OBJECTIVE Bladder management programs for patients with spinal cord injury and neurological disease (SCIND) include intermittent catheterization and sphincterotomy with external catheter drainage. These programs depend on maintaining a patent urethra. Once urethral stricture, erosion, diverticulum or urethrocutaneous fistula occurs, the only treatments available are urethral reconstruction and urinary diversion. We evaluate the role of urethral reconstruction in this subset of patients. METHODS The charts of 18 patients with SCIND (spinal cord injury 16, cerebral palsy 1, meningomyelocele 1) were retrospectively analyzed. Different surgical procedures had been performed according to the presenting pathology and tissue availability. RESULTS Urethral reconstruction was performed in 17 patients with a mean age of 42.2 years (range 27 to 60). Of the patients 13 are paraplegic and 4 are quadriplegic. Urethral defects included urethral stricture in 6 cases, urethral erosion in 4, urethrocutaneous fistula in 3, urethral diverticula in 1 and combined defects in 3. Mean followup is 3.7 years (range 1 to 13) and the mean number of reoperations was 1.4 (range 0 to 4). Of the 17 patients 11 (64.7%) who underwent urethral reconstruction eventually required urinary diversion for end stage urethral pathology (incontinent ileovesicostomy 5, right colon pouches 2, other procedures 4). The mean time from first urethral reconstruction to eventual urinary diversion was 3.3 years (range 0.7 to 7). Four patients maintain a patent urethra while 1 patient was lost to followup. CONCLUSIONS Patients with SCIND in whom urethral reconstruction is considered should be advised that urethral surgery carries a high risk of reoperation and eventual need for urinary diversion. Clearly, many patients with neurological disease and severe urethral pathology are best treated with urinary diversion.