Autologous Rectus Fascia
Rectus fascia is the patient's own abdominal-wall fascia, usually harvested from the anterior sheath for a pubovaginal sling. It is used for female stress urinary incontinence (SUI). Other applications, including prolapse and penile reconstruction, have a smaller and less comparative evidence base. A free fascial graft is distinct from a vascularized rectus muscle or myofascial flap.
The autologous pubovaginal sling procedure page covers placement and tensioning.
Benefits and Risks
Autologous fascia avoids implantation of a synthetic sling mesh and donor-tissue transmission concerns. Inflammation, infection, pain, graft failure and urinary-tract injury can still occur. Permanent fixation sutures may still be used, and postoperative obstruction or recurrent incontinence can require further treatment.
Autologous fascia is commonly chosen when the patient declines synthetic mesh, has a high risk of mesh erosion (immunocompromise, chronic steroid use, prior radiation), has had a prior mesh-sling failure or mesh complication or a failed Burch colposuspension, or has intrinsic sphincter deficiency, neurogenic bladder-neck incompetence or severe SUI.
The AUA/SUFU guideline includes autologous fascia PVS among options for index SUI patients. Counseling on these options is a Strong Recommendation (Statement 12; Grade A). Clinicians should not use a synthetic midurethral sling during concomitant urethral diverticulectomy, urethrovaginal fistula repair or urethral mesh excision ; if a concurrent continence procedure is needed, a biological material, preferably autologous fascia, should be considered. Clinicians should strongly consider avoiding mesh in patients at risk for poor wound healing, such as after radiation therapy or with significant scarring or poor tissue quality . For a fixed, immobile urethra, pubovaginal slings, retropubic or adjustable retropubic midurethral slings and bulking agents may be offered , and the panel considered autologous PVS a preferred approach.[1]
The FDA's 2019 transvaginal POP mesh action should not be described as a ban on all sling or sacrocolpopexy mesh.[2]
Harvest Planning
Prior abdominal scars, hernia repair, mesh, fascial quality and potential future flap needs are reviewed before harvest. A low transverse (Pfannenstiel) incision exposes the anterior sheath; dimensions depend on the operation and available tissue. Miller’s sling technique describes a 10 cm rectus fascial segment, Cardenas-Trowers modeled a 10 × 2 cm cadaveric harvest site, and a separate surgical review describes a 10–12 × 2 cm graft; dimensions must fit the abdominal wall.[3][4][25] Nonabsorbable stay sutures are commonly tied at each end of the strip. For cystocele repair, Cormio used a trapezoidal graft (6 cm major base, 4 cm minor base, 5 cm height) suspended on four sutures.[12]
In 12 female anatomical donors, Cardenas-Trowers et al. modeled a site 5.4 cm above the pubic symphysis, where the graft's inferior edge could be 9.4 cm long across the midline. The 9.4 cm measurement is transverse length, not a second vertical landmark. Their closer-to-pubis estimate relied on extrapolation.[3]
Viable fascial edges are preserved and the donor defect is closed with an appropriate abdominal-wall technique, commonly a running nonabsorbable or slowly absorbable suture. Counseling covers hematoma, wound infection/dehiscence, pain, sensory change and incisional hernia. Fascia lata is an alternative when the abdominal donor site is unsuitable; it substitutes thigh morbidity for abdominal harvest morbidity.[1]
Female SUI: Evidence That Helps Counseling
| Evidence | Result and interpretation |
|---|---|
| SISTEr randomized trial: 655 women | At 24 months, autologous rectus PVS had greater SUI-specific success than Burch colposuspension: 66% versus 49%. The stricter overall continence outcome was 47% versus 38%. Outcome assessment was available for 520 women; UTI, voiding difficulty and postoperative urgency incontinence were more frequent after the sling.[5] |
