International Urogynecology Journal

https://doi.org/10.1007/s00192-021-04929-1

REVIEW ARTICLE

Synthetic mid-urethral slings for the treatment of stress urinary

incontinence in women with neurogenic lower urinary tract
dysfunction: a systematic review
Clément Sarrazin 1 & Maximilien Baron 2 & Caroline Thuillier 1 & Alain Ruffion 3 & Marie-Aimée Perrouin-Verbe 2,4 &
Gaëlle Fiard 1,5

Received: 24 May 2021 / Accepted: 29 June 2021

# The International Urogynecological Association 2021

Abstract
Introduction and hypothesis The aim of our study was to evaluate the efficiency and safety of synthetic mid-urethral slings
(sMUS) for the treatment of stress urinary incontinence (SUI) in women with neurogenic lower urinary tract dysfunction
(NLUTD).
Methods A systematic review was performed and reported according to the Preferred Reporting Items for Systematic Reviews
and Meta-Analyses statement. MEDLINE, Embase and Cochrane controlled trials databases were systematically searched from
January 1995 to April 2021. Studies including adult women with NLUTD who had a sMUS for SUI were considered for
inclusion. Primary outcome was success of the surgery according to study criteria. Secondary outcomes were complications,
especially de novo urgency, urinary retention, tape exposure and revision for complications.
Results A total of 752 abstracts were screened and 9 studies were included, representing 298 patients. The mean age was 52 years
and median follow-up was 41.3 months. sMUS insertion was successful in 237 patients (79.5%). The median rate of de novo
urgency was 15.7% (range 8.3–30%). In patients with spontaneous voiding, the median rate of retention was 19.3% (range 0–
46.7%) and 21 out of 26 patients required intermittent self-catheterisation. Four cases of tape exposure were reported, and 8
patients underwent a revision for complications.
Conclusions This review suggests that sMUS might offer interesting success rates and acceptable morbidity and could be
considered for the treatment of SUI in women with NLUTD. Further studies are required to define which patients would be
more likely to benefit from this intervention, as well as its place among the other surgical treatments for SUI.

Keywords Stress urinary incontinence . Neurogenic urinary bladder . Suburethral sling . Mid-urethral sling . Tension-free vaginal
tape . Trans-obturator tape

Introduction

Neurological diseases may lead to various patterns of lower

urinary tract dysfunction, depending on the site and type of the
* Clément Sarrazin lesion [1]. The International Continence Society define adult
csarrazin1@chu-grenoble.fr
neurogenic lower urinary tract dysfunction (ANLUTD) as fol-
lows: “ANLUTD refers to abnormal or difficult function of
1
Department of Urology, Grenoble Alpes University Hospital, the bladder or urethra in mature individuals in the context of
Grenoble, France clinically confirmed relevant neurologic disorder” [2]. Among
2
Department of Urology, Nantes University Hospital, Nantes, France these dysfunctions, stress urinary incontinence (SUI) is de-
3
Department of Urology, Lyon Sud Hospital-Pierre-Bénite, fined as a “complaint of involuntary loss of urine on effort
University of Lyon, Lyon, France or physical exertion including sporting activities, or on sneez-
4
University of Nantes, U 1235 TENS, Nantes, France ing or coughing” [2]. SUI can be the consequence of a sphinc-
5
Grenoble Alpes University, CNRS, Grenoble INP, TIMC-IMAG, ter or pelvic floor muscle weakness caused by the neurological
Grenoble, France disease itself, especially in the case of sacral spinal cord or
 Int Urogynecol J

