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Autologous Rectus Fascia

Autologous rectus fascia — harvested from the patient's anterior abdominal wall — is the gold-standard biological sling material for female stress urinary incontinence. It is the salvage operation for complex SUI, mesh-sling failure, and intrinsic sphincter deficiency.

Rationale​

  • Immunologically inert — no rejection, no foreign-body reaction
  • Durable — retains tensile strength long-term
  • No erosion risk into the urethra or vagina
  • Reoperation-friendly — tissue planes heal predictably
  • The reconstructive community's default when synthetic or xenogenic alternatives are contraindicated or have failed

Harvest Technique​

  • Low transverse (Pfannenstiel) incision through skin and subcutaneous tissue
  • Expose the anterior rectus fascia
  • Mark and excise a strip approximately 7–10 cm long × 1.5–2 cm wide
  • Tag each end with absorbable sutures
  • Fascial defect closure with running non-absorbable or slowly-absorbable suture
  • Prepare the fascial strip — trim fat, shape ends, tension-test

Placement — Pubovaginal Sling​

The prepared fascial strip is passed through the retropubic space using the Raz-Pereyra trocar or an equivalent ligature carrier, positioned at the bladder neck, and anchored to the rectus fascia above — see the Raz-Pereyra page for technique details.

Evidence & Indications​

  • Gold standard for complex SUI per multiple guidelines and systematic reviews[1][2]
  • Indicated for:
    • Prior mesh-sling failure or mesh complications
    • Failed Burch colposuspension
    • Intrinsic sphincter deficiency (ISD)
    • Neurogenic bladder-neck incompetence
    • Patients declining synthetic mesh
    • Severe SUI

Trade-offs​

  • Longer operation than mesh sling
  • Additional incision (abdominal) with associated wound risk
  • Abdominal wall morbidity — rare herniation at the harvest site
  • Higher technical demand than mid-urethral sling placement

References​

1. Kobashi KC, Vasavada S, Bloschichak A, et al. Updates to Surgical Treatment of Female Stress Urinary Incontinence (SUI): AUA/SUFU Guideline (2023). Journal of Urology. 2023;209(6):1091–1098. doi:10.1097/JU.0000000000003435

2. Lukacz ES, Santiago-Lastra Y, Albo ME, Brubaker L. Urinary Incontinence in Women: A Review. JAMA. 2017;318(16):1592–1604. doi:10.1001/jama.2017.12137

See also: Fascia Lata, Raz-Pereyra Trocar, Polypropylene Mesh.