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Autologous Fascial Pubovaginal Sling (PVS)

The autologous fascial pubovaginal sling (PVS) is a durable, mesh-free surgical option for female stress urinary incontinence (SUI) that uses the patient's own fascia — most commonly rectus abdominis or, alternatively, fascia lata — as the sling material. Historically the gold-standard anti-incontinence operation, it has experienced a major resurgence following the FDA mesh communications and growing evidence of long-term efficacy comparable to synthetic midurethral slings (MUS).[1][2][3]

For the broader female-SUI ladder, see Female Stress Incontinence Database. For synthetic alternatives, see Female Slings & Suspensions. For the mesh-free retropubic alternative, see Burch Colposuspension. For salvage of severe outlet disease, see Artificial Urinary Sphincter and Bladder Neck Reconstruction (04ab).

Mechanism​

The autologous fascia provides a compressive hammock beneath the urethra (bladder neck or, in modified techniques, midurethra). Increases in abdominal pressure compress the urethra against the pubic symphysis, increasing outlet resistance. Unlike synthetic mesh, the autologous graft integrates with surrounding tissue and avoids erosion / foreign-body reaction.[4][2]

Indications (AUA / SUFU 2023)​

The 2023 AUA/SUFU guideline identifies the autologous PVS as a preferred approach for several special populations:[5][2]

  • Intrinsic sphincter deficiency (ISD) — fixed, immobile urethra; preferred over retropubic MUS or bulking.[5][6]
  • Failed / complicated synthetic MUS — durable salvage after one or more failed mesh slings.[7][8]
  • Mesh complications requiring removal — concomitant or staged after excision.[9]
  • Immunocompromised / prior pelvic radiation — high erosion risk makes autologous tissue preferable.[10][2]
  • Violated urethral lumen — prior diverticulectomy, urethrovaginal fistula.[2]
  • Primary SUI — increasingly used in patients who decline synthetic mesh.[4][3]

Graft Harvest — Rectus Fascia (most common)​

Pfannenstiel or low transverse 6–8 cm incision; expose anterior rectus sheath.[11][10][2]

  • Graft dimensions — typically 8–12 × 2 cm.
  • Stay sutures — nonabsorbable (0-Prolene / 1-0 polypropylene) at each end as handles for retropubic passage and abdominal-wall fixation. Keep moist in saline-soaked gauze.
  • Donor closure — running absorbable (0-Vicryl / PDS) to prevent incisional hernia.

Cardenas-Trowers safety zone for harvest based on cadaveric ilioinguinal / iliohypogastric nerve mapping:[12]

  • Harvest 5.4 cm superior to the pubic symphysis with the inferior border ≤ 9.4 cm in length (4.7 cm bilaterally from midline).
  • The closer to the symphysis, the shorter the safe graft (at 2.7 cm above the symphysis the safe length narrows to 4.8 cm).
  • Low transverse fascial incisions should not extend beyond the lateral borders of the rectus muscles to protect the inferior epigastric vessels and nerves.[12]

Graft Harvest — Fascia Lata (alternative)​

Iliotibial band; useful when rectus fascia is unavailable (prior abdominal surgery / fascial compromise) or when a larger graft is needed.[1][2]

  • Position — ipsilateral leg with knee slightly flexed and hip internally rotated; non-dominant leg preferred.
  • Incision — 3–5 cm longitudinal incision over the lateral thigh, ~ 2–3 cm above the lateral femoral condyle, centered over the ITB.
  • Crawford fascial stripper introduced deep to the fascia and advanced proximally, cutting at a predetermined width (1.5–2 cm) — typical PVS graft 10–15 × 2 cm; up to 24–28 cm for bladder-neck-wrap configurations.
  • Closure — layered; compressive dressing / elastic bandage to the thigh.

Donor-site morbidity (Buckley 2026, n = 201, median 12 mo):[7]

  • 32% any thigh issue at 6 wk (pain / discomfort 17%); decreasing to 17% at 12 mo (cosmetic 8%, paresthesia 4%, mild discomfort 5%).
  • No functional deficits; complaints diminish over time.
  • 2 / 201 (1%) required hernia repair with biological graft.

