[Role of partial nephrectomy in the treatment of kidney cancer]. / La place de la néphrectomie partielle dans le traitement des cancers du rein.

Incidental finding of small renal carcinoma by radiologic exams (ultrasound, computed tomography, MRI) performed for non urological purposes raises therapeutic and management problems (therapeutic abstinence and surveillance, partial or radical nephrectomy). Radical nephrectomy is recognized as a curative treatment for renal cell carcinoma. However, partial nephrectomy was suggested for renal cell carcinoma of solitary functional kidney or bilateral tumors in order to avoid dialysis or renal transplantation. The debate remains open for the small renal carcinomas with a normal controlateral kidney. Is partial nephrectomy an adequate treatment or rather perform radical nephrectomy? The present study was performed to analyse the published literature on the subject.

Structural alteration of p53 protein in patients with muscle invasive bladder transitional cell carcinoma.

PURPOSE: Recent data imply that 3-dimensional (D) p53 protein modeling provides more specific information on its function in patients with pancreatic adenocarcinoma. In addition to immunohistochemical and single strand conformational polymorphism analysis, we performed 3-D p53 protein modeling and correlated our results with the disease-free survival of patients with muscle invasive transitional cell carcinoma of the bladder who underwent surgery. MATERIALS AND METHODS: We identified 43 patients and analyzed p53 status in each by immunohistochemical testing, single strand conformational polymorphism and DNA sequencing with 3-D protein modeling. Median followup was 38 months (range 4 to 92). The results of each analysis were compared and correlated with cancer specific survival. Statistical analysis was performed using the log rank test on Kaplan-Meier survival curves. RESULTS: The population included 30 men and 13 women 35 to 84 years old (median age 65). Nuclear over expression of p53 protein was observed in 26 of the 43 cases (60%). Lymph node involvement did not correlate with p53 over expression. Significantly more patients with lymph node metastasis died of cancer. Median survival in the 26 patients with p53 over expression was 28 months versus 57 in those with negative staining (p = 0.25). Mutation analysis by single strand conformational polymorphism revealed no abnormality in 24 patients (56%) with a median survival of 28 months, whereas we noted abnormal mutational analysis in 19 (44%) with a median survival of 38 months (p = 0.33). Of 19 single strand conformational polymorphism positive cases DNA sequencing showed mutation near the DNA binding site in 10 (53%), mutation away from the site in 6 (32%) and no mutation in 3 (17%). No survival difference was detected in cases with mutation away and near the DNA binding site, respectively (p = 0.69). CONCLUSIONS: In this group of patients treated with radical cystectomy for muscle invasive bladder transitional cell carcinoma, analysis of p53 protein and the p53 gene by immunohistochemical testing, single strand conformational polymorphism and mutational analysis did not correlate with cancer specific survival.

Impact of preoperative serum PSA level from 0 to 10 ng/ml on pathological findings and disease-free survival after radical prostatectomy.

BACKGROUND: To determine the impact of various preoperative serum prostate specific antigen (PSA) levels in the range from 0.1 to 10 ng/ml on pathological stage and disease-free survival after radical prostatectomy. METHODS: We selected a cohort of 585 patients who underwent radical prostatectomy between 1991-1996 for clinically localized prostate cancer and presented with preoperative serum PSA levels from 0.1 to 10 ng/ml. RESULTS: Pathological organ-confined disease was present in 57.6% of patients. The rate of organ-confined disease decreased from an average of 85% for patients with a PSA value < 2 ng/ml, to 46.8% for patients with a PSA value > 7 ng/ml. We found statistically significant correlations between preoperative serum PSA level and overall pathological stage (P = 0.001), pathologically organ-confined disease (P = 0.001), margin positive rates (P = 0.001), extra prostatic extension (P = 0.001), and seminal vesicle invasion (P = 0.001). The overall disease-free survival rate was 87%, with a median follow up of 42.4 months. Disease free survival was significantly better for patients with PSA up to 4 ng/ml (P = 0.005). CONCLUSIONS: Our data suggests that PSA detection programs should strive to detect prostate cancer in men before the PSA level rises above 7 ng/ml. In addition, since patients with a PSA level < 4 ng/ml had better disease-free survival rates than those with a PSA level between 4.1-10 ng/ml, eliminating an arbitrary cutoff of 4 ng/ml, may lead to improved disease-free survival.

