Stress urinary incontinence in the neuropathic population can have a profound effect on the quality of life of the more disabled patients. It can lead to significant skin breakdown issues and non-healing pressure sores.  The mainstay of surgical management is the autologous pubovaginal sling (PVS) which 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 aim to report the long-term outcomes of PVS in this population

A retrospective review of patient notes, urodynamic tracings and operation notes was performed of all female patients undergoing insertion of an autologous rectus fascia PVS in a specialised spinal injury unit between 2/6/15 and 25/9/19. Twenty-two patients were identified with a median age of 49.5 years (range 19-80). Patient demographics are displayed in table 1. All patients had undergone urodynamics preoperatively confirming stress urinary incontinence; all had normal bladder compliance; even after occlusion of the urethra beyond the leak point pressure.

The median length of stay was 3 days (range 2-35). There were three clavian-dindo grade III-IV post-operative complications (13.6%) – one lower respiratory tract infection requiring HDU admission, one superficial wound dehiscence requiring VAC dressing treatment and one patient required a return to theatre for washout of haematoma. . The mean ICIQ-UI score decreased from 17.2 pre-operatively to 1 at 6 months post-operatively. The mean pad use decreased from 5 pads per day preoperatively to 0.28 at three month review post-operatively. Long-term pad use was 0.2 at a mean follow-up of 20 months. At three months follow-up 18 patients were completely dry i.e. no pad use (81.8%) and four had an improvement i.e. a decrease in pad use. At the last recorded follow-up appointment (mean 20 months) 19/22 patients were completely dry. One patient developed recurrent SUI at 34 months post-operatively and one had developed de-novo urgency urinary incontinence (managed with an anticholinergic). Of those who were not catheter dependent pre-operatively, three out of five required either intermittent or suprapubic catheterisation post-operatively while two patients were able to continue to void spontaneously while maintaining continence.

Stress urinary incontinence in the neuropathic population is a significant disabling feature of urinary tract dysfunction. 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 81.8% were completely dry and the remainder substantially improved at three months. At long term follow-up only one patient developed recurrent SUI (34 months post-operatively) while one developed de novo urgency incontinence and another remained on 1 pad per day. Our complication rates are similar to those reported in the literature.

In conclusion the autologous pubovaginal sling is a safe and efficacious surgical treatment for neuropathic stress incontinence both with short-term and long-term follow up with acceptable morbidity and good patient satisfaction.