infrasacral (cauda equina and peripheral nerves) lesions, lead- sMUS implantation to treat SUI. The success of sMUS im-
ing to intrinsic sphincter deficiency [2] and is referred to as plantation had to be the primary outcome. Subjects were
neurogenic SUI (nSUI). SUI can also be due to sphincter adult women with NLUTD. Studies including women with
injury as the result of prolonged urethral indwelling catheter- and without NLUTD were included only if results for women
isation or previous interventions. It can also arise from non- with NLUTD were reported separately. Studies including
neurogenic causes such as urethral hypermobility, or a com- male and female patients, or female adult and child patients
bination of those aetiologies [3]. Owing to the diverse spec- were included only if results for adult women with NLUTD
trum of clinical conditions applying to women with NLUTD, were reported separately. Screening of articles was performed
the prevalence of SUI in this population is not known. A by two reviewers (CS and MB). Corresponding authors of the
prevalence of 49% of any type of urinary incontinence has screened articles were contacted if precision was needed re-
been reported in a population of women with spinal cord in- garding outcomes of interest. Discrepancy between the two
jury and was associated with decreased quality of life [4]. authors was resolved by discussion or by consulting a third
Although synthetic mid-urethral sling (sMUS) insertion is reviewer (GF or MAPV).
the most frequently performed anti-incontinence surgery in
non-neurological women, owing to its good results and low Data collection process
morbidity [5], its use to treat SUI in women with NLUTD is
currently not recommended. However, the European The author CS extracted data from the publications included
Association of Urology and The International Consultation using a standardised data extraction form. The primary out-
on Continence consider sMUS as an option [3, 6]. come was the success rate of sMUS according to the definition
No systematic review has yet focused on the results of used by each study. Secondary outcomes were complications
sMUS in women with neurological diseases. The aim of our after sMUS implantation. De novo urgency symptoms were
study was to evaluate the efficiency and safety of sMUS for defined as the description of urgency in women who had
the treatment of SUI in women with NLUTD. never experienced urgency before surgery. Urinary retention
was the description of the inability to properly empty the blad-
der [2]. Instauration of catheterisation owing to urinary reten-
Materials and methods tion was also noted. Tape exposure was the description of any
unusual tape display [8]. Pelvic organ perforation was the
Protocol and registration description of any abnormal opening into hollow organs or
viscus [8]. Revision for complication was the necessity to
The study protocol was registered (CRD42019134339) and perform a new intervention because of a complication.
published on PROSPERO (http://www.crd.york.ac.uk/ Description of any other complication with a non-
PROSPERO). This systematic review was performed and standardised term was extracted.
reported according to the Preferred Reporting Items for Intervention was detailed in terms of sling route
Systematic Reviews and Meta-Analyses (PRISMA) statement (retropubic, transobturator or single-incision) and tension ap-
[7]. plied to the string, when available. The population included in
each study was described with their mean age, neurological
Information sources and search disease, urodynamic observation, and pre-operative voiding
mode. The types of neurogenic lesions were defined as
A systematic review was conducted on MEDLINE, Embase, suprapontine lesion (SPL), suprasacral spinal cord/pontine le-
Cochrane Central Register of Controlled Trials and Controlled sion (SSL), sacral spinal cord lesion, cauda equina and periph-
Database of Systematic Records (CENTRAL) from January eral nerve lesion (SSCL/CEPNL) according to ICS
1995 (date of the first description of sMUS implantation by U. standardised adult NLUTD clinical diagnoses [2]. Length of
Ulmsten) to March 2021. The search strategy is available in follow-up in each study was defined as short-term, medium-
Supplementary Material 1. Articles in English or French were term and long-term follow-up if the median follow-up was
considered. Duplicates were removed. less than 1 year, from 1 to 5 years and above 5 years respec-
tively [5].
Eligibility criteria and study selection
Risk of bias and quality assessment
Titles and abstracts were screened, and the full texts of all
relevant studies were reviewed to identify those that met the The Strengthening the Reporting of Observational Studies in
inclusion criteria. Inclusion criteria were placebo-controlled Epidemiology (STROBE) 22-item checklist was used to as-
randomised trials, meta-analysis, systematic reviews, cohort sess the quality of observational and non-randomised studies
studies, case series and retrospective studies evaluating [9]. As we included only single-group before/after studies, we
Int Urogynecol J