Intraoperative T staging in radical retropubic prostatectomy: is it reliable?

OBJECTIVES: During radical prostatectomy, wide local excision of the lateral prostatic fascia and neurovascular bundle on the ipsilateral side of the tumor is advocated if nerve sparing is likely to result in a positive surgical margin. Our intent was to validate whether intraoperative T staging can predict the presence of positive surgical margins and aid in the decision of whether to perform nerve-sparing prostatectomy. METHODS: One surgeon performed 100 consecutive radical prostatectomies, and one pathologist interpreted the pathologic findings. Topographic distribution of tumor within the specimen was assessed intraoperatively by palpation. The margin status was similarly assessed. This tactile clinical impression was compared with the final pathologic findings. RESULTS: The surgical margins were positive in 39 (39%) of 100 cases. The intraoperative assessment of the margin status had a high false-negative rate and a sensitivity of only 7%. However, the specificity was 96%, because few margins were falsely positive. The overall accuracy was 62%, with a negative predictive value of 62%. The sensitivity of the intraoperative assessment of tumor location was 73%, and the positive predictive value was 65%. CONCLUSIONS: The results of our study indicate that the intraoperative assessment of the margin status is not accurate and thus cannot help determine which patients require excision of the neurovascular bundle. We believe the decision to preserve the neurovascular bundle should be based on the preoperative prognostic factors and the presence of an intact capsule covering the region of the gland adjacent to this structure.

[Contribution of surgical techniques used in liver transplantation in the treatment of retroperitoneal tumors]. / Apport des techniques chirurgicales utilisées en transplantation hépatique pour traiter les tumeurs du rétropéritoine.

The authors describe the surgical technique used in liver transplantation and its application to treat retroperitoneal tumours. This technique comprises primary mobilization of the liver with easy vascular control. This technique, used in 29 patients, is simple, facilitates exposure of great vessels which can be controlled and allows excellent exposure in difficult cases. Analysis of the postoperative course emphasized the absence of hepatic and renal complications, as reflected by normal renal function and liver enzymes. The use of this technique for renal and adrenal surgery avoids the need for extracorporeal circulation and a thoracophrenoabdominal approach, thereby limiting the specific complications related to these two procedures.

[Acute urinary retention secondary to clear cell adenocarcinoma of the urethra]. / Rétention urinaire aiguë secondaire à un adénocarcinome à cellules claires de l'urèthre.

The authors report a case of primary clear cell cancer of the urethra in a woman presenting with acute urinary retention. The diagnosis was based on cystoscopy and confirmed by histological examination of urethral biopsies. Treatment consisted of urethrocystectomy with creation of an "Indiana pouch". The pathological stage was T3N2M0 [1]. Three months postoperatively, the patient presented with inguinal lymph node metastases. She was treated with 3 courses of chemotherapy (mitomycin and 5-fluorouracil) combined with radiotherapy. With a follow-up of 10 months, the patient is still alive and inguinal lymph nodes have regressed. This case report emphasizes the rarity of this histological type and describes the management of urinary retention in a woman when an underlying specific disease is suspected.

Biochemical recurrence after radical prostatectomy in black and white American men with a positive or negative family history of prostate cancer.

