Introduction 
Stress Urinary Incontinence (SUI) affects around one in three women. When symptoms do not improve sufficiently with conservative management, women can be offered surgery.  Following the pause on the use of mesh women are increasingly opting for non-mesh continence surgery, with Autologous Fascial Slings (AFS) being one of the surgical treatment options. Newer AFS techniques such as the “Sling on a String” (SOAS) were developed to address concerns about surgical morbidity, operative time and cosmetic results of slings with traditional slings.

Aims
Primary Aim: To analyse short-, medium- and long-term success rates after AFS and compare outcome after primary and secondary SUI surgery. 
Secondary Aims: Intra and post-operative complication rates including rates of voiding dysfunction.

This was a retrospective review of patients who underwent Autologous Fascial Slings (AFS- SOAS) for primary and secondary SUI over 7 years (Jan 2013 – March 2020) within a single tertiary referral unit. Patients who had AFS3, were identified through the audit database and electronic notes were reviewed to look at surgical outcomes.

Obstructive sling or tight slings were typically placed at the bladder neck with a higher likelihood of needing to perform CISC post-operatively while non-obstructive slings were tension-free and placed at the mid-urethra. Nature of the sling was discussed with women pre-operatively depending on their clinical findings, urethral pressure profile and patient choice. Women were taught to perform clean intermittent self catheterisation (CISC) routinely before AFS surgery.

Women were considered to have voiding dysfunction if clinically they had post void residual urine of over 150mls and needed to CISC to empty their bladder or had a prolonged flow on Urodynamics with peak flow rates less than 15mls/sec when voiding a volume of at least 200mls.

4 Point Likert Scale was used to quantify symptoms of SUI post-operatively as “Worse”, “No Change”, “Improved” or “Cure”. Success was considered when symptoms of SUI were “Improved” or “Cured”. This was looked at in the short (<1 year), medium (1-5 years) and long term (>5 years).

121 women were identified, of whom AFS-SOAS was performed as a primary procedure for SUI in 62(51%)  women (primary group).  In 59(49%) women it was performed for recurrent SUI (secondary group). In this Secondary group AFS was performed after at least 1 failed procedure for SUI: colposuspension, mid urethral mesh tapes or AFS

Of the women who had AFS as a secondary procedure:
•	44/59 (75%) had 1 previous SUI surgery, 
•	11/59 (19%) had 2 previous SUI surgeries and 
•	4/59 (7%) had 3 previous SUI surgeries

4 women (6%) in the secondary group had mesh-tape excision surgery prior to AFS surgery for recurrent SUI.

The average age in this cohort was 51.9 years (51.9:primary group vs. 51.8:secondary) and BMI 30.9 (30:primary group vs. 32.2:secondary group).

Preoperative urodynamics(URODS) results was available for 116 women. 48/61 (79%) in the primary group and 42/55 (76%) in the secondary group had urodynamic stress urinary incontinence (USI). The remaining women in both groups had mixed UI with stress being the most troubling symptom (21%: Primary vs 24%: Secondary). 11(18%) women in the primary group and 3 women(5%) in the secondary group had pre-operative voiding dysfunction on URODS with further 3 patients in both groups needing to perform CISC (5% in both groups) preoperatively.. 

3/62(5%) women in the primary group  and 17/59(29%) women in the secondary group had obstructive slings (29%) 

At short term follow up overall success rate was high (91.3%) and comparable in  both groups (primary : 91.5%; secondary: 91%) and this was maintained at medium and long term (Table 1).

Perioperative complications:

Intra-operative outcome was available for 115(95%)  patients. 6 (5%)patients were lost to follow up. 

Intra-operatively 2 (3%) patients had bladder injury one in each groups (1.6%:primary group vs 1.7%:secondary group). 2 women in the primary group (3%) had blood loss >500mls vs. none in Secondary group. 

Post-operatively, 23 (19%) woman had a wound problem overall which were all managed conservatively. 
Superficial wound dehiscence - 0:Primary group vs. 1 (1.7%):Secondary group 
Wound haematoma - 2 (3%):Primary group vs. 4 (6.4%):Secondary group. Of these, 1 (1.7%) woman in the secondary group needed a blood transfusion and IV antibiotics after a wound haematoma.
Wound Infection - 6 (10%):Primary group vs. 8(13%):Secondary group. Of these, 1 woman (1.65%) in the primary group had a prolonged stay for IV antibiotics and 1 (1.65%) was readmitted needing observation and antibiotics. 

14 (22.6%) women in the primary group and 6 (11%) women in the secondary group had pre-operative voiding dysfunction and were excluded from analysis of new onset post-operative voiding dysfunction.

Overall, there was 44% risk of de novo voiding dysfunction requiring CISC in short term but only 7% at >2 years follow up. This risk is particularly low in the primary group with non-obstructive slings were this risk was 2% only.

It is seen that this surgery had high overall success rate of (91%) which is comparable between both primary and secondary groups. The success is maintained at medium and long term follow up although numbers in long term follow up  group is small .

Rate of Voiding dysfunction is high in immediate postoperative period but drops significantly at 1 year follow up with only 7% patient needing to perform CISC at > 2 years follow up overall and only 2% in our tension free primary slings

With growing concerns around mesh use for SUI surgery, use of AFS for primary and secondary SUI has been increasing. 

The low long-term risk of self-catheterisation especially in the primary group with non-obstructive slings is reassuring and will aid counselling of patients opting for AFS as primary SUI procedure.

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