Hong 2024 NSQIP (n = 41,533) — fascia lata harvest had 2.1× increased odds of 30-day composite adverse events vs rectus fascia, driven primarily by UTI; not significant when UTIs were excluded (aOR 1.93, 95% CI 0.81–4.63).[17]

Rectus Fascia vs Fascia Lata​

FeatureRectus FasciaFascia Lata
Typical PVS graft8–12 × 2 cm10–15 × 2 cm
ApproachPfannenstielLateral thigh ± fascial stripper
Same operative fieldYesNo (separate field)
Donor painMild abdominalThigh; 17% at 6 wk
Nerve riskIlioinguinal / iliohypogastric if too lateralLateral femoral cutaneous (rare)
30-d adverse eventsLoweraOR 2.11 vs rectus (UTI-driven)[17]
AvailabilityLimited by prior abdominal surgeryGenerally available; preferred when abdomen scarred
EfficacyEquivalentEquivalent (Latini 2004: 85% dry / improved at 4.4 yr)

Sling Placement — Traditional Bladder-Neck Technique​

  1. Inverted-U vaginal incision at the bladder neck (palpate the Foley balloon).[11][4]
  2. Paraurethral dissection with combined blunt + sharp dissection to perforate the endopelvic fascia and enter the retropubic space bilaterally.
  3. Trocar passage — Stamey needles, Pereyra ligature carriers, or long clamps from the vaginal incision through the retropubic space and out through the abdominal incision; thread the stay sutures and pull the graft through.
  4. Position — fascial graft as a hammock beneath the proximal urethra / bladder neck.
  5. Tensioning — sling sits loosely beneath the urethra; place a clamp, right-angle, or spacer between the sling and urethra to prevent over-tightening. Optional Q-tip test.
  6. Cystourethroscopy — mandatory to exclude bladder perforation and confirm bilateral ureteral efflux.
  7. Fixation — stay sutures tied over the rectus fascia in a tension-free position.

Modified "Sling on a String" — Midurethral Placement​

Osman / Asfour modification: shorter graft (~ 6 cm) placed at the midurethra rather than the bladder neck, suspended on absorbable loop-0-PDS sutures rather than nonabsorbable suture tied to the rectus fascia.[4][13][14]

  • 6-cm suprapubic incision; harvest rectus sheath.
  • Loop-0-PDS at each end with a midpoint marking suture to facilitate tension-free adjustment.
  • Vaginal incision at the midurethra.
  • Paraurethral tunnels as for synthetic MUS.
  • PDS ends passed retropubically with one hand abdominally below the rectus to palpate / guide.
  • Cystoscopy to confirm bladder integrity.
  • Tension-free graft adjustment; PDS eventually absorbs, leaving the autologous fascia integrated.

Outcomes (Osman 2018, primary SUI): 87.8% subjective cure, 2% ISC, 8.2% de-novo urgency — significantly less voiding dysfunction and de-novo storage symptoms than traditional bladder-neck PVS.[4]

Fayyad 2024 described a novel laparoscopic mid-urethral autologous rectus-fascia sling (n = 10): 100% cure of SUI at 12 mo with normal voiding.[15]

Outcomes​

EndpointResultSource
Pooled cure (12 trials, MUS comparison)67% AFS vs 74% MUSWu 2021 NEJM[1]
SISTEr trial stress-specific success at 24 mo66% AFS vs 49% Burch (p < 0.001)Albo 2007 NEJM[16]
SISTEr overall success at 24 mo47% AFS vs 38% Burch (p = 0.01)Albo 2007[16]
Meta-analysis: AFS vs MUS cureNo significant difference (10 RCTs)Grigoryan 2024[18]
14.5-yr UDI-6 success53%Kim 2022[19]
17-yr RCT satisfaction67.2% (standard vs short — no difference)Nair 2024[20]
24-mo dryness, TO-AFS vs TVT-O92.4% vs 94.6% (p = 0.47)Kilinc 2022[21]
After failed MUS69.7% SUI cure (mean 14.5 mo)Milose 2015[7]
After ≥ 2 failed MUS88.9% cure / improved (median 80 mo)Chen 2022[8]
After mesh removal91% objective success (mean 16 mo)McCoy 2016[9]
Medium-term comparative (5.9 yr)62% AFS vs 64% TVT; lowest complication rate (22.6%) for AFSOffiah 2025[22]
15-yr reoperation-free survival (E-SISTEr single-center)85.2%Kuprasertkul 2019[23]