PURPOSE: We investigated the impact of a family history of prostate cancer on predicting biochemical recurrence in black and white American men. MATERIAL AND METHODS: Between January 1991 and December 1996, 910 men underwent radical retropubic prostatectomy for clinically localized prostate cancer, of whom 676 had data available on prostate cancer family history. Statistical analysis was performed to identify any correlation among the known predictors of biochemical outcome and family history in each race. RESULTS: Median followup was 34 months (range 2 to 103). We identified 355 (52%) and 321 (48%) white and black American men, respectively, for whom data were available on prostate cancer family history, including 177 (26%) with a positive and 499 (74%) with a negative history. Family history was positive in 94 black (29%) and 83 white (23%) men. No significant difference was noted in the incidence of familial prostate cancer in the 2 races (p = 0.10). In black men the biochemical failure rate was 32% and 26% in those with a positive and negative history (log rank test p = 0.51), while in white men the rate was 17% and 18%, respectively (log rank test p = 0.79). A family history positive for prostate cancer was not associated with biochemical failure in either race. CONCLUSIONS: Biochemical recurrence was not significantly worse in patients with a family history of prostate cancer than in those with nonfamilial disease in either race.

De novo muscle invasive bladder cancer: is there a change in trend?

PURPOSE: We reviewed our radical cystectomy series to determine whether the majority of patients present with muscle invasive bladder cancer. MATERIALS AND METHODS: The records of 184 radical cystectomies performed by 1 surgeon from 1992 to 1999 were reviewed, and all slides of presenting pathology were reviewed by 1 pathologist. The pathological stage of the tumor at presentation was noted in each case, and the number of muscle invasive tumors at presentation was compared to 2 earlier series. RESULTS: Radical cystectomy was performed for muscle invasive transitional cell carcinoma of the bladder in 176 cases and for other histology in 8. There were 101 (57.3%) patients with muscle invasive cancer at presentation compared to 84% and 91% in the 2 earlier series, respectively, which was a statistically significant decrease (p <0. 0001) in the number of de novo muscle invasive bladder cancers. Women were more likely to be diagnosed with muscle invasion primarily than men (85.2% and 50.7%, respectively), and younger patients (younger than 50 years) were more likely to present with superficial bladder cancer compared to those older than 50 years who were more likely to present with de novo muscle invasive bladder cancer. CONCLUSIONS: Analysis of our data supports the findings of the earlier series that the majority of patients present with muscle invasive bladder cancer. However, there is a significant decrease in the percentage of tumors invading the muscularis propria at presentation. Although this observation is encouraging, we emphasize that it is not as dramatic as the stage migration associated with prostate cancer, which may be largely attributed to the widespread use of prostate specific antigen for early detection. Therefore, we support the suggestion that therapeutic gains might follow from improved education regarding the signs and symptoms associated with bladder cancer, with enhanced focus on women and consideration of screening methods for those at high risk for bladder cancer.

Gleason score 7 prostate cancer: a heterogeneous entity? Correlation with pathologic parameters and disease-free survival.

OBJECTIVES: Gleason score 7, in different proportions of grades 3 and 4, is the score most frequently assigned to prostate cancer in our radical prostatectomy specimens (RPSs). We correlated the major grade component of score 7 tumors with clinicopathologic parameters and disease-free survival. METHODS: All Gleason score 7 RPSs were classified as having a major grade of 3 or 4 carcinoma. The two groups were compared according to patient age, race, serum prostate-specific antigen (PSA) level, clinical and pathologic stage, tumor volume, and biochemical recurrence. RESULTS: Of the 534 patients analyzed, 356 and 178 had major grade 3 or 4 tumors, respectively. Compared with patients with 3+4 tumors, those with 4+3 had significantly more advanced clinical and pathologic stages, larger tumor volume, higher preoperative PSA levels, and older age and a higher proportion were African American (P <0.05 for all above parameters). With a mean follow-up of 34.6 months, patients with 3+4 tumors experienced lower rates of PSA recurrence than did those with 4+3 tumors (P = 0.0021). Furthermore, for the subset of patients with organ-confined disease, multivariable analysis that included race, age, clinical stage, preoperative PSA level, tumor volume, and major grade component found only the latter to be a significant predictor of recurrence, with patients who had major grade 4 component tumors experiencing a higher incidence of PSA recurrence than those with major grade 3 tumors (P = 0.012). CONCLUSIONS: The major grade 4 component in Gleason score 7 carcinoma indicates a higher likelihood of biochemical recurrence, particularly for the increasing proportion of patients with organ-confined disease after radical prostatectomy.

