Neurogenic lower urinary tract dysfunction (NLUTD) is heterogeneous because of the multiplicity of underlying causes and mechanisms. In women with NLUTD, stress urinary incontinence may be due to intrinsic sphincter deficiency caused by the neurological disease itself or from sphincter injury from prolonged urethral catheterisation or previous surgery. Current guidelines state that slings may be offered to select patients with acceptable bladder storage parameters, autologous fascial slings being preferred where an occlusive sling is being considered or when intermittent self-catheterisation (ISC) is required. Sarrazin and co-authors examine longer-term (five-year) outcomes of synthetic mid-urethral slings (MUS) in women with NLUTD to make the case that this is a viable treatment option in select cases. It is the largest multicentre cohort study for MUS in the NLUTD population with long-term follow-up using International Urogynecological Association / International Continence Society (IUGA/ICS) joint classifications for reporting complications, but is limited by being retrospective, observational, and without a control arm. A total of 115 patients were included, 78% provided questionnaire responses. Complete continence was achieved in 49%, and 76% were satisfied, i.e., most patients reported being improved even those who had surgical failure. The median discomfort score was three and 39% experienced failure. Surgical failure was associated with a negative TOT test and the transobturator route, but not the type of neurological lesion. De novo overactive bladder (OAB) occurred in 44% which were all treated conservatively with medication. Mesh erosion occurred in 7.8% (nine patients) which required reoperation for partial or total removal. Urinary retention occurred in 20% of patients who could void spontaneously prior, 44% of whom required reoperation and some required ISC. Overall, 36 patients (31%) underwent at least one reoperation because of complications or failure. This is an important study as it may expand minimally invasive options available for SUI treatment in women with NLUTD, but the high complication and failure rate underscores the need for very careful patient selection, better patient-reported outcomes, and of course better surgical options.