| Khan long-term randomized-cohort follow-up: 162/201 respondents | At median 10 years, dry or improved was 75.4% after autologous fascia versus 73% after TVT; completely dry was 50.8% versus 31.7%. No further operation for persistent SUI was reported in the autologous arm.[6] |
| E-SISTEr observational extension: 482 enrolled | Continence declined over time, while most respondents remained satisfied. The five-year cumulative composite continence estimate was 30.8% after sling versus 24.1% after Burch; these estimates retain prior failure. At the five-year visit, satisfaction was 83% (148/179) versus 73% (126/172) among respondents. The endpoint differed from the original trial, and women with persistent incontinence were more likely to enroll.[7] |
| 2020 Cochrane traditional-sling review | 34 trials/3,244 women, with the search run to February 2017. Versus open colposuspension, traditional slings probably left more women continent at one to five years (69% vs 59%; moderate-quality evidence) and required repeat continence surgery less often (RR 0.15; high-quality evidence). Versus mid-urethral slings, traditional slings were probably no better and may be less effective at one to five years (67% vs 74%; OR 0.67, 95% CI 0.44 to 1.02), and mid-urethral slings may have fewer perioperative complications. Autologous, donor-derived and synthetic materials are pooled.[18] |
| Athanasopoulos retrospective series: 264 women | Mean follow-up 27.8 months. 224 (85%) were successfully treated and satisfied, including 200 (75.8% of all patients) totally dry. The complication rate was 29.2%, and postoperative urgency was the most common problem (18.5%). Retrospective design and pad-based, satisfaction-linked success define these figures.[19] |
| 2024 randomized-trial review | No statistically clear cure difference was detected between autologous fascia and synthetic midurethral slings. Operative time, hospital stay and de novo urgency favored synthetic slings; reported long-term complications favored fascia. The review pooled 10 RCTs in its meta-analysis; de novo urgency was more frequent with autologous slings (RR 2.84, 95% CI 1.13 to 7.10). Heterogeneous procedures and outcome definitions prevent a blanket claim of equal efficacy or universally lower morbidity.[8] |
| Zargham prospective cohort: 125/166 women analyzed | Classic rectus PVS (52) versus a polyvinylidene fluoride tape sling (73) at a mean of 38 and 41 months. Reported success was 94% and 93%. Operating time was longer with PVS (91.1 vs 32.4 minutes). The authors reported overall complication rates of 47.2% vs 25% (p = 0.049). The comparator was a single tape type in a nonrandomized cohort.[21] |
Placement and postoperative emptying
Classic PVS supports the bladder neck and proximal urethra; short midurethral fascial slings are a modification. In Miller's technique, cystoscopy after retropubic passage checks for bladder perforation and confirms sling tensioning, and the suprapubic tube was removed on postoperative day 7 after a capping trial.[1][4]
Osman's retrospective midurethral "sling on a string" series included 106 patients with mean nine-month follow-up. A short fascial strip is suspended on sutures and placed loosely at the midurethra, with more tension only in patients with intrinsic sphincter deficiency. In primary SUI (46.2%), subjective cure was 87.8%, de novo storage symptoms 8.2% and intermittent self-catheterization beyond two weeks 2.0%.[9] After prior surgery, the figures were 72.0%, 14.0% and 10.5%.[9] A laparoscopic midurethral technique has been described in 10 patients, all reporting cure at 12 months.[22]
An autologous transobturator sling was compared with TVT-O in a randomized trial (dryness 92.4% [49/53] vs 94.6% [53/56] at 24 months; p = 0.47).[20] A 2024 review of 11 studies (323 patients) reported pooled 12-month negative-cough-stress-test success of 96.8% in six single-arm studies (155 patients) and similar success and complication rates to synthetic transobturator slings in comparative studies, with longer operative time.[10] The authors describe the data as limited and without long-term follow-up.[10]
Prolapse Reconstruction
Rectus fascia can be used in selected sacrocolpopexy or vaginal reconstructive techniques when the patient wishes to avoid synthetic mesh.
