Controversy still exists regarding the balance of benefits and harms for the different surgical options for neurogenic stress urinary incontinence (N-SUI).
To identify which surgical option for N-SUI offers the highest cure rate and best safety without compromising urinary tract function and bladder management.
A systematic review was performed under the auspices of the European Association of Urology Guidelines Office and the European Association of Urology Neuro-Urology Guidelines Panel according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement.
A total of 32 studies were included. Overall, 852 neurourological patients were surgically treated for N-SUI. The treatment offered most often (13/32 studies) was an artificial urinary sphincter (AUS; 49%, 416/852) and was associated with a need for reintervention in one-third of patients. More than 200 surgical revisions were described. Overall, 146/852 patients (17%) received concomitant bladder augmentation, mainly during placement of an AUS (42%, 62/146) or autologous sling (34% of women and 14% of men). Following pubovaginal sling placement, dryness was achieved in 83% of cases. A significant improvement in N-SUI was observed in 87% (82/94) of women following placement of a synthetic midurethral sling. Efficacy after insertion of an adjustable continence therapy device (ACT 40%, proACT 60%) was reported for 38/128 cases (30%). The cure rate for bulking agents was 35% (9/25) according to 2/32 studies, mainly among men (90%). The risk of bias was highly relevant. Baseline and postoperative cystometry were missing in 13 and 28 studies, respectively.
The evidence is mainly reported in retrospective studies. More than one intervention is often required to achieve continence because of coexisting neurogenic detrusor overactivity, low compliance, or the onset of complications in the medium and long term. Urodynamic data are needed to better clarify the success of N-SUI treatment with the different techniques.
Our review shows that insertion of an artificial urinary sphincter for urinary incontinence is effective but is highly associated with a need for repeat surgery. Other surgical options may have lower continence rates or a risk of requiring intermittent catheterization, which patients should be informed about before deciding on surgery for their incontinence.
European urology focus. 2021 Sep 08 [Epub ahead of print]
Stefania Musco, Hazel Ecclestone, Lisette 't Hoen, Bertil F M Blok, Barbara Padilla-Fernández, Giulio Del Popolo, Jan Groen, Jürgen Pannek, Thomas M Kessler, Gilles Karsenty, Véronique Phé, Andrea M Sartori, David Castro-Diaz, Hamid Rizwan
Department of Neuro-Urology, Careggi University Hospital, Florence, Italy. Electronic address: ., Department of Urology, Taranaki District Health Board, New Plymouth, New Zealand., Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands., Department of Urology, Hospital Universitario de Canarias, Universidad de La Laguna, Santa Cruz de Tenerife, Spain., Department of Neuro-Urology, Careggi University Hospital, Florence, Italy., Neuro-Urology, Swiss Paraplegic Center, Nottwil, Switzerland., Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland., Department of Urology, Aix Marseille University, Marseille, France., Department of Urology, Sorbonne University, Pitié-Salpêtrière Academic Hospital, Assistance-Publique-Hôpitaux de Paris, Paris, France., Department of Urology, University College London and London Spinal Injuries Unit, London, UK.