AFS vs Synthetic MUS — Operative Tradeoffs​

Grigoryan 2024 SR / meta of RCTs:[18]

  • Cure — no significant difference between AFS and synthetic MUS.
  • AFS advantages — lower long-term postoperative complications (RR 0.12, p = 0.004); no mesh erosion / exposure; lower bladder-perforation rates.[18][3]
  • MUS advantages — shorter OR time (~ 30 vs 55–90 min), shorter LOS (outpatient vs 1–7 days), lower de-novo urgency (RR 2.84 favoring MUS, p = 0.03).[18][3]
  • QoL / sexual function — similar between groups.[3]

Complications​

Perioperative:

  • Longer OR time — 55–125 min vs 25–32 min for synthetic.[3]
  • Longer LOS — 1–7 d vs same-day discharge.[3]
  • Bladder perforation — during trocar passage; manage conservatively with catheterization (lower than retropubic synthetic).[3][10]
  • Wound infection / hematoma at harvest site.
  • Donor-site morbidity — pain, dehiscence (rare); ilioinguinal / iliohypogastric nerve injury if rectus harvest too lateral.[12]

Postoperative:

  • Voiding dysfunction / urinary retention — 10–28% may require prolonged ISC; risk factors PVR > 100 mL, Qmax ≤ 20 mL/s.[24][16][4]
  • De-novo urgency / urge incontinence — 8–14% (higher than MUS); more common with bladder-neck placement and tighter tension.[4][18][16]
  • UTI — higher than synthetic.[16]
  • Surgical revision for voiding — ~ 2–6%.[16]

The midurethral "sling on a string" sharply reduces voiding dysfunction (2% ISC) and de-novo urgency (8.2%) vs traditional bladder-neck placement.[4]

Urodynamic Predictors of Voiding Difficulty​

Mitsui 2007 — preoperative PVR > 100 mL or Qmax ≤ 20 mL/s significantly predicts prolonged ISC after PVS. Postoperatively, pressure-flow studies show increased detrusor opening pressure and Pdet@Qmax, confirming intentional outlet resistance.[24]

Fulford 1999 — pre-existing urge syndrome resolves in 69% after PVS, particularly when bladder-neck closure at rest is achieved postoperatively.[25]

Salvage After Failed Synthetic Sling​

SettingOutcomeSource
Single failed MUS69.7% SUI cure at mean 14.5 moMilose 2015[7]
≥ 2 failed MUS88.9% cure / improved at median 80 moChen 2022[8]
After mesh removal91% objective success; staged ≈ concomitantMcCoy 2016[9]
Pure SUI vs mixed62.5% vs 30% complete cure of all incontinenceMilose 2015[7]

Role in the Severely Compromised Outlet — A Continuum​

Autologous fascia plays a graded role from supportive sling through formal bladder-neck closure for patients with severe ISD or a "devastated outlet":[5][26]

  1. Loose midurethral AFS (sling-on-a-string) — primary SUI, mesh avoidance.[4]
  2. Traditional bladder-neck AFS — ISD, recurrent SUI.[16][27]
  3. Obstructing AFS with planned ISC — severe ISD / devastated outlet (synthetic mesh must not be placed under tension).[5][26] Kakizaki 1995 fascial sling around the bladder neck (n = 13, 10 male / 3 female, mostly neurogenic) — continence in 9 / 13 with significant improvement in 3 more; 10 / 12 successful patients required ISC; 9 had concomitant augmentation cystoplasty.[26]
  4. Formal bladder neck closure + catheterizable stoma — irreversible; permanent suprapubic or Mitrofanoff drainage.[28][29][5]
  5. Urinary diversion (ileal conduit / continent diversion) — when the bladder is also non-functional.[5]

