Autologous Fascial Sling for Primary and Secondary Operative treatment of Stress Urinary Incontinence : A retrospective case series over 8 years

Watson F1, Guerrero K1, Pringle S1, Tyagi V1

Research Type

Clinical

Abstract Category

Female Stress Urinary Incontinence (SUI)

Abstract 237
Female Stress Urinary Incontinence
Scientific Podium Short Oral Session 12
Wednesday 29th August 2018
16:22 - 16:30
Hall B
Stress Urinary Incontinence Female Surgery
1. Queen Elizabeth University Hospital, Glasgow
Presenter
F

Felicity Watson

Links

Abstract

Hypothesis / aims of study
To analyse the success and complication rates of Autologous Fascial Slings (AFS) for Stress Urinary Incontinence (SUI) in clinical practice – 8 years data.
Study design, materials and methods
Retrospective case note review of patients who underwent AFS over the last 8 years (2010-2017) within a single tertiary referral unit. 96 procedures were identified through the audit database and electronic notes were reviewed with full follow-up data identified for 84 procedures (87.5%). 70 (72.91%) patients are more than 1 year and 13 (13.54%) more than 5 years since surgery.
Results
All 84 patients had “Sling-on-a-String” . 59 patients had a non-obstructive autologous sling performed while 24 had obstructive slings. With growing concerns around mesh use for SUI surgery, use of AFS for primary SUI has been increasing. 26 (30.95%)  of procedures were for primary treatment of SUI and 12 (14.28%) patients had AFS for primary SUI with complicated histories such as low mid urethral pressure profile, pre-existing voiding dysfunction or significant previous pelvic surgery. 46 (54.76%) patients had previously undergone at least one procedure for SUI of which 17 patients (20.23%) had previously experienced complications associated with mid urethral vaginal tapes. 42 (50%) patients had only SUI and 42 (50%) had mixed urinary symptoms. 15 (17.85%) had pre-existing voiding dysfunction.  3 patients performed Clean Intermittent Self Catheterisation (CISC) pre-operatively – the remaining 81 patients were taught CISC pre-procedure. The numbers of procedures have increased dramatically year on year with only 2 in 2010, 10 in 2014 and 23 in 2017.

Outcomes:
Success : 80 (95.23%) patients reported improvement in SUI symptoms.76 patients (90.47%) were cured and 4 patients (4.88%) reported improvement in their SUI symptoms.  2 of these patients have opted for tightening of sling – 1 of which was subsequently cured and the other awaiting the procedure. 
4 (4.76%) patients reported no improvement of SUI symptoms at 6 months follow up. Two patients underwent redo of AFS both with subsequent cure of SUI.  One patient opted for bladder neck injections. The final patient is considering further options. 
(Table 1)
2 patients underwent release of sling (despite cure of stress incontinence symptoms)– 1 as she was experiencing pain and the other as she was not coping with CISC.

Complications:
Intraoperative : 3 Patients (3.57%) sustained bladder injuries which were managed conservatively. 
Postoperative : 
 • 12 patients (14.28%) experienced worsening of overactive bladder symptoms. 
 • 18 Patients (21.42%) had UTI 
 • 25 (29.76%) developed abdominal wound infections requiring antibiotic treatment. 
 • 1 patient had wound dehiscence resulting in abdominal hernia 
 • 3 Patients (3.57%) have developed denovo chronic abdominopelvic pain which they attributed to AFS.
	
Voiding dysfunction : Graph 1
i) 49 patients (58.33%) were discharged using either CISC or with Foley catheter in situ. Of these 3 Patients were doing ISC preoperatively and have been excluded in further analysis of data.  
ii) 20 (24.69%) patients continued to use CISC beyond 3 months postoperatively. 
iii) Of 68 patients for whom > 1 year follow was available 13 patients (19.11%) were still doing  CISC -  6 of these were doing so only once or twice per day with some spontaneous voiding. 8 of those continuing with CISC beyond 1 year had other risk factors for doing so - 5 of them had post-operative Botox for refractory overactive bladder and 3 of them had pre-operative voiding dysfunction. Patients undergoing obstructive slings, as expected, were more likely to have continued CISC use at each follow-up and beyond one year post-operatively.
Interpretation of results
AFS offer a good overall success rate (91.64%) both with primary (92.18%) and recurrent (89.13%) SUI in clinical practice. The significant year on year increase in numbers within our own unit demonstrates increasing patient and clinician confidence in AFS as an alternative to mesh based midurethral tapes. 

Our data shows overall 54.32% risk of short term voiding dysfunction (less than 1 month) and 19.40% risk of long term (> 12 months) CISC. Women opting for non-obstructive AFS slings with no preoperative voiding dysfunction can expect lower rates (13.16%) of long term CISC.
Concluding message
AFS provides an effective alternative to traditional mesh based mid urethral vaginal tapes.
Figure 1
Figure 2
References
  1. A Randomised controlled trial comparing two autologous fascial sling techniques for the treatment of stress urinary incontinence in women: short, medium and long-term follow-up. Guerrero K, et al. Int Urogynecol J Pelvic Floor Dysfunct. 2007 Nov;18(11):1263-70
Disclosures
Funding None Clinical Trial No Subjects Human Ethics not Req'd Retrospective case review only. Helsinki Yes Informed Consent Yes