Current concepts in androgen deprivation therapy--is there a "best" endocrine treatment?

Androgen deprivation therapy has become the mainstay treatment for locally advanced and metastatic prostate cancer. Castrate testosterone levels can be achieved by a multitude of treatments. We performed a medline literature search to answer the question, is there a "best" endocrine treatment? In conclusion we found that the "best" endocrine therapy for advanced prostate cancer is complete androgen blockade (CAB) with a luteinizing hormone-releasing hormone (LHRH) agonist and a nonsteroidal antiandrogen.

Unilateral hydronephrosis resulting from intraluminal obstruction of the ureter by adenosquamous endometrioid carcinoma arising from disseminated endometriosis.

A case of adenosquamous carcinoma arising in the background of disseminated pelvic endometriosis presented as unilateral hydronephrosis and a polypoid intraluminal ureteral mass. This is the first case of a malignancy arising in endometriosis presenting as an obstructive ureteral mass. The patient had a history of total hysterectomy and bilateral salpingo-oophorectomy 5 years earlier because of an endometriotic cyst, and had since been under unopposed estrogen replacement therapy. An analysis of the case and related literature is presented. Possible pathogenic mechanisms are discussed.

Grading the invasive component of urothelial carcinoma of the bladder and its relationship with progression-free survival.

Although grading is valuable prognostically in pTa and pT1 papillary urothelial carcinoma, it is unclear whether it provides any prognostic information when applied to the invasive component in muscle-invasive carcinoma. The authors analyzed 93 cases of muscle-invasive urothelial carcinoma of the bladder treated with radical cystectomy for which follow-up information was available. Each case was graded using the Malmström grading system for urothelial carcinoma, applied to the invasive component. Pathologic stage, lymph node status, and histologic invasion pattern were also recorded and correlated with progression-free survival. Thirty-four cases (37%) were pT2, 40 (43%) were pT3, and 19 (20%) were pT4. Of the 77 patients who had a lymph node dissection at the time of cystectomy, 34 (44%) had metastatic carcinoma to one or more lymph nodes. The median survival for pT2, pT3, and pT4 stages was 85, 24, and 29 months, respectively (p = 0.0001). Lymph node-negative and lymph node-positive patients had a median survival of 63 and 23 months, respectively (p = 0.0001). Fifteen patients (16%) were graded as 2b and 78 patients (84%) were graded as 3. Median survival of patients graded as 2b was 34 months compared with 31 months for patients graded as 3 (p value not significant). Three invasive patterns were recognized: nodular (n = 13, 14%), trabecular (n = 39, 42%), and infiltrative (n = 41, 44%). The presence of any infiltrative pattern in the tumor was associated with a median survival of 29 months, compared with 85 months in tumors without an infiltrative pattern (p = 0.06). Pathologic T stage and lymph node status remain the most powerful predictors of progression in muscle-invasive urothelial carcinoma. In this group of patients histologic grade, as defined by the Malmström system and as applied to the invasive component, provided no additional prognostic information. An infiltrative growth pattern may be associated with a more dismal prognosis.

Impact of location and multifocality of positive surgical margins on disease-free survival following radical prostatectomy: a comparison between African-American and white men.

