Several modes of urinary tract drainage exist for the spinal cord-injured (SCI) patient, but the use of an indwelling catheter is discouraged. We retrospectively reviewed the charts of our traumatic SCI patients followed twenty years or more since initial injury to compare urinary tract preservation and the incidence of urologic complications in patients with neurogenic bladders voiding spontaneously with those using long-term indwelling catheters. Eighty-one patients with long-term injuries were identified; 73 of them fit the study criteria. Forty-one patients voided spontaneously having a balanced bladder or performing intermittent catheterization or have undergone sphincterotomy or vesicostomy, and 32 had indwelling suprapubic or Foley catheters. Renal function measured by creatinine clearance was similar in both groups: 81.3 +/- 20.2 mL/min for spontaneous voiders and 83.7 +/- 24.9 mL/min for catheterized patients. Review of urinary tract imaging and incidence of complications in both groups was very comparable, with the exception that the catheterized group had a higher prevalence of scarring and calicectasis on radiologic imaging of the upper urinary tracts which was statistically significant. Of the remaining population, in 6 of 81 patients, bladder cancer developed, and they underwent radical cystectomy and urinary diversion and 2 had proximal diversion alone. Of the 6 patients with bladder cancer, 2 were spontaneous voiders with transitional cell carcinoma (TCC) developing. Three of the 6 patients had indwelling catheters: in 1 patient TCC developed, in 1 adenocarcinoma, and in 1 squamous cell carcinoma. In 1 patient TCC developed in a defunctionalized bladder after ileal conduit formation. Based on this study, we can conclude that in select groups of SCI patients, the choice of an indwelling catheter may be made if other methods fail, provided patients undergo regular upper urinary tract imaging and cystoscopy.