could not use the Cochrane risk of bias assessment tools. A list diagram are presented in Fig. 1. Overall, 1,047 citations were
of the main confounders for surgical interventions for SUI in identified, 752 titles and abstracts were considered for inclu-
adult neuro-urological patients had been developed previously sion, 189 full texts were read and 9 studies [12–20] were
and included age, mixed versus stress urinary incontinence, included.
underlying neuro-urological disease, perineal sensation, pre-
vious treatment for SUI and previous pelvic surgery [10]. For Study characteristics, quality of studies and risk of
each study, we considered whether each confounder was con- bias assessment
sidered and whether, if necessary, the confounder was con-
trolled for in the analysis. The risk of bias was high if the The characteristics of the studies included are presented in
confounder had not been considered and was imbalanced be- Table 1. There were 8 observational before/after studies [12,
tween patients or not corrected during analysis [11]. The risk 13, 15–20] and 1 non-randomised pilot trial [14], for which
of bias summary and graph were computed in Review only one of the two groups of patients was considered.
Manager 5.2 (Informatics and Knowledge Management Overall, the studies were of medium quality according to the
Department, Cochrane, London, UK). Quality and risk of bias STROBE checklist. Two studies satisfied the majority of
assessments were performed independently by two reviewers items on the checklist and were considered to be of high qual-
(CS and MB) and discrepancy between the two authors was ity [14, 15]. One study satisfied the lowest number of checklist
resolved by discussion or by consulting a third reviewer (GF items and was deemed to be of lower quality than the other
or MAPV). studies (Supplementary Table 1) [17]. Risk of bias assessment
revealed moderate or high risk of bias (Fig. 2).
Statistical analysis
Participants
Percentages were calculated for each study by dividing the
number of patients eligible for each outcome measure by the The 9 studies reviewed included 298 patients. Mean age was
number of patients who completed the last follow-up assess- 52 years (range 18–88 years). Neurological disease was avail-
ment. Results for comparable variables (age, length of follow- able for 235 patients (78.9%). The most common neurological
up, standardised complications) were reported using mean or disease was spinal cord injury in 111 (47.2%) cases, followed
median rates and ranges. Results on success were reported by cerebrovascular accidents and intervertebral disc hernia in
narratively as we anticipated the definition of success to be 38 (16.2%) and 24 (10.2%) patients respectively. The type of
different in most studies. neurological lesion could reliably be defined for 260 patients
(87.2%). It was SPL for 81 (35.2%), SSL for 74 (23.1%) and
SSPL/CEPNL in 105 (41.7%). Preoperative neurogenic
Results detrusor overactivity (NDO) was reported in 113 patients
(39%), for which at least 85 (75%) patients received specific
Study selection treatment. It was a detrusor injection of botulinum toxin and
anticholinergics in 39 (45.9%) and 14 (16.5%) patients respec-
The literature search was carried out in October 2020 and tively. NDO medication was not reported for 28 patients
actualised until April 2021. The search strategy and flow (32.9%). Four (4.7%) patients had surgical treatment for

Fig. 1 Preferred Reporting Items

for Systematic Reviews and
Meta-Analyses (PRISMA) flow
diagram of studies identified, ex-
cluded and included
Table 1 Characteristics of the studies included

References Study design Level of Median follow-up Number Sling route Age, mean Neurological disease, n Level of Urodynamic Treatment for Pre-operative
evidence duration (months) of (years) injury, n observation, NDO, n voiding
patients n mode, n

[12] Before/after 4 111 12 Retropubic 12 53 Disc surgery 6; SCI 3; spinal SSCL/CEPNL NDU 11; Anticholinergics 1 ISC 9; no
stenosis 3 9; SSL 3 NDO 1 catheterisa-
tion 3
[13] Before/after 4 All patients were 34 Retropubic and NR; mean age Radical pelvic surgery ± SSCL/CEPNL NDU 34 NA No
followed up to transobturat- of the pelvic radiotherapy 20; 25; NR 9 catheterisa-
12 months or whole Pelvic RT alone 5; SCI 9 tion 34
cohort (NU
and
non-NU
patients) 65
[14] Non-randomised 2b 36 20 Retropubic 20 34 SCI 16; MMC 3; spinal SSCL/CEPNL NDO 13 Anticholinergics 13 ISC 5; no
uncontrolled tumour 1 20 catheterisa-
trial tion 15
[15] Before/After 4 52.8 54 Retropubic 54 57 Intracranial 28; intraspinal SPL 28; NDU 13 NA No
20; peripheral nerves 6 SSCL/CEP- catheterisa-
NL 6; NR tion 54
20
[16] Before/after 4 67.2 27 Transobturator 56 SCI 27 SSL 16; NDO 6; LOC Detrusor injection of ISC 11n IC 11;
27 SSCL/CEP- 4 botulinum toxin 6 no
NL 11 catheterisa-
tion 5
[17] Before/after 4 6.8 9 Transobturator 45 SCI 9 SSL 8; NDO 7; NDU Detrusor injection of ISC 7; IC 1; no
9 SSCL/CEP- 2 botulinum toxin 3; catheterisa-
NL 1 augmentation tion 1
cystoplasty 3;
sacral
deafferentation 1
[18] Before/after 4 20 9 Retropubic 3; 54 SCI 9 SSL 9 NDO 9; LOC Detrusor injection of ISC 8; IC 1
transobturat- 1 botulinum toxin 9
or 6
[19] Before/after 4 44.5 38 Retropubic 21; 56 SCI 38 SSL 38 NDO 21; Detrusor injection of ISC 12; IC 22;
transobturat- LOC 6 botulinum toxin no
or 11; 21 catheterisa-
single-- tion 4
incision 5
[20] Before/after 4 NR; Median 95 Transobturator 63 Cerebrovascular accident 38; SPL 53; NDO 56 NR 28 No
follow-up of the 95 intervertebral hernia 18; SSCL/CEP- catheterisa-
whole cohort spinal stenosis 13; NL 33; NR tion 95
(NLUTD and Parkinson’s disease 10; 9
non-NLUTD brain tumour 5; other 2;
patients) 49.8 NR 9