OBJECTIVES: Although the rate of positive surgical margins is higher in African-American men (AAM) than in white men (WM), the impact of this difference on survival is not clear. Furthermore, it is unknown whether there are racial differences in the distribution of the positive surgical margins after radical retropubic prostatectomy (RRP). We investigated the differences between AAM and WM in terms of the site and multifocality of the positive surgical margins and their effect on disease-free survival (DFS) following RRP. METHODS: Between January 1991 and December 1995, 493 patients (288 WM and 205 AAM) were treated with RRP as monotherapy. Positive surgical margins were observed in 179 patients (86 WM and 93 AAM). Patients were divided in two groups: group 1 = WM and group 2 = AAM. The incidence and location of the positive surgical margins and their correlation with DFS were determined and compared. RESULTS: Overall, AAM had a higher rate of positive surgical margins than WM (48% versus 33%, respectively, P = 0.001). There was no significant difference in the frequency of multifocality of the positive margins (P = 0.4). Positive surgical margins were located significantly more often at the base in AAM (P = 0.015); however, the location of the positive surgical margins did not impact on DFS between groups. In those with multifocal positive surgical margins, AAM had a worse DFS compared with WM (P = 0.03). CONCLUSIONS: Race is an independent prognostic factor for DFS in patients with positive surgical margins. There were no differences in DFS between WM and AAM based on the margin location. In WM, prognostic factors for DFS in those with positive surgical margins were preoperative serum prostate-specific antigen, Gleason score, and pathologic stage. Conversely, in AAM none of these parameters were significant predictors of failure.

Deferred treatment of localized prostate cancer in the elderly: the impact of the age and stage at the time of diagnosis on the treatment decision.

OBJECTIVE: To assess the clinical behaviour of clinically localized prostate cancer in elderly patients monitored until progression, and the impact of clinical variables, i.e. clinical stage, Gleason score, the dynamics of prostate specific antigen (PSA) and age, on the natural history of the disease. PATIENTS AND METHODS: Between February 1991 and January 1998, 54 patients (mean age 76.4 years, median 77 at the time of diagnosis) with clinically localized prostate cancer who elected for watchful waiting were identified. They were monitored regularly and treatment deferred until progression. Progression was defined as local stage progression (as assessed on a digital rectal examination), biochemical progression or metastasis. All patients who progressed were offered either radiation therapy or hormonal treatment. Each clinical variable was assessed by univariate and multivariate analysis to predict disease progression. The mean follow-up was 47 months. RESULTS: Of the 54 patients, 28 (52%) progressed; 10 had biochemical, 11 local and four biochemical and local progression, and three developed metastasis. All the patients who progressed elected to receive hormonal treatment. The mean time to progression was 35 months. Gleason score ( 6), age ( 75 years) and serum PSA level ( 10 ng/mL) were statistically significant predictors of disease progression (P = 0.04, < 0.001 and 0.02, respectively). The clinical stage at the time of diagnosis had a borderline effect on disease progression (P = 0.06). On multivariate analysis, Gleason score and PSA level were statistically significant predictors of disease progression. CONCLUSION: These results suggest that the treatment of prostate cancer should not be deferred in patients aged > 75 years with a good performance status when the biopsy has a Gleason score >/= 6 and the serum PSA level is >/= 10 ng/mL.

Management of shotgun injuries to the pelvis and lower genitourinary system.

