As more patients express reservations about the placement of synthetic mesh during sling procedures, the use of autologous rectus fascia pubovaginal slings has risen. The concept of using a patient's own tissue as a sling to support the urethra dates to the early 20th century, but it was not until late in that century that the procedure gained widespread appreciation and evolved into its current form. Initially, the procedure entailed mobilizing a strip of abdominal muscle (either rectus or pyramidalis), freeing one end of the strip from its attachment, passing that end under the bladder neck, and reaffixing it to the abdominal muscle wall, forming a "U"-shaped sling around the bladder outlet. Subsequently, overlying abdominal fascia was included in the sling, eventually replacing the muscle altogether. The final innovation: An isolated strip of fascia was suspended by free sutures that were tied to the abdominal wall or attached on top of the abdominal rectus sheath.
The autologous pubovaginal sling supports the proximal urethra and bladder neck to achieve continence by providing a direct compressive force on the urethra and bladder outlet, or by reestablishing a reinforcing platform or hammock against which the urethra is compressed during the transmission of increased abdominal pressure.
The sling is suspended on each end by free sutures that are attached directly to the abdominal wall musculature or, more commonly, tied to each other on the anterior surface of the abdominal wall.
as a way to functionally close the urethra to abandon urethral access to the bladder.
In our opinion, the autologous pubovaginal sling is appropriate for patients with SUI who decline to have synthetic material implanted because of concerns related to long-term placement of synthetic mesh. Other good candidates are women who experience recurrent incontinence after placement of a synthetic sling or who develop a complication, such as vaginal erosion (VIDEO 1, Rectus fascia pubovaginal sling after an unsuccessful TVT), after placement of a synthetic sling. We also prefer to use an autologous sling in patients who have been radiated or who have sustained urethral injuries, as well as in patients who are undergoing simultaneous repair of urethrovaginal fistula or diverticulum—or those who have already undergone such repair.
What is the optimal sling material?
Rectus abdominis fascia versus fascia lata. The two most commonly used autologous tissues are rectus abdominus fascia and fascia lata. Both of these materials have been studied extensively and proven to be effective and reliable. Most surgeons prefer rectus fascia because it is easier and quicker to harvest.
Allogenic and xenogenic tissues. Allogenic (cadaveric) fascia lata and cadaveric dermis provide reasonable efficacy, but durability remains an issue, as high failure rates have been reported. Bovine and porcine dermis, as well as porcine small-intestine submucosa, are also effective for SUI, although durability remains a concern.