IC indwelling catheterisation, ISC intermittent self-catheterisation, LOC loss of compliance, MMC meningomyelocele, NDO neurogenic detrusor overactivity, NDU neurogenic detrusor underactivity,
NLUTD neurogenic lower urinary tract dysfunction, NR not reported, RT radiotherapy, SCI spinal cord injury, SPL supra-pontine lesion, SSL pontine/suprasacral spinal cord lesion, SSCL/CEPNL sacral
spinal cord lesion or cauda equina and peripheral nerve lesion
Int Urogynecol J
Int Urogynecol J

The median follow-up length was 41.3 months (range 6.8–

111). Most of the studies [14–16, 19, 20] had a medium-term
follow-up. One study had a short-term follow-up [18] and two
studies had a long-term follow-up [13, 17].

Intervention

The sling route could reliably be extracted for 254 patients

(88%): it was retropubic for 110 (43.3%) and transobturator
for 139 (54.7%). A single-incision sMUS was implanted in 5
(2%) patients. Five studies [12–14, 16, 19] reported an in-
creased tightening of the tape during the implantation compared
with the standard surgical technique in non-NLUTD patients.
The success of sMUS implantation is shown in Table 2.
Using the definition of success defined by each study (see
details in Table 2), sMUS insertion was successful in 237 patients
(79.5%). Five studies reported a success rate of at least 80%
(range 33–100%). The success rate ranged from 52.4 to 100%
and from 33 to 100% in patients who had their sMUS implanted
using the retropubic and transobturator routes respectively.
Success rates seemed comparable between transobturator and
retropubic route (Supplementary Table 3) and irrespective of
the type of lesion (Supplementary Table 4).

Complications

The median de novo urgency rate was 15.7% (range 8.3–

30%). Anticholinergic medications or detrusor injection of
botulinum toxin resolved urgencies in all cases (Table 3).
Out of 211 patients who were spontaneously voiding be-
fore surgery, 26 (12.3%) presented with postoperative urinary
retention. The median urinary retention rate was 19.3% (range
0–46.7%). Urinary retention was managed with the introduc-
tion of ISC in 21 patients (81%). Nineteen (90.4%) had
SSCL/CEPNL, 1 (1.8%) had SPL and the level of injury could
Fig. 2 Risk of bias summary: review of authors’ judgements about each not be defined for the other patient. Five patients required
risk of bias item for each study included
secondary surgery to release the tension of the tape, which
solved urinary retention in all cases. Two of those patients
NDO, 3 (3.5%) augmentation cystoplasty and 1 (1.2%) sacral had SPL, the level of injury could not reliably be assessed
deafferentation. Other urodynamic observations were neuro- for the other 3 patients (Supplementary Table 5).
genic detrusor underactivity (NDU) in 60 (13%) and low com- Among the 52 patients who had already performed ISC
pliance in 11 patients (3.7%). Before sMUS insertion, 211 before the intervention, no de novo difficulty performing
(70.8%) voided without bladder catheterisation (spontaneous ISC after sMUS implantation was reported.
voiding), 52 (17.4%) required intermittent self-catheterisation Tape exposure was reported in 4 cases (range 0–11%).
(ISC) and 35 (11.7%) had indwelling catheters. Voiding mode Two were vaginal exposure, 1 was urethral and the last site
according to level of injury could be assessed for 251 patients. of exposure was not reported. Management of tape exposure
81 (100%) patients with SPL voided spontaneously. Among consisted of complete tape removal for vaginal erosion in 1,
SSL patients, 5 (7.5%) voided spontaneously, 28 (42.5%) urinary diversion for urethral erosion and vesico-vaginal fis-
voided with ISC and 33 (50%) had an indwelling catheter. tula in another and it was not reported in the other 2 cases.
For patients with SSPL/CEPNL, 86 (82.7%) voided sponta- Three cases of pelvic organ perforation were reported
neously, 17 (16.3%) with ISC and 1 (1%) had an indwelling (range 0–9.1%). In all cases it was a bladder perforation fol-
catheter (Supplementary Table 2). lowing RP-sMUS insertion. Three cases of transient thigh
 Int Urogynecol J

