Between 1977 and 1989, an artificial urinary sphincter was implanted in 57 female patients. In 6 patients inadvertent intraoperative injuries to pelvic organs occurred, 5 of whom had a history of an average 2.8 previous operations for incontinence (range 2 to 4). The remaining patient was a 16-year-old girl with primary internal sphincter incompetence. All 6 patients presented with total incontinence. Intraoperative injury included 4 women who sustained vaginal perforations, while 1 had an anterior bladder perforation and in 1 the urethra was entered. Mechanisms of injury were sharp perforation of structures adherent to the pubis and blunt tears of distorted urethrovaginal tissues. Primary closures of the urethra, bladder and vaginal defects followed by insertion of the artificial urinary sphincter were accomplished successfully. Postoperative management included vaginal antiseptic packs, appropriate antibiotics and delayed sphincter activation. Of the 6 patients 5 remained dry after initial placement with a mean followup of 32 months (range 7 to 77). The remaining patient required replacement with a higher pressure balloon and a smaller cuff, which resulted in complete continence.