Autologous Fascial Pubovaginal Sling (PVS)
An autologous fascial sling uses the patient's own rectus sheath or fascia lata to support the urethra. It is an established surgical option for female stress urinary incontinence (SUI), including primary and selected recurrent cases. It avoids a synthetic sling mesh but adds a harvest wound and can cause obstruction, pain, infection or recurrent incontinence. Traditional bladder-neck PVS and modified midurethral fascial slings differ in position and fixation; their outcomes and operative details should be identified separately.[1][2]
For other options, see the female SUI database, synthetic slings and Burch colposuspension. The FDA's 2019 action concerned transvaginal mesh for prolapse, not a ban on every SUI sling or abdominal sacrocolpopexy mesh.[3]
Selection and Counseling
| Situation | Decision points |
|---|---|
| Primary SUI or stress-predominant mixed incontinence | Autologous fascia PVS is one option alongside synthetic MUS, Burch and bulking. Discuss expected stress-leakage benefit, existing urgency, recovery, harvest morbidity and the possibility of catheterization. |
| Fixed or poorly mobile urethra | AUA/SUFU includes PVS, retropubic MUS, bulking and adjustable retropubic slings as options. Its discussion favors PVS for a non-mobile urethra. Urethral mobility and intrinsic sphincter deficiency are related assessments, not interchangeable diagnoses. |
| Recurrent SUI after prior surgery | Reassess the mechanism: recurrent stress leakage, obstruction, urgency, mesh complications and impaired emptying need different treatment. A salvage PVS is an option; prior surgery does not guarantee success or mandate immediate sling placement. |
| Concomitant urethral diverticulectomy, urethrovaginal fistula repair or urethral mesh excision | AUA/SUFU advises against a synthetic MUS during these repairs. If concurrent continence surgery is appropriate, autologous fascia is preferred over other biological sling substitutes. This is different from a remote, healed history of urethral surgery. |
| Radiated, scarred or otherwise poorly healing tissue | Consider avoiding synthetic mesh. Autologous harvest and recipient-site healing still carry risks; timing and reconstruction should be individualized. |
These distinctions follow the AUA/SUFU guideline's index-patient and special-case recommendations; they do not establish one operation as best for every patient.[1]
Before surgery, document demonstrable stress leakage, symptom burden, pelvic examination, urinalysis and residual urine. Additional evaluation is appropriate for diagnostic uncertainty, substantial voiding dysfunction, recurrent surgery or other non-index features. Discuss what will happen if the patient cannot empty: temporary drainage, intermittent catheterization and possible sling revision.[1]
Graft Choice and Harvest
The rectus-fascia page covers abdominal anatomy, harvest planning and the cadaveric nerve-mapping study. The fascia-lata page covers thigh harvest and donor-site follow-up. A free graft has no retained vascular pedicle and should not be confused with a vascularized muscle/myofascial flap.
| Donor site | Practical considerations |
|---|---|
| Anterior rectus sheath | Convenient when the abdominal donor site is suitable. Inspect prior incisions, hernia repair, mesh and fascial quality. Harvest dimensions and stay-suture material depend on the chosen sling construction. Preserve viable edges and close the donor defect; closure reduces a defect but does not guarantee freedom from hernia or pain. |
| Fascia lata | Useful when the abdominal fascia is unsuitable or another donor site is preferred. Direct exposure and fascial-stripper techniques are distinct approaches. Account for thigh anatomy, mobility, prior surgery and the required graft width/length; counsel about hematoma, sensory change, contour changes, pain and herniation. |
Do not infer equivalent continence or a universally safer donor site from tissue strength or small series. Hong's registry included 41,533 sling operations but only 160 rectus-fascia and 81 fascia-lata cases. Its 30-day associations were affected by UTI and lacked key information about previous continence surgery, retention and long-term outcomes. It is not a randomized donor-site comparison.[4]
In Buckley's 201-woman pelvic-floor harvest cohort, 64 women reported a thigh issue at six weeks. One postoperative thigh hematoma required transfusion and drainage, and two women underwent donor-site hernia repair. Reported absence of functional deficit in that cohort is not an assurance for every patient. Graft sizes differed between sling and prolapse operations.[5]
Traditional Bladder-Neck PVS
The aim is support at the proximal urethra/bladder neck with an individualized balance between continence and emptying. A published rectus-fascia technique uses a roughly 10-cm graft and nonabsorbable stay sutures; other constructions use different dimensions and fixation. The following stages describe the operative principles, not a universal suture or spacer prescription.[6][1]
- Plan and harvest the graft. Select the donor site, maintain tissue hydration, prepare secure end sutures appropriate to the construction and close the donor defect.
