Stress urinary incontinence (SUI) significantly impacts the quality of life in middle-aged women, often associated with urethral hypermobility and pelvic floor weakness. While synthetic mid-urethral slings have been the gold standard, there is a growing interest in autologous techniques to avoid mesh-related complications. We present the case of a 51-year-old female patient with a history of three vaginal deliveries, presenting with significant SUI during physical activities such as walking and lifting heavy objects. Despite the absence of prior pelvic surgeries, her symptoms were refractory to conservative measures, necessitating a surgical intervention that provides robust urethral support while minimizing long-term foreign body risks.

A detailed preoperative assessment was conducted to characterize the incontinence type and pelvic anatomy:Gynecological Examination: Revealed a Grade 2-3 cystocele. A stress test was positive for leakage.Q-tip Test: Measured at >45° , confirming significant urethral hypermobility.Uroflowmetry: Showed a high Qmax of 35 ml/s and a voided volume of 805 ml, indicating good detrusor function without obstruction.The surgical strategy chosen was the Autologous Rectus Fascial Sling (specifically the 'Sling on a String' technique). This procedure involves harvesting a strip of the patient's own rectus sheath fascia through a small suprapubic incision. The fascial graft is then positioned beneath the mid-urethra and secured using non-absorbable sutures ("strings") passed through the retropubic space, providing a natural, tension-free support mechanism.

The procedure was completed successfully without perioperative complications. Surgical Outcome: The autologous graft provided excellent urethral coaptation. By using the 'Sling on a