In Wang's single-center 132-patient cohort, median follow-up was 2.2 years. Five-year survival estimates were 28.3% composite failure, 6.8% anatomic failure and 13.0% retreatment, with wide confidence intervals. Quoting only anatomic failure would conceal symptomatic and retreatment outcomes.[11]
Cormio's 30-patient pubovaginal cystocele-sling series reported no anterior recurrence at mean 62.6 months, with one apical/posterior recurrence and one superficial donor-wound dehiscence.[12]
Other Reconstructive Uses
| Application | Evidence boundary |
|---|---|
| Peyronie/tunical grafting | A cadaveric comparison and 12-patient series using the dorsal rectus sheath found similar histological architecture to tunica and straightening in 10 patients; six had minor complications.[13] |
| Corporal coverage during penile prosthesis placement | In a 15-patient series with severe corporal or tunical fibrosis, all 14 patients evaluated had functioning implants at a mean 18 months, with no infection or graft erosion reported.[14][26] |
| Bladder-neck sling/cinch for complex pediatric incontinence | Increasing outlet resistance requires assessment of bladder storage pressures, upper tracts and a catheterization plan. In Bauer’s mixed-etiology series of 11 girls (nine with neurogenic bladder dysfunction and two with other causes), eight were dry on intermittent catheterization at 3 to 24 months after a rectus fascial sling; the 8/11 result is for the entire group, not the neurogenic subgroup.[24] In Bugg’s 15 children undergoing concurrent augmentation, nine were dry by the study definition at 10 to 36 months; the authors subsequently changed their technique because results did not meet expectations.[15] |
| Vascularized myofascial wrap | A pedicled rectus muscle/sheath construct is a flap with its own blood supply and different harvest burden.[16] |
| Rectus abdominis muscle flap at bladder neck closure | In a six-patient retrospective series, a rectus abdominis muscle flap was interposed between the bladder neck and urethral stump when omentum was unavailable. All six were continent at a mean of 45.5 months without related fistula. This is a muscle flap, not a free fascial graft.[23] |
| Recurrent metoidioplasty fistula | Johnsen reported no recurrence in three patients at median seven months. Free fascia separates suture lines but does not provide the vascular supply of a pedicled interposition flap.[17] |
The tissue source, graft dimensions, fixation material, donor-site closure and any associated reconstructive procedure are documented in the operative note.
References
1. American Urological Association/SUFU. Surgical Treatment of Female Stress Urinary Incontinence. 2023 amendment. Statements 12, 16–18 and autologous fascia PVS discussion. Guideline.
2. US Food and Drug Administration. Pelvic Organ Prolapse (POP): Surgical Mesh Considerations and Recommendations. Regulatory overview.
3. Cardenas-Trowers OO, Bergden JS, Gaskins JT, et al. Development of a Safety Zone for Rectus Abdominis Fascia Graft Harvest Based on Dissections of the Ilioinguinal and Iliohypogastric Nerves. American Journal of Obstetrics and Gynecology. 2020;222(5):480.e1-480.e7. doi:10.1016/j.ajog.2019.12.009
4. Miller AR, Linder BJ, Lightner DJ. Autologous Rectus Fascia Sling Placement in the Management of Female Stress Urinary Incontinence. International Urogynecology Journal. 2018;29(9):1403-1405. doi:10.1007/s00192-018-3643-1
5. Albo ME, Richter HE, Brubaker L, et al. Burch Colposuspension versus Fascial Sling to Reduce Urinary Stress Incontinence. N Engl J Med. 2007;356:2143–2155. doi:10.1056/NEJMoa070416.
6. Khan ZA, Nambiar A, Morley R, et al. Long-Term Follow-Up of a Multicentre Randomised Controlled Trial Comparing Tension-Free Vaginal Tape, Xenograft and Autologous Fascial Slings for the Treatment of Stress Urinary Incontinence in Women. BJU International. 2015;115(6):968-977. doi:10.1111/bju.12851
7. Brubaker L, Richter HE, Norton PA, et al. Five Year Continence Rates, Satisfaction and Adverse Events of Burch Urethropexy and Fascial Sling Surgery for Urinary Incontinence. J Urol. 2012;187:1324–1330. doi:10.1016/j.juro.2011.11.087. Full text.