Table 2 Results on the success of

sMUS implantation References Definition of success Success rate

Studies evaluating retropubic route only

[12] Completely dry, no pads 9/12 (75%)
[14] Negative cough stress test and no leakage during physical examination 16/20 (80%)
[15] No recurrence of UI during follow-up. Recurrence of UI defined as the presence 46/54
of any bothersome symptoms of SUI reported by the patient and/or by a stress (85.2%)
urinary incontinence index score>0 indicative of bothersome symptoms of
SUI on a validated questionnaire and/or a positive standardised stress test at
follow-up
Studies evaluating transobturator route only
[16] No pads at last follow-up 22/27
(81.5%)
[17] No use of any pads (continent), pad use reduced by 50% (improved) 3/9 (33%)
Shin 2020 No patient reported SUI and no pad usage due to SUI 86/95
[20] (93.7%)
Studies evaluating both routes
[13] Improved incontinence, indicating patients who became dry or had marked Overall
improvement of SUI based on the reported changes of the urine leakage 26/34
severity from baseline to the postoperative condition at 12 months. Urine (76.4%)
leakage severity was classified according to patients’ subjective grading as
mild, moderate and severe
[18] Patient satisfied with the procedure and no demonstrable incontinence Overall 9/9
associated with either NDO or stress on the VUDS during follow-up (100%)
RP 3/3
(100%)
TO 6/6
(100%)
[19] Use of no or a single safety pad per 24 h at 1 year Overall
20/37
(52.6%)
RP 11/21
(54.5%)
TO 6/12
(50%)
SI 3/5 (60%)
Total 237/298
(79.5%)

NDO neurogenic detrusor overactivity, NR not reported, RP retropubic, SI single-incision, SUI stress urinary
incontinence, TO transobturator, UI urinary incontinence, VUDS video-urodynamics studies

pain were reported after TO-sMUS, 2 resolved at 3 days and women with NLUTD. Five studies reported a success rate of
1 at 6 months. at least 80%, with success rates in individual studies ranging
Eight patients had tape revision for complications (range from 33 to 100%.
0–11.1%), 5 had tape release for urinary retention, 1 had tape About half of the patients included in this review had
removal for erosion, 1 had urinary diversion for erosion, and 1 sacral spinal cord or infrasacral lesions leading to lower
had tape removal for frequent autonomic dysreflexia episodes. motor neuron lesions. These lesions classically generate
The complication rate did not seem to differ with either nSUI related to intrinsic sphincter deficiency. Other pa-
sling route or type of neurological lesion (Supplementary tients had lesions above the sacral spinal cord (upper low-
Tables 3 and 4). er motor lesions). As those patients usually have a pre-
served innervation of the striated sphincter, SUI is most
likely to have a “non-neurogenic cause” (i.e. hypermobil-
Discussion ity) [1].
Finally, in the case of extended grey matter lesions of the
This systematic review is, to our knowledge, the first to look at spinal cord (e.g. ischaemia), involving the sympathetic
the efficiency and safety of sMUS for the treatment of SUI in thoraco-lumbar centre and the sacral centres, the intrinsic
Int Urogynecol J