Bladder-neck closure outcomes:

SeriesApproachnInitial successAfter revisionFollow-up
Willis 2015[30]Transvaginal vs retropubic6485.7% (TV) vs 81.5% (RP)——
O'Connor 2005[29]Suprapubic / retropubic3583%94% (1 revision)mean 79 mo
Kavanagh 2012[28]+ augmentation + Mitrofanoff2896.4%100% (after VVF repair)median 69 mo

Transvaginal bladder-neck closure offers shorter OR (78 vs 137.5 min), shorter LOS (1.5 vs 4.9 d), and fewer short-term complications (5.7% vs 31%) vs retropubic, with equivalent continence.[30] Most common indication: urethral erosion from chronic indwelling catheter. Long-term failure mode: bladder-neck fistula; stones in augmented bladders; stomal complications.[29][28]

Current Role and Guidelines​

The AUA / SUFU 2023 Guideline positions autologous PVS as:[5]

  • Preferred approach for SUI in patients with a fixed, immobile urethra (ISD).
  • An option for severe outlet dysfunction and recurrent / persistent SUI after prior anti-incontinence surgery.
  • A consideration when an obstructing sling is needed for severely compromised outlets (synthetic mesh must not be placed under tension).

The procedure has experienced a resurgence driven by FDA mesh communications, patient preference for mesh-free options, and growing evidence of comparable long-term efficacy.[2][3][23] Offiah 2025 recommended AFS as the procedure of choice for surgical management of SUI based on the lowest complication rate (22.6%) among studied SUI procedures with TVT-equivalent efficacy.[22] Fellowship training is increasingly emphasizing AFS to ensure availability as mesh alternatives gain importance.[2]

Summary​

The autologous fascial PVS — rectus fascia by default, fascia lata when the abdomen is hostile — is a mesh-free, durable SUI operation with cure rates equivalent to synthetic MUS in modern meta-analyses, and the preferred approach for ISD, failed MUS salvage, mesh-related complications, irradiated tissue, violated urethra, and patients declining mesh. Tradeoffs are longer OR time, longer LOS, and higher rates of voiding dysfunction and de-novo urgency — substantially mitigated by the midurethral sling-on-a-string modification (Osman 2018: 88% cure, 2% ISC, 8.2% urgency). Autologous fascia also supports a graded escalation from loose midurethral sling → bladder-neck PVS → obstructing PVS with planned ISC → bladder-neck closure with catheterizable stoma → urinary diversion for the severely compromised outlet.[1][4][5][16][18][23]

References​

1. Wu JM. Stress incontinence in women. N Engl J Med. 2021;384(25):2428-2436. doi:10.1056/NEJMcp1914037.

2. Mahdy A, Ghoniem GM. Autologous rectus fascia sling for treatment of stress urinary incontinence in women: a review of the literature. Neurourol Urodyn. 2019;38 Suppl 4:S51-S58. doi:10.1002/nau.23878.

3. Chen YA, Jean-Michel M. Resurgence of autologous fascial slings in a challenging climate for sling surgery: a 20-year review of comparative data. Obstet Gynecol Surv. 2022;77(11):696-706. doi:10.1097/OGX.0000000000001072.

4. 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. Eur Urol. 2018;74(2):191-196. doi:10.1016/j.eururo.2018.04.031.

5. Kobashi KC, Vasavada S, Bloschichak A, et al. Updates to surgical treatment of female stress urinary incontinence (SUI): AUA/SUFU guideline (2023). J Urol. 2023;209(6):1091-1098. doi:10.1097/JU.0000000000003435.

6. Hillary CJ, Osman N, Chapple C. Considerations in the modern management of stress urinary incontinence resulting from intrinsic sphincter deficiency. World J Urol. 2015;33(9):1251-1256. doi:10.1007/s00345-015-1599-z.

7. Buckley VA, Vereeck S, Karjalainen PK, Rosamilia A. Morbidity associated with autologous fascia lata harvesting for pelvic floor surgery. Int Urogynecol J. 2026;37(4):1049-1054. doi:10.1007/s00192-025-06421-6.