- Expose the proximal urethra. An inverted-U anterior vaginal incision is one described approach. Develop controlled paraurethral planes and identify the intended entry into the retropubic space; prior surgery or scarring can alter these planes.
- Pass the suspension sutures. Use the chosen carrier and controlled retropubic passage. Match needle direction, vaginal dissection and abdominal guidance to the specific technique and the patient's anatomy.
- Check lower-tract integrity. Perform intraoperative cystourethroscopy to identify bladder or urethral injury and intraluminal material. If a passage is revised, reassess integrity. Tailor repair and drainage to any injury's location and extent.
- Position and fix the sling. Support the intended urethral level without twisting the graft. Adjust fixation for the intended support and emptying strategy. No particular instrument under the sling, Q-tip maneuver or visual cystoscopic appearance guarantees absence of postoperative obstruction.
- Close and plan drainage. Confirm hemostasis and document the graft source, dimensions, fixation, cystoscopic findings, any injury and the postoperative voiding/drainage plan.[6][1]
Modified Midurethral Fascial Slings
“Sling on a string” describes a family of modifications, not one interchangeable recipe. Asfour's illustrated modified Aldridge technique uses a 6-cm skin incision to harvest approximately 1 × 8 cm of rectus sheath, with doubled 0 PDS suspension sutures and a midpoint marker. The graft is placed at the midurethra, with controlled bottom-to-top passage, cystoscopy and tension adjustment. The incision length should not be mistaken for the graft length.[7]
Osman's retrospective series included 106 women, with mean follow-up of nine months. Subjective cure was 87.8% in primary SUI and 72.0% after previous surgery; intermittent catheterization beyond two weeks occurred in 2.0% and 10.5%, respectively. These are selected, short-term subgroup observations, not a randomized demonstration that this modification eliminates retention or is superior to traditional bladder-neck PVS. Shaw's separate 19-woman midurethral series included four women with voiding dysfunction and three sling loosenings.[8][9]
Adjustment evidence: a 2025 randomized trial compared 3-cm and 6-cm suspension-knot heights above the aponeurosis for a specified midurethral rectus-fascial technique. Among 52 analyzed women, retention at two weeks occurred in 9/27 versus 5/25; the difference was uncertain. With 12-week follow-up and limited precision, the trial does not establish an optimal universal gap or prove the methods equivalent. It did not test a clamp placed beneath the urethra as a universal safeguard.[10]
Transobturator and laparoscopic fascial modifications have separate, smaller evidence bases. They should not inherit the long-term results of a different retropubic operation merely because all use autologous fascia.[2]
Evidence for Continence and Durability
| Evidence | Finding that helps counseling | Interpretation |
|---|---|---|
| SISTEr RCT, 655 women | At 24 months, rectus-fascia PVS achieved 66% versus 49% SUI-specific success compared with Burch; strict overall success was 47% versus 38%. | Participants had urethral hypermobility; outcome assessment was available for 520 women. These are cumulative success estimates. Sling patients had more UTI, voiding difficulty and postoperative urgency incontinence. This is a Burch comparison, not a synthetic-MUS comparison.[11] |
| E-SISTEr extension, 482 enrolled | Five-year cumulative continence estimates were 30.8% sling versus 24.1% Burch; most respondents remained satisfied. | Observational follow-up preferentially enrolled women with persistent incontinence. The cumulative endpoint differs from both cross-sectional dryness and the original trial's definition.[12] |
| 2020 Cochrane synthesis, 34 trials/3,244 women | Traditional slings offered better medium-term continence than open colposuspension, with more voiding morbidity. Against MUS, 1–5-year continence was 67% versus 74%, OR 0.67 (95% CI 0.44–1.02). | Fully incorporated search ended February 2017. The six-trial medium-term MUS analysis included 458 women and heterogeneous traditional sling materials. This is not proof of equal efficacy or an autologous-only pooled cure rate.[2] |