sphincter deficiency can also be associated with bladder neck and to detect changes in bladder pressure during filling, in
incompetence. order to protect the upper urinary tract in the long term.
Although no direct comparison can be made between the A concern frequently raised when discussing sMUS im-
different mechanisms involved, the good results reported irre- plantation in NLUTD patients is the theoretical increased risk
spective of the type of neurological lesion suggest that sMUS of tape erosion. In this review, only 4 cases of tape erosion
could be used for treating SUI whatever the level of the lesion, were reported (range 0–11%). This rate does not seem signif-
and whatever the theoretical presence of intrinsic sphincter icantly higher than in the non-neurogenic population [21],
deficiency. Success rates did not seem to differ significantly where the mean incidence is 2.5% (range 0–26%). Pelvic or-
between the retropubic and the transobturator route either. gan perforation was also a rare event, and its frequency did not
Pre-operative evaluation is the key to ensuring a high suc- seem to be increased compared with non-NLUTD patients.
cess rate and avoiding complications. Except for the study by The European Association of Urology and the International
Holdø et al. [15], urodynamic studies were always performed Consultation on Continence guidelines both recommend the
and any co-existing findings, such as NDO, were treated to use of autologous slings or an artificial urinary sphincter to
ensure low bladder pressure before surgery. This management treat stress incontinence in women with NLUTD [3, 6].
is mandatory to ensure post-operative results, by preventing Autologous slings increase bladder outlet resistance by di-
subsequent leakage due to urgency urinary incontinence, and rectly compressing the proximal urethra and bladder neck.
to prevent upper urinary tract deterioration [3, 6]. This technique has a good success rate at mid term for treating
Urinary retention was a frequently reported complication neurogenic incontinence in adult women, with a success rate
of sMUS implantation in this population. The rate of voiding ranging from 72 to 84% [14, 24–26]. Augmentation
dysfunction reached 46.7%, with a median rate of 19.3%, cystoplasty was frequently performed before or at the time
higher than the mean incidence of 7.3% in the non- of autologous sling implantation in those series.
neurogenic population [21]. After sMUS implantation, even Catheterisation was almost always necessary after this sur-
tension free, obstruction can occur owing to increased bladder gery. De novo urgency was also reported after this procedure,
outlet resistance related to the tension directly applied against with rates ranging from 10 to 13.3% [14, 26].
the urethra, as well as a kinking effect on the vaginal wall and Artificial urinary sphincter remains the gold standard in the
proximal urethra cephalad to its placement [22]. This increase case of SUI with intrinsic sphincter deficiency, with good
in bladder outlet resistance may alter bladder emptying, espe- long-term success rates. Costa et al. reported 49 out of 54
cially in patients with detrusor underactivity, and trigger the (90.7%) fully continent women with NLUTD after AUS and
need for bladder catheterisation. In the present review, women a mean follow-up of 9.6 years [27]. Phé et al. reported a con-
with SSPL/CEPNL were more likely to require de novo ISD tinence rate of 57.7% in 26 neurological females after a mean
(Supplementary Table 5). Therefore, women with NLUTD follow-up of 7.5 years. Fourteen (53.8%) had had at least one
should always be assessed for their ability to perform ISC previous anti-incontinence surgery, including retropubic
before surgical treatment for SUI, in the case of preoperative sMUS [28]. However, these good success rates must balanced
voiding dysfunction (poor bladder emptying, high post- against the high revision rates. Costa et al. reported that the
voiding residual, detrusor underactivity). If ISC is not possi- presence of neurogenic bladder increased the risk of sphincter
ble, they should be informed of the possibility of temporary revision and explantation [27]. Phé et al. reported a survival
indwelling catheterisation or intermittent catheterisation by a rate of AUS without revision of 51% at 20 years [28].
caregiver and the risk of surgical revision after sMUS The success and complication rates of sMUS reported in
insertion. this review compare favourably with these two treatments,
Another frequent complication was de novo urgency. The suggesting that sMUS insertion could be an interesting alter-
median rate was 15.7% (range 8.3–31%), which again seems native treatment option for SUI in selected neurological wom-
higher than for non-NLUTD women, for whom the mean en with NLUTD, reducing the need for ISC compared with
range is around 10.2% [21]. This higher rate could be ex- autologous slings, and representing a mini-invasive first-line
plained by preoperative NDO or poor bladder compliance, treatment before considering artificial urinary sphincter place-
and the evolution of the neurological disease. This could also ment. However, no conclusion can be drawn in the absence of
be due to changes induced by increased bladder outlet resis- a randomised controlled trial comparing those surgical
tance. Dave et al. showed that NDO or poor compliance could treatments.
occur after isolated bladder outlet procedures for neurogenic We must acknowledge the limitations of the present re-
incontinence in children and young adults [23]. In this review, view. Studies included were of medium quality and presented
de novo urgency was treated conservatively with with a moderate to high risk of bias. The analysis and conclu-
antimuscarinic agents or detrusor injections of botulinum tox- sions of this review are therefore limited by the quality of the
in. This advocates for a prolonged clinical and urodynamic studies included.
follow-up in NLUTD patients, to treat any new symptom
Table 3 Complications after synthetic mid-urethral sling (sMUS) insertion