8. 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.

9. 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.

10. Leow JJ, Gurbani C, Yeow S, Bang S. Autologous pubovaginal sling for the treatment of stress urinary incontinence in a patient with high risk of mesh erosion. Urology. 2020;143:266. doi:10.1016/j.urology.2020.05.031.

11. Miller AR, Linder BJ, Lightner DJ. Autologous rectus fascia sling placement in the management of female stress urinary incontinence. Int Urogynecol J. 2018;29(9):1403-1405. doi:10.1007/s00192-018-3643-1.

12. 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. Am J Obstet Gynecol. 2020;222(5):480.e1-480.e7. doi:10.1016/j.ajog.2019.12.009.

13. 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.

14. Shaw JS, Gerjevic KA, Pollack C, Strohbehn K. Minimally invasive autologous fascia sling at the midurethra: a case series. J Minim Invasive Gynecol. 2022;29(10):1165-1169. doi:10.1016/j.jmig.2022.07.001.

15. 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.

16. Albo ME, Richter HE, Brubaker L, et al. Burch colposuspension versus fascial sling to reduce urinary stress incontinence. N Engl J Med. 2007;356(21):2143-2155. doi:10.1056/NEJMoa070416.

17. 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.

18. Grigoryan B, Kasyan G, Pushkar D. Autologous slings in female stress urinary incontinence treatment: systematic review and meta-analysis of randomized controlled trials. Int Urogynecol J. 2024;35(4):759-773. doi:10.1007/s00192-024-05768-6.

19. Kim S, Wong DG, Lee D, Christie AL, Zimmern PE. Very long-term follow-up of autologous pubovaginal fascia slings in women with stress urinary incontinence. Int Urogynecol J. 2022;33(4):821-828. doi:10.1007/s00192-021-04737-7.

20. 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.

21. Kilinc MF, Yildiz Y, Hascicek AM, Doluoglu OG, Tokat E. 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.

22. 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.

23. Kuprasertkul A, Christie AL, Lemack GE, Zimmern P. Long-term results of Burch and autologous sling procedures for stress urinary incontinence in E-SISTEr participants at 1 site. J Urol. 2019;202(6):1224-1229. doi:10.1097/JU.0000000000000421.

24. Mitsui T, Tanaka H, Moriya K, Kakizaki H, Nonomura K. Clinical and urodynamic outcomes of pubovaginal sling procedure with autologous rectus fascia for stress urinary incontinence. Int J Urol. 2007;14(12):1076-1079. doi:10.1111/j.1442-2042.2007.01909.x.

25. Fulford SC, Flynn R, Barrington J, Appanna T, Stephenson TP. An assessment of the surgical outcome and urodynamic effects of the pubovaginal sling for stress incontinence and the associated urge syndrome. J Urol. 1999;162(1):135-137. doi:10.1097/00005392-199907000-00033.

26. Kakizaki H, Shibata T, Shinno Y, et al. Fascial sling for the management of urinary incontinence due to sphincter incompetence. J Urol. 1995;153(3 Pt 1):644-647. doi:10.1097/00005392-199503000-00025.

27. Zoorob D, Karram M. Role of autologous bladder-neck slings: a urogynecology perspective. Urol Clin North Am. 2012;39(3):311-316. doi:10.1016/j.ucl.2012.06.009.

28. Kavanagh A, Afshar K, Scott H, MacNeily AE. Bladder neck closure in conjunction with enterocystoplasty and Mitrofanoff diversion for complex incontinence: closing the door for good. J Urol. 2012;188(4 Suppl):1561-1565. doi:10.1016/j.juro.2012.02.027.

29. O'Connor RC, Stapp EC, Donnellan SM, et al. Long-term results of suprapubic bladder neck closure for treatment of the devastated outlet. Urology. 2005;66(2):311-315. doi:10.1016/j.urology.2005.03.009.

30. Willis H, Safiano NA, Lloyd LK. Comparison of transvaginal and retropubic bladder neck closure with suprapubic catheter in women. J Urol. 2015;193(1):196-202. doi:10.1016/j.juro.2014.07.091.