| 2024 and 2025 randomized-study syntheses | No clear cure difference between autologous and synthetic sling groups; autologous operations took longer. | The 2025 review included three studies of primary surgery; studies, methods, outcome definitions and follow-up overlap. Nonsignificance is not equivalence.[13][14] |
| Khan randomized-cohort follow-up, 162/201 respondents | At median ten years, dry or improved was 75.4% after fascia versus 73% after TVT; completely dry was 50.8% versus 31.7%. | Selected long-term responders and a single trial. No further operation for persistent SUI in the fascia arm does not mean no complication or intervention of any kind.[15] |
| Nair standard-versus-short fascial-sling follow-up, 107/165 original participants | At median 17 years, symptom/QoL comparisons did not clearly differ; reported satisfaction was 67.2%. | This compares two fascial techniques, not fascia versus mesh or rectus versus thigh tissue. Satisfaction is not a complete-dry rate.[16] |
Observational comparisons require cautious counseling. Offiah's 2025 single-center survey analyzed 395 respondents, including only 34/90 invited fascia-sling patients. Reported SUI absence was similar for fascia and TVT, but procedure choice was not randomized, follow-up and technique varied, and mesh exposure was not assessed. These limitations prevent a reliable overall safety ranking or a recommendation to prefer fascia for every patient.[17]
Emptying, Urgency and Follow-up
- Voiding trial and drainage: assess postoperative emptying and arrange a specific catheterization plan if the patient cannot empty safely. Persistent difficulty warrants review for obstruction and other causes, with discussion of the continence consequences of sling loosening, incision or revision.[1]
- Urgency and mixed incontinence: stress leakage may improve while urgency persists or develops. Evaluate bothersome new symptoms, infection and impaired emptying rather than assuming every symptom is idiopathic OAB. A urodynamic detrusor-overactivity endpoint is not interchangeable with patient-reported urgency.[1][2]
- Donor and recipient wounds: monitor pain, hematoma, infection, dehiscence and hernia; examine persistent vaginal symptoms or concern for urinary-tract injury. Autologous tissue does not eliminate graft/suture-related or wound complications.[1][4][5]
- Long-term assessment: distinguish SUI recurrence, all-incontinence burden, satisfaction and retreatment. A patient can remain satisfied without being completely dry; a low reoperation rate does not prove durable complete continence.[12][16]
Preoperative residual urine and flow help identify patients needing more evaluation and catheterization counseling. A small historical series does not make PVR >100 mL or Qmax ≤20 mL/s a universally validated predictive cutoff, and low flow alone does not diagnose obstruction.[1]
Salvage and the Severely Compromised Outlet
Autologous PVS can be offered for selected persistent/recurrent SUI after a synthetic sling or mesh complication, with realistic expectations:
| Series | Observed outcome | Limitation |
|---|---|---|
| Milose, 66 women after at least one failed MUS | 46/66 reported SUI cure at mean 14.5 months; only 25/66 had neither stress nor urgency incontinence. | Retrospective; most had mixed incontinence. SUI-specific benefit is not cure of all leakage.[18] |
| Chen, 18 women after at least two failed MUS | 16/18 were cured or improved at median 80 months. | All also had partial sling excision and urethrolysis; small selected cohort, not an isolated-sling efficacy estimate.[19] |
| McCoy, 46 women after mesh removal | 42/46 objective and 35/46 subjective success at mean 16 months; 22% required subsequent interventions. | Staged/concomitant groups were not randomized. No detected difference does not prove that timing strategies are equivalent.[20] |
For severe outlet dysfunction or recurrent/persistent SUI, AUA/SUFU permits consideration of an obstructing autologous PVS or bladder-neck closure with drainage after counseling. These require an explicit plan for bladder storage safety, upper-tract protection and catheterization; they are not routine next steps in a fixed escalation sequence. The guideline discussion advises against tensioning a synthetic sling to create this obstructing effect.[1]
See bladder-neck closure and bladder-neck reconstruction for the distinct outlet-closure and diversion decisions.