References De novo urgency Urinary retention Pelvic Tape Other Sling revision for
among patients who organ exposure complication
voided without perforation
catheterisation

Studies evaluating retropubic route only

[12] 1/11 (9.1%); 1 treated with anticholinergics 0/3 1/12 0 0 0
(9.1%);
bladder
perfora-
tion
[14] 6/20 (30%); 6 treated with anticholinergics 7/15 (46.7%); 7 0 1/20 (5%) 0 0
(100%) requiring
definitive ISC
[15] 7/31 (22.6%); treatment not reported 5/54 (9.3%); 2 (40%) 2/54 0 Hematoma 2/54 (3.7%) 3/54 (5.6%); 3 tape
requiring definitive (3.7%); releases for urinary
ISC bladder retention
perfora-
tion
Studies evaluating transobturator route only
[16] 2/24 (8.3%); 2 treated with detrusor injection of 2/5 (40%); 2 (100%) 0 0 Thigh pain 3/27 (11.1%); 2 resolved at 3 days; 1 resolved at 0
botulinum toxin requiring definitive 6 months
ISC
[17] NR 0/1 (0%) 0 1/9 0 1/9 (11.1%); urinary
(11.1- diversion for erosion
%)
[20] 4/22 (18.2%); medical treatment not reported 2/95 (2.3%); 0 0 1/95 0 2/95 (2.3%); 2 tape
requiring definitive (1.1%) release for urinary
ISC retention
Studies evaluating both routes
[13] NR 10/34 (29.4%); 10 NR NR NR NR
(100%) requiring
definitive ISC
[18] NA (all patients had urgencies before intervention) NA (all patients were 0 0 0 0
on ISC or IC)
[19] 5/38 (13.2%); 3/21 (14.3%) after RP-sMUS; 2/12 0/4 (0%) 0 1/38 1/38 (2.7%) pelvic hematoma after TVT+SPC; 2/38 (5.4%) 2/38 (7.9%); 1 tape
(18.1%) after TO-sMUS; 3 treated with anti- (2.7%); vaginal bleeding; 1/38 (2.7%) frequent autonomic removal for erosion; 1
cholinergics; 2 treated with detrusor injection of after dysreflexia episodes after TVT; 1/38 (2.7%) leakage tape removal for
botulinum toxin TO-s- around SPC after TVT autonomic dysreflexia
MUS
Median 15.7% 19.3%
rate

IC indwelling catheter, ISC intermittent self-catheterisation, NA not applicable, NR not reported, RP retropubic, TO transobturator
Int Urogynecol J
Int Urogynecol J

Each study used a different definition of success, which is Supplementary Information The online version contains supplementary
material available at https://doi.org/10.1007/s00192-021-04929-1
consistent with the review of Reuvers et al. The authors found
considerable heterogeneity in outcome parameters and defini-
tions of cure used to report outcomes of surgical interventions Declarations
for SUI in neurological patients [10]. It was not possible to
pool the primary outcome in unified systematic meta-analysis. Conflicts of interest None.
As we did not have access to most individual patient data,
we were not able to describe predictive factors of success or
failure for sMUS insertion in this population. Efficiency of References
mid-urethral slings in patients without neurological disease
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