Stress urinary incontinence (SUI) affects 20-30% of the female population. The incidence in the neuropathic population is unknown yet presents a significant disabling factor with a profound impact on quality of life. The autologous pubovaginal sling (PVS) produces increased bladder outlet resistance during episodes of increased intra-abdominal pressure. The efficacy of the procedure is well established in the non-neuropathic population however evidence for its use in female neuropathic patients is limited. We performed a retrospective review of all female neuropathic patients in our unit undergoing autologous PVS insertion to evaluate its efficacy and rate of complications.

14 female patients underwent insertion of autologous PVS in a single specialised spinal injury unit between 2/6/15 to 3/10/17. Median age was 49 (range 19-80). 11 patients had a spinal cord injury, one had a congenital anorectal abnormality with associated neuropathy and two had a suprapontine disorder. 8 mobilised with a wheelchair, one was dependant on crutches and the remainder were ambulant. Nine were on treated for neurogenic detrusor overactivity and thirteen were catheter dependant preoperatively. All patients had undergone urodynamics preoperatively confirming stress urinary incontinence. The median bladder capacity was 467ml (range 123ml-600ml). Three patients had evidence of neurogenic detrusor overactivity (NDO); all were on anticholinergic medication and 2 had intravesical botulinum toxin A administered at the time of sling insertion. Only one patient demonstrated poor compliance at the end of filling (500ml) however she was safely managing her bladder with ISC at lower volumes

The mean length of stay was 2.5 days (range 1-21) with no unplanned readmissions and 90 day mortality was 0. Seven patients had additional planned procedure during sling insertion (two botulinum toxin A injections, one cystalolithopaxy, one insertion of SPC, two vaginal hysterectomy and one anterior vaginal repair –carried out by an experienced urogynaecologist). Three patients required intraoperative repositioning of sling sutures. There were two clavian-dindo grade III-IV post-operative complications (14.3%). One patient developed a severe lower respiratory tract infection which required HDU admission for antibiotics and inotrope support. The other developed a haematoma in her abdominal wound that require a return to theatre for washout – this patient subsequently developed acalculus cholecystitis requiring IV antibiotics. The mean pad use decreased from 5 pads per day preoperatively to 0.23 post-operatively while the mean ICIQ-UI score decreased from 17 to 0. All patients were subjectively happy following the procedure. Eleven patients were completely dry i.e. no pad use (78.6%) and three had an improvement (21.4%). All patients required either intermittent or suprapubic catheterisation post-operatively as expected. Three patients developed de novo neurogenic detrusor overactivity which was managed with anticholinergics.

Stress urinary incontinence in the neuropathic population is a significant disabling feature of urinary tract dysfunction. Mid-urethral synthetic slings are currently a mainstay of management of non-neuropathic stress urinary incontinence with reported success rates of 93% at 1 year and 73% at 10 years. However evaluation of their use in the neuropathic population has shown varying success. Current UK NICE guidelines recommend the autologous PVS as first line surgical management of neuropathic stress incontinence. While the evidence for PVS is well established in the paediatric neuropathic population and males with neurogenic urethral incompetence, the evidence for its use in the adult female neuropathic population is limited. In our cohort of patients 100% had a good outcome with 78.6% completely dry and the remainder substantially improved. Our complication rates are similar to those reported in the literature and we had a 0% mortality rate.

We have found the autologous pubovaginal fascial sling to be a safe and efficacious treatment for neuropathic stress urinary incontinence; with success rates comparable to those in the literature.

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