8. Grigoryan B, Kasyan G, Pushkar D. Autologous Slings in Female Stress Urinary Incontinence Treatment: Systematic Review and Meta-Analysis of Randomized Controlled Trials. International Urogynecology Journal. 2024;35(4):759-773. doi:10.1007/s00192-024-05768-6
9. Osman NI, Hillary CJ, Mangera A, et al. The Midurethral Fascial "Sling on a String": An Alternative to Midurethral Synthetic Tapes in the Era of Mesh Complications. European Urology. 2018;74(2):191-196. doi:10.1016/j.eururo.2018.04.031
10. Vasudeva P, Yadav S, Sinha S, et al. Autologous Versus Synthetic Midurethral Transobturator Sling: A Systematic Review and Meta-Analysis of Outcomes. Neurourology and Urodynamics. 2024;43(8):2017-2029. doi:10.1002/nau.25527
11. Wang R, Reagan K, Boyd S, Tulikangas P. Sacrocolpopexy Using Autologous Rectus Fascia: Cohort Study of Long-Term Outcomes and Complications. BJOG. 2022;129(9):1600-1606. doi:10.1111/1471-0528.17107
12. Cormio L, Mancini V, Liuzzi G, Lucarelli G, Carrieri G. Cystocele Repair by Autologous Rectus Fascia Graft: The Pubovaginal Cystocele Sling. The Journal of Urology. 2015;194(3):721-727. doi:10.1016/j.juro.2015.03.104
13. Craatz S, Spanel-Borowski K, Begemann JF, et al. The Dorsal Lamina of the Rectus Sheath: A Suitable Grafting Material for the Penile Tunica Albuginea in Peyronie's Disease? BJU International. 2006;97(1):134-137. doi:10.1111/j.1464-410X.2006.05876.x
14. Pathak AS, Chang JH, Parekh AR, Aboseif SR. Use of Rectus Fascia Graft for Corporeal Reconstruction During Placement of Penile Implant. Urology. 2005;65(6):1198-1201. doi:10.1016/j.urology.2004.12.062
15. Bugg CE, Joseph DB. Bladder Neck Cinch for Pediatric Neurogenic Outlet Deficiency. The Journal of Urology. 2003;170(4 Pt 2):1501-1503. doi:10.1097/01.ju.0000084145.34813.97
16. Kolligian ME, Palmer LS, Cheng EY, Firlit CF. Myofascial Wrap to Treat Intractable Urinary Incontinence in Children. Urology. 1998;52(6):1122-1127. doi:10.1016/s0090-4295(98)00490-7
17. Johnsen NV, Voelzke BB. Autologous Rectus Fascia Graft Interposition Repair of Urethrocutaneous Fistulae in Female-to-Male Metoidioplasty Patients. Urology. 2018;116:208-212. doi:10.1016/j.urology.2018.03.013
18. Saraswat L, Rehman H, Omar MI, et al. Traditional suburethral sling operations for urinary incontinence in women. Cochrane Database Syst Rev. 2020;1:CD001754. doi:10.1002/14651858.CD001754.pub5. Full text.
19. Athanasopoulos A, Gyftopoulos K, McGuire EJ. Efficacy and preoperative prognostic factors of autologous fascia rectus sling for treatment of female stress urinary incontinence. Urology. 2011;78(5):1034-1038. doi:10.1016/j.urology.2011.05.069
20. Kilinc MF, Yildiz Y, Hascicek AM, et al. Long-term postoperative follow-up results of transobturator autologous rectus fascial sling versus transobturator tension-free vaginal tapes for female stress urinary incontinence: randomized controlled clinical trial. Neurourol Urodyn. 2022;41(1):281-289. doi:10.1002/nau.24813
21. Zargham M, Merasie R, Aghdas FS, et al. Comparing mid-term outcomes of pubovaginal slings using rectus autologous fascia with polyvinylidene fluoride tape slings in the management of female stress urinary incontinence: a prospective cohort study with at least 3 years of follow-up. Eur J Obstet Gynecol Reprod Biol. 2026;317:114843. doi:10.1016/j.ejogrb.2025.114843
22. Fayyad AM, Hasan MR. Novel technique of laparoscopic mid-urethral autologous rectus fascial sling for stress urinary incontinence. BJOG. 2024;131(12):1587-1590. doi:10.1111/1471-0528.17877
23. Smith EA, Kaye JD, Lee JY, et al. Use of rectus abdominis muscle flap as adjunct to bladder neck closure in patients with neurogenic incontinence: preliminary experience. J Urol. 2010;183(4):1556-1560. doi:10.1016/j.juro.2009.12.044
24. Bauer SB, Peters CA, Colodny AH, et al. The use of rectus fascia to manage urinary incontinence. J Urol. 1989;142(2 Pt 2):516-519. doi:10.1016/s0022-5347(17)38801-8
25. Bang SL, Belal M. "Autologous pubovaginal slings: back to the future or a lost art?" Res Rep Urol. 2016;8:11-20. doi:10.2147/RRU.S96957
26. Tran VQ, Lesser TF, Kim DH, Aboseif SR. "Penile Corporeal Reconstruction during Difficult Placement of a Penile Prosthesis." Adv Urol. 2008;2008:370947. doi:10.1155/2008/370947