Consider autologous fascial sling surgery for people with neurogenic stress incontinence.


Do not routinely use synthetic tapes and slings in people with neurogenic stress incontinence because of the risk of urethral erosion.

Relative value placed on the outcomes consideredThe GDG placed a high value on the outcome of continence however the lack of data on quality of life was noted.
Quality of evidenceOverall, the studies were observational studies of very low quality. The majority of studies compared status before with after surgery. Most importantly, there were no attempts to eliminate threats to internal validity through the use of a matched comparison group, although in most studies patients had failed to respond to a period of antimuscarinic medication and intermittent self catheterisation, and so it is unlikely that confounding time effects could wholly explain the changes seen from before to after surgery. In general, longer-term follow-up data was not reported in the studies. There was a lack of evidence for quality of life. For children, the majority of data was on patients with spinal bifida. The GDG noted that there was variation in the surgical techniques used.
The very limited and low quality data on synthetic tapes and slings reported an improvement in continence. However, the surgery was also associated with a need for reoperation and increased incidence on urinary tract infections (UTIs). The data on autologous and biological slings was of very low quality, but the studies demonstrated that surgery was associated with an improvement in continence pre vs post surgery in those with and without augmentation cystoplasty. The overall rate of adverse events ranged from 2 to 24%. The incidence of UTIs ranged from 0 to 54% and the frequency of reoperation ranged from 12 to 23%
Trade-off between clinical benefits and harmsUrethral sling procedures are capable of rendering a proportion of patients with neurogenic stress incontinence continent.
There are associated risks which include the possibility of damage to the urethra or bladder during or after surgery. The GDG considered that tapes or slings that are made from synthetic materials are likely to carry an excess risk of tissue erosion and local infection. Furthermore there is extremely limited data available for synthetic tape procedures.
Stress incontinence frequently coexists with abnormal bladder storage due to detrusor overactivity or impaired compliance in patients with NLUTD. Therefore it is common for a patient to undergo a combined operation that is designed to treat the abnormality of sphincter and bladder function. The case series that have been reviewed illustrate this as many include patients who have undergone sling surgery and augmentation cystoplasty. The GDG felt that It is important to recognise that upper tract deterioration can be associated with the treatment of stress incontinence in patients with NLUTD if bladder storage pressures are high. Bladder storage requires thorough pre-operative assessment. Post-operative upper urinary tract surveillance should be maintained. A subsequent augmentation cystoplasty may be required if bladder storage is unsafe.
Economic considerationsThe GDG considered the costs of slings and tapes and the surgeries required to install them. The surgeries are high cost but the GDG considered that the costs are likely to be offset by the long term reduction in the use of continence aids. In addition, the GDG thought they would improve the quality of life of the patient due to the reduced incontinence.
These interventions are currently performed in selective patients and as the difference in costs is negligible, the recommendation should be based on clinical grounds. The cost of these interventions is fairly high, however if shown to be effective, the costs could be offset by a reduction in the costs of incontinence aids and an increase in quality of life. The sling operation is marginally cheaper than the cost of synthetic tape surgery, as the sling is made of human tissue and therefore no extra cost is incurred. However, with no useful effectiveness data it is difficult to draw conclusions on the cost effectiveness of either intervention. If the effectiveness of the two operations is considered equivalent, then autologous sling surgery is likely to be cost saving.
Other considerationsThe GDG noted that whilst there is a risk of damage to the urethra or bladder for any patient having this procedure it is particularly high in the neuropathic population due to the anatomical changes that can be present and the effects of chronic inflammation in the tissues.

From: 9, Treatment for stress incontinence

Cover of Urinary Incontinence in Neurological Disease
Urinary Incontinence in Neurological Disease: Management of Lower Urinary Tract Dysfunction in Neurological Disease.
NICE Clinical Guidelines, No. 148.
National Clinical Guideline Centre (UK).
Copyright © 2012, National Clinical Guideline Centre.

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