Videos
References
1. American Urological Association/SUFU. Surgical Treatment of Female Stress Urinary Incontinence. 2023 amendment. Evaluation, counseling, autologous fascia PVS, Statements 12, 16–18 and 22, and follow-up. Full guideline.
2. 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.
3. US Food and Drug Administration. Pelvic Organ Prolapse (POP): Surgical Mesh Considerations and Recommendations. Regulatory overview.
4. Hong CX, Son Y, Patel VJ, Lince K, Gupta P. Comparison of perioperative adverse events following suburethral sling placement using synthetic mesh, autologous rectus fascia, and autologous fascia lata in a national surgical registry. Neurourol Urodyn. 2024;43(4):925-934. doi:10.1002/nau.25434.
5. Buckley VA, Vereeck S, Karjalainen PK, Rosamilia A. Morbidity Associated With Autologous Fascia Lata Harvesting for Pelvic Floor Surgery. International Urogynecology Journal. 2026;37(4):1049-1054. doi:10.1007/s00192-025-06421-6
6. 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
7. Asfour V, Nikolopoulos KI, Digesu GA, Emery S, Khan Z. Modified autologous fascial sling technique ('sling on a string') for stress incontinence. Int Urogynecol J. 2022;33(2):435-438. doi:10.1007/s00192-021-04815-w.
8. 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
9. Shaw JS, Gerjevic KA, Pollack C, Strohbehn K. Minimally Invasive Autologous Fascia Sling at the Midurethra: A Case Series. Journal of Minimally Invasive Gynecology. 2022;29(10):1165-1169. doi:10.1016/j.jmig.2022.07.001
10. Bortolini T, de Oliveira RT, Borges AG, et al. Urinary retention after autologous fascial sling placement: a randomised trial comparing adjustment techniques. BJU Int. 2025;136:271–279. doi:10.1111/bju.16755.
11. 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.
12. 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.
13. 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
14. Mangir N, Güler H, Keskin H. Comparison of Surgical Outcomes of Autologous Mid-Urethral Fascia Slings and Retropubic Mid-Urethral Slings for Women Undergoing a Primary Surgery for Stress Urinary Incontinence: A Systematic Review and Meta-Analysis. Neurourol Urodyn. 2025;44:136–142. doi:10.1002/nau.25593.
15. 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
16. Nair DB, Khan Z, Mishra T, et al. Autologous fascial slings for stress urinary incontinence: a 17-year follow-up of a randomised controlled study. Int Urogynecol J. 2024;35(3):649-659. doi:10.1007/s00192-023-05702-2.
17. Offiah I, Carolina Ochoa D, Alvarado JM, et al. A medium to long-term study comparing stress urinary incontinence procedures. Neurourol Urodyn. 2025. doi:10.1002/nau.70101.
18. Milose JC, Sharp KM, He C, et al. Success of autologous pubovaginal sling after failed synthetic mid urethral sling. J Urol. 2015;193:916–920. doi:10.1016/j.juro.2014.09.038.
19. Chen J, Li B, Peng L, Shen H, Luo D. Autologous pubovaginal sling for recurrent stress urinary incontinence after two or more failed synthetic midurethral sling. Eur J Obstet Gynecol Reprod Biol. 2022;272:213-216. doi:10.1016/j.ejogrb.2022.03.024.
20. McCoy O, Vaughan T, Nickles SW, et al. Outcomes of autologous fascia pubovaginal sling for patients with transvaginal mesh related complications requiring mesh removal. J Urol. 2016;196(2):484-489. doi:10.1016/j.juro.2016.02.2976.