OBJECTIVES: Shotgun injuries are rare, with the extent of injury best determined at time of surgical exploration. There are no defined workup or management guidelines for patients with shotgun injuries to the genitourinary system. Injuries are usually treated on an individual basis. This study was conducted to determine the management and extent of genitourinary tract injuries in 10 patients with shotgun injuries to the pelvis during a 6-year interval. METHODS: Between September 1990 and December 1996, 140 patients were treated for firearm injuries to the lower genitourinary tract, of which 10 were secondary to shotgun blasts. We performed a retrospective hospital and clinic chart review and telephone interview to assess organs injured, initial treatment, follow-up surgeries, mortality, and erectile function. RESULTS: Mean patient age was 20 years at the time of the injury. The mean follow-up was 4 years (range 1 to 7). Two patients died, both with major vascular injuries, one in the operating room and the other 1 week later from sepsis. Eight patients underwent radiographic examinations (1 intravenous urogram and 7 urethrocystograms). The bladder was injured in 5 patients, 2 with concomitant complete posterior urethral transection. Of the 5 patients without bladder injury, one had an incomplete penile urethral injury and one had a complete bulbar urethral transection. The initial management consisted of repairing nongenitourinary injuries in 8 cases (80%), most commonly involving injuries to the rectum and small bowel. All patients were treated operatively, including 8 who required laparotomy and 4 who required suprapubic cystotomy. A total of four urethral injuries were noted. Subsequent reconstructive surgeries included two urethroplasties and one permanent supravesical diversion for 3 patients with extensive urethral loss. Erectile dysfunction was present in 3 of 6 patients available for telephone interview. CONCLUSIONS: Shotgun injuries involving the lower genitourinary tract are associated with significant soft tissue injury and morbidity. Death usually results from major associated vascular injuries. All hemodynamically stable patients should undergo retrograde urethrograms and cystograms to evaluate possible urethral and bladder injuries. Open primary repair should be attempted for distal urethral, testicular, and corporal injuries. Delayed repair with staged urethral reconstruction should be reserved for patients with extensive loss of urethral tissue. Impotence is common in patients with extensive perineal injuries.

Current investigations and treatment of interstitial cystitis.

Interstitial cystitis (IC) is a chronic condition characterized by a constellation of symptoms such as urinary frequency, nocturia, urinary urgency, suprapubic pressure, and bladder and pelvic pain. Since its original description, the etiology of the disorder has remained unknown despite intense investigations. The International Cystitis Association (ICA) and the National Institutes of Arthritis, Diabetes, Digestive and Kidney Diseases (NIDDK) have been instrumental in supporting the United States Interstitial Database (ICDB) and foster research to study the disorder. The NIDDK developed criteria to ensure that all groups of patients treated would be relatively comparable. However, many patients who would be clinically considered to have IC do not fulfill all the NIDDK criteria. Many clinical criteria for the diagnosis of IC, such as the presence of glomerulations and the intravesical potassium chloride test, are being challenged. The epidemiology of the disorder is not well established, but there are an estimated 700,000 cases of IC in the United States. Numerous pathophysiologic mechanisms have been proposed, but none have been proven. There is no representative animal model of IC. Both the oral and intravesical treatments of IC are noncurative, and few are based on a plausible mechanism or scientific evidence. Surgical treatment should be considered with extreme caution; it is the last therapeutic option because failure rate can be substantial.

Patients with abnormal ultrasound of the prostate but normal digital rectal examination should be classified as having clinical stage T2 tumors.

PURPOSE: The current TNM staging system classifies prostate tumors with abnormal transrectal ultrasound but normal digital rectal examination as clinical stage T2. However, most urologists consider these tumors as clinical stage T1c due to the perceived inaccuracy of transrectal ultrasound in clinical staging. To determine the role of transrectal ultrasound in the clinical staging of prostate cancer we evaluated the pathological stage and disease-free survival of patients undergoing radical prostatectomy who had tumor detected by needle biopsy because of elevated serum prostate specific antigen with or without transrectal ultrasound abnormalities. MATERIALS AND METHODS: Between 1991 and 1996, 738 patients underwent radical retropubic prostatectomy as monotherapy for clinically localized prostate cancer. Patients were classified into group 1-normal digital rectal examination and transrectal ultrasound (138), group 2-normal digital rectal examination but abnormal transrectal ultrasound (366) and group 3 -abnormal digital rectal examination (234). We compared pathological parameters and disease-free-survival among the 3 groups. RESULTS: Tumors were organ confined in 61%, 42% and 41% of patients in groups 1, 2 and 3, respectively (p = 0.0001). Overall disease-free survival was 80% with a mean followup of 68 months. Disease recurred in 8%, 22% and 25% of patients in groups 1, 2 and 3, respectively (p = 0.007). Group 1 had better disease-free survival compared to groups 2 and 3 (p = 0.003 and p = 0.002, respectively), and there was no difference in disease-free survival between groups 2 and 3 (p = 0.39). CONCLUSIONS: We provide evidence to support the use of transrectal ultrasound findings in the clinical staging system for prostate cancer. Patients with normal digital rectal examination, elevated serum prostate specific antigen and abnormal transrectal ultrasound should be considered as having clinical stage T2 disease.

