reimplantation was done a median of 9 months (IQR 6, 13) after explantation. Patients treated with reimplantation after erosion or infection were more likely to require repeat explantation than those with primary implantation (13 of 69 or 19% vs 32 of 497 or 6.4%, p = 0.002). However, when evaluating repeat procedures, the 5-year device survival rate after reimplantation due to erosion or infection vs primary implantation was 68% vs 76% (p = 0.38). Our findings suggest that artificial urinary sphincter reimplantation after explantation for urethral erosion and/or device infection is associated with an increased rate of recurrent erosion/infection requiring repeat explantation. However, in appropriately selected and counseled patients clinically acceptable long-term device use can be achieved.

Surgery for Post-Prostatectomy Incontinence - A Changing Field

The most common cause of male stress urinary incontinence is intrinsic sphincter deficiency secondary to iatrogenic injury during prostate cancer surgery. While conservative management is typically offered during the first 6-12 months, most efficacious therapeutic options are surgical in nature. The most common treatments include periurethral bulking, artificial urinary sphincter, and various male slings. During the last 15 years, innovations in malesling design and technique have resulted in a substantially greater interest in this particular option. With several choices now available to patients, the number of sling surgeries performed each year is steadily increasing. Recent evidence has demonstrated that male slings are most efficacious in men with mild to moderate stress incontinence, no history of pelvic radiation, and without prior artificial sphincter placement. In this population, high efficacy with verylow complication rates can be expected. In men with more severe incontinence, especially following radiotherapy, the artificial urinary sphincter typically offers predictably reliable efficacy, with an acceptably low complication rate. Recent advancements in sling technology may provide improved efficacy even in those with more severe leakage.

Slings for Stress Urinary Incontinence in Men: An Update

Stress urinary incontinence is usually caused by iatrogenic injury during prostate cancer surgery. Most treatment options are surgical in nature and include periurethral bulking, artificial urinary sphincter, and male slings. During the past decade, innovations in male sling surgery have contributed to an increased interest in their use among treating urologists and their patients. Currently, male slings are most efficacious in men with mild to moderate stress incontinence, with no prior history of pelvic radiation, and without prior artificial sphincter placement. In this population, high efficacy rates and low complication rates are typically achieved.

Perineal Approach for Artificial Urinary Sphincter Implantation Appears to Control Male Stress Incontinence Better Than the Transscrotal Approach

Traditionally cuff placement of an artificial urinary sphincter is done through a perineal approach. A new approach through a penoscrotal incision or transscrotal approach is reportedly more rapid and easier than the traditional incision. These 2 approaches were evaluated to determine which one controlled male stress urinary incontinence better. We performed a retrospective chart review of 94 patients who underwent artificial urinary sphincter placement procedures from April 1987 to March 2004. A total of 126 artificial urinary sphincter cuffs (120 procedures, including double cuff placement in 6) were placed in 94 patients with 63 placed penoscrotally and 63 placed perineally. Of the double cuff placements 1 was perineal and 5 were transscrotal. In patients with a single initial or revision cuff the self-reported completely dry rate was 28.6% with the penoscrotal approach and 56.5% with the perineal approach (p = 0.01), while for initial cuffs only the dry rate was 28.0% and 56.7% for the penoscrotal and perineal approach, respectively (p = 0.03). Five of 28 patients (17.9%) with initial penoscrotal placement later underwent tandem cuff placement for continued incontinence, whereas only 1 of 32 (3.1%) with initial perineal placement later had a tandem cuff added (p = 0.06). There was no difference in the estimated failure-free survival (failure for any reason) of the device. When the artificial urinary sphincter cuff is placed through a perineal approach, there appears to be a higher completely dry rate and fewer subsequent tandem cuff additions than when the artificial urinary sphincter cuff is placed through a penoscrotal incision.

