In the UK, the use of autologous fascial slings (AFS) in the management of stress urinary incontinence (SUI) has seen a continued revival in the context of ongoing concerns regarding synthetic mid-urethral slings (MUS). At our centre, AFS surgery was re-introduced as a treatment option for SUI in 2019. We aimed to perform an outcomes analysis of the success and complication rate of our initial 5-year cohort.

A retrospective review of all patients undergoing AFS between 2019 and 2024 at a single UK centre was performed. Data was collected from electronic patient records regarding demographic information, co-morbidities, previous treatment for SUI, operative technique, complications, revision rate, length of hospital stay, and symptoms at 3-month follow-up.

There were 21 patients with a mean age of 53 years ± 8 years. All patients underwent urodynamics and were discussed at incontinence MDT before surgery. The indications for AFS were primary SUI (n=11) and mixed (10). Prior to AFS, 18 patients failed conservative management with supervised pelvic physiotherapy and 8 patients had undergone urethral bulking procedures. A “sling on string” technique was adopted using rectus fascia in all but one patient, who underwent fascia lata harvesting due to previous abdominoplasty. A technique of simultaneous flexible cystoscopy during sling insertion was incorporated during the study period to reduce risk of bladder perforation. The average hospital stay was 2 days (+/-2).

At follow up, all 21 patients (100%) reported complete resolution of SUI. 

Four patients experienced post-operative urinary retention, of which three proceeded to revision surgery to loosen the sling and one performed intermittent self-catheterisation for a few weeks.  

Three patients’ procedures were complicated by bladder perforation which were all treated conservatively. 

One patient experienced post-operative obturator nerve-related neuropathic pain which resolved completely with a few days of anti-inflammatories and Pregabalin. 

Two out of ten patients with pre-operative mixed urinary incontinence (MUI) had persistent urinary urgency, while one patient (out of 11 without pre-operative urgency) reported de novo urinary urgency (9%).

AFS resolves urinary incontinence in a vast majority of patients. The unusually high resolution rate (100% for SUI and 80% for pre-existing urgency) in our cohort may be due to small numbers. 

However, 20% of patients initially failed to void and 14% required repeat surgery for sling mobilisation. We feel that meticulous care should be taken to ensure a tension free sling to mitigate this risk. In addition, early follow up of patients who fail to void initially is crucial to ensure timely revision surgery, if required, is performed before any significant fibrosis sets in. 

Bladder perforation was encountered in 14% patients, and although these were small and reliably managed with an indwelling catheter, we found that simultaneous flexible cystoscopy during the passage of the trocar was useful in mitigating this risk. 

Patients should be informed about the risk of obturator neuralgia, and consideration should be given to including this information in patient education materials.

Finally, although AFS seems like a very good option for mixed urinary incontinence, these patients should be carefully counselled that the chances of resolution of urgency are high but not 100%.