Management of neurogenic bladder dysfunction with incontinent ileovesicostomy.

OBJECTIVES: Incontinent ileovesicostomy is an alternative form of urinary management applied to patients with neurogenic vesical dysfunction who are either unable or unwilling to perform clean intermittent self-catheterization or assisted catheterization. We review our operative results, urodynamic data, and complications observed in patients who underwent creation of incontinent ileovesicostomy at our institution. METHODS: Thirteen patients (mean age 43.2 years) with neurogenic bladder dysfunction underwent an incontinent ileovesicostomy between 1994 and 1998. The etiologies of the neurogenic bladder dysfunction were spinal cord injury in 8 patients, multiple sclerosis in 4 patients, and tuberculous meningitis in 1 patient. The preoperative data, surgical records, urodynamic findings, and postoperative complications were assessed. RESULTS: All patients experienced complications of their pretreatment bladder management. The mean operating room time was 242 minutes (range 170 to 395), including 14 additional procedures in 1 1 patients. The mean estimated blood loss was 403.8 mL (range 50 to 2000). No patient required blood transfusion. There were no intraoperative complications. Only 1 patient required reoperation for stomal revision. One patient had a ureteral stone 2 years after surgery; 1 patient has continued to have urinary tract infections despite a negative workup. The mean follow-up was 23 months (range 6 to 57). The mean bladder leak point pressure through the stoma was 8.2 cm H2O. CONCLUSIONS: The incontinent ileovesicostomy is a useful technique in the treatment of patients with neurogenic bladder unable to perform clean intermittent catheterization. It provides patients with a low-pressure urinary conduit that empties readily without an in dwelling catheter.

Collagen injection in the management of post-radical prostatectomy intrinsic sphincteric deficiency.

Transurethral injection of collagen is a minimally invasive option for the treatment of urinary incontinence secondary to intrinsic sphincteric deficiency (ISD). We report on the results of transurethral injection in 21 men with urinary incontinence secondary to ISD. Twenty-one consecutive men with a mean age of 69.5 years (range, 51-84), with ISD documented by demonstrating urinary leakage with Valsalva maneuver on physical examination and by video-urodynamic studies were treated with transurethral collagen injection. The etiologies of the incontinence were radical retropubic prostatectomy (RRP) in seven (33.3%), RRP followed by external radiation therapy in seven (33.3%), and transurethral resection of the prostate (TURP) with subsequent RRP in seven (33. 3%). The mean total volume of collagen injected per patient was 18.4 mL (range, 1-44.5). The average number of injections was 2.9 (range, 1-5). The mean follow-up was 12.5 months (range, 1-39). One (5%) patient became dry, 12 (57%) had significant improvement, and eight (38%) had no change. Overall pad use decreased from 2.5 pads/day to 1.68 pads/day, before and after collagen injection (P = 0.014). No difference in outcomes was demonstrated in African American men versus Caucasian American men (P = 0.38), age (<65 and >65 years, P = 0.88), presence of erectile dysfunction, or duration of incontinence (<20 or >20 months, P = 0.71). There were no reported complications. Collagen injection has minimal morbidity and is a viable option for improving incontinence status in men. Neither age, race, erectile function, nor duration of incontinence appears to affect treatment outcome. Neurourol. Urodynam. 18:653-658, 1999.