MORBIDITY AND FUNCTIONAL OUTCOMES OF SALVAGE RADICAL PROSTATECTOMY FOR LOCALLY RECURRENT PROSTATE CANCER AFTER RADIATION THERAPY

Few patients with locally recurrent prostate cancer after external beam (EB) or interstitial (I) radiotherapy (RT) are considered candidates for salvage radical prostatectomy (RP) due to high reported rates of major complications and urinary incontinence. We report the morbidity associated with salvage RP in 100 consecutive patients. From 1984 to 2003 salvage RP was performed for recurrent prostate cancer following EBRT in 58 cases, and IRT in 42 (28 retropubic) and (14 transperineal). Clinical information was obtained from a prospective database. Since 1993, the major complication rate has decreased significantly (13% vs 33%, p = 0.02), including the rectal injury rate (2% vs 15%, p = 0.01). Compared with retropubic IRT and/or pre-radiotherapy pelvic lymph node dissection the risk of major complications following EBRT or transperineal IRT was significantly less (OR 0.2, p = 0.006). At 5 years an estimated 39% of patients were dry and 68% required 1 pad daily or less. A total of 23 patients with moderate-severe incontinence underwent artificial sphincter placement. The anastomotic stricture rate was 30%. The 5-year potency rate was 28% following unilateral or bilateral nerve sparing RP and 45% in previously potent patients. Due to patient selection the major complication rate after salvage RP has improved significantly with time and it is similar to that of standard RP. Rates of anastomotic stricture and moderate to severe incontinence are higher than those observed after standard RP. However, most patients recover reasonable urinary continence and a substantial number of select patients recover potency. The acceptable morbidity profile of salvage RP following EBRT and transperineal IRT should persuade more physicians to consider patients for this potentially curative procedure.

Transcorporal Artificial Urinary Sphincter Cuff Placement in Cases Requiring Revision for Erosion and Urethral Atrophy

A distal cuff location is often required in patients undergoing artificial urinary sphincter reimplantation after previous erosion or in those requiring revision because of urethral atrophy at the original cuff site. Dissecting the urethra at a more distal site increases the risk of urethral injury and erosion, and often the urethral circumference is so small that a 4 cm. cuff is too large. We present a novel technique for distal cuff placement using transcorporal dissection that leaves corporal tunica albuginea on the dorsal surface of the urethra, allowing for its safer mobilization and adding to its bulk. We reviewed the charts of 31 men who underwent this technique and contacted 26 by telephone. The indications for distal transcorporal cuff placement varied. In 7 men with inadequate urethral coaptation with a 4 cm. proximal cuff at initial implantation a primary transcorporal tandem cuff was implanted distal. In 8 men persistent or recurrent incontinence despite a 4 cm. proximal cuff led to secondary distal reimplantation. Previous artificial urinary sphincter erosion and/or infection in 10 cases, previous urethral surgery at the optimal cuff site in 5 and radiation changes at the optimal cuff site in 1 led to selection of the more distal site and technique. Of the transcorporally placed cuffs 18 were 4 cm. and 13 were 4.5 cm. Preoperatively 5.2 pads were used daily. Of the 31 patients 27 were impotent preoperatively, 1 had normal erections, 1 had partial erections with the MUSE drug delivery system (Vivus, Inc., Menlo Park, California) and 2 had a previously placed penile prosthesis. At a mean followup of 17 months 26 of the 31 patients (84%) had occasional or no stress incontinence requiring 0 to 1 pad daily, 2 with pure urge incontinence used 1 to 2 pads daily and 3 had mixed incontinence requiring 0 to 3 pads daily. Of the 26 men surveyed 25 were very satisfied with the postoperative level of incontinence. Postoperatively erectile function deteriorated in 1 patient and was unchanged in the remainder. There was no erosion or infection of the transcorporally placed cuffs, although 3 were replaced for malfunction. This technique offers significant advantages in cases of revision. The technique protects the urethra from intraoperative dissection injury and decreases the risk of erosion because the urethra is buttressed at its vulnerable location. In addition, bulk is added to the urethra, allowing for better cuff sizing, which is usually a problem at this location where the urethra is small, thereby, improving continence in revised cases. Our success has recently led us to abandon tandem cuff placement altogether. There is a potential for deteriorating erectile function in potent men who undergo implantation in this fashion.

MANAGEMENT OF CUFF EROSION OF THE DOUBLE CUFF ARTIFICIAL URINARY SPHINCTER

We report on a series of patients with erosion of 1 cuff of an AMS800 double cuff artificial urinary sphincter and determine the success rate of removing the eroded cuff, leaving the other components behind and converting the device to a single cuff system. In 9 patients with a double cuff artificial sphincter 1 eroded cuff was removed and the system was converted to a single cuff sphincter. Followup was based on an incontinence scoring system. In 1 patient the remaining cuff was removed because it also eroded. In another patient a wound infection developed 5 months after placement and the entire device was removed. The remaining 7 patients had better continence scores than before artificial sphincter placement but each remarked that continence was better with 2 cuffs. An eroded cuff of a double cuff artificial urinary sphincter system can be successfully removed and the device can be converted to a single cuff system.

OBLITERATIVE VESICOURETHRAL STRICTURES FOLLOWING RADICAL PROSTATECTOMY FOR PROSTATE CANCER: RECONSTRUCTIVE ARMAMENTARIUM

Purpose We report the reconstructive techniques used to correct obliterative vesicourethral strictures related to prostate cancer surgery. Materials and Methods Four men with anastomotic obliteration after radical prostatectomy underwent primary excision with end-to-end anastomosis, penile fasciocutaneous flap, free-graft urethroplasty with rectus muscle flap or anterior bladder tube with omental flap procedure. Results At mean followup of 33.8 months all patients had urethral patency but none was continent. Conclusions Single stage reconstruction of the obliterated vesicourethral anastomosis after prostatectomy successfully restored urethral patency. No technique was applicable in all cases. Sphincteric function is likely to be compromised after the primary procedure, resulting in incontinence after successful urethral reconstruction. Subsequent artificial sphincter placement appears to be safe and helpful in restoring continence.

Bladder Neck Reconstruction: Long-term Followup of Reconstruction With Omentum and Silicone Sheath

Purpose In 1986 we reported the placement of a silicone sheath sandwiched between layers of omentum around a newly reconstructed bladder neck. We now present long-term followup of 94 cases of silicone sheath bladder neck reconstruction. Materials and Methods A total of 94 silicone sheaths was placed in 84 patients between August 1983 and October 1992. We retrospectively reviewed our results and divided the reconstructions into 3 groups according to modifications in surgical technique. We report the results of each modification and current recommendations for use. Results Each sequential modification of silicone sheath bladder neck reconstruction significantly reduced the risk of erosion from 100 percent, 32 percent 7 percent, respectively (p less than 0.05). Erosion was independent of patient age, sex, pathological condition or whether bladder neck reconstruction was a repeat procedure. Patients who had silicone sheath erosion did not have different continence or loss of urethral continuity than those with no erosion. In 13 patients (16 percent) artificial sphincter placement was clearly facilitated by the silicone sheath. Conclusions Modifications in the surgical technique of silicone sheath placement around a reconstructed bladder neck have resulted in a decrease in the erosion rate to 7 percent. The primary benefit of silicone sheath placement is ease of subsequent sphincter placement. Currently we reserve silicone sheath placement for a small subset of patients who are most likely to benefit from subsequent artificial sphincter placement.

Influence of Preoperative Bladder Capacity and Compliance on the Outcome of Artificial Sphincter Implantation in Patients with Neurogenic Sphincter Incompetence

We performed a retrospective study of 23 patients with neurogenic sphincteric incompetence who had undergone implantation of an artificial urinary sphincter to determine if bladder capacity and compliance as determined by cystometrography could predict the need for enterocystoplasty. Study criteria were neurogenic sphincteric incompetence, no previous operations on the lower urinary tract, and performance of preoperative and postoperative cystometrography. Patients were 5 to 17 years old at implantation.Incontinence was caused by myelomeningocele (18 patients), sacral agenesis (3) and spinal cord tumor (2). The 8 patients for whom preoperative cystometric bladder capacity was greater than 60% of the expected capacity for age have been followed for a mean of 60 months. All 8 patients are continent and none required enterocystoplasty. Preoperative bladder compliance exceeded 2ml./cm. water in all patients (group 1). Of the 15 patients for whom preoperative cystometric bladder capacity was less than 60% of the expected value (group 2, small bladders) 8 followed an average of 72 months had a compliance greater than 2ml./cm. water and have done well without bladder augmentation. In contrast, 7 patients in this group (46%) required enterocystoplasty: 6 for persistent or recurrent incontinence and 1 for upper tract changes. The average interval between artificial sphincter placement and enterocystoplasty was 14 months. Patients with a small bladder that required augmentation had a preoperative bladder compliance of less than 2ml./cm. water.We conclude that small bladder capacity, as determined by cystometrography in patients with neurogenic sphincteric incompetence but a bladder compliance of less than 2ml./cm. water predicts the future need for bladder augmentation. In all other patients, with good medical treatment and followup, the possible adverse effects of a small capacity bladder can be prevented or corrected. With this strategy we have been able to avoid enterocystoplasty with its attending potential complications in 70% of our patients with neurogenic incontinence and favorable urodynamics regardless of preoperative cystometric bladder capacity.