The autologous fascial pubovaginal sling (AFPVS) has been considered the gold standard treatment of both simple and complicated stress urinary incontinence in women since the late 1990s. Further, since the US Food and Drug Administration warning regarding transvaginal mesh, there has been an increase in AFPVS placement. We believe this increase will continue as the full extent of the risks associated with synthetic midurethral slings (SMUS) come to light.

A 35-year-old woman presented with severe stress urinary incontinence after a prolonged and difficult 30 hour vaginal delivery. She had ineffective pelvic floor exercise and biofeedback treatment. This video demonstrates our technique of AFPVS.

This video highlights changes in our original technique. The steps include: 1) small transverse incision below the pubic hairline (decreasing the length of the incision to 8 – 12 cm, 2) securing  a 12 – 18 cm rectus fascial graft, 3) placing corner sutures on either side of the fascia to facilitate closure at the end of the case, 4) 4  cm transverse incision over bladder neck staying superficial to the pubocervical fascia, 5) perforating the endopelvic fascia and entering the retropubic space, 6) passing the sling into the retropubic space with a finger protecting the bladder and urethra from injury, 7) cystoscopy to check for bladder or urethral injury, 8) passing the sling through the fascia through a separate stab wound, 9) closing the fascia, 10) placing the sling loosely with no tension at all, 11) close abdominal and vaginal wounds.

She voided on post op day 1 and at 5 months post operatively, she reported no incontinence, but had polyuria. Uroflow and residual urine were normal.

The pubovaginal sling has re-emerged as a safe and effective alternative to synthetic slings. This video presents all of our improved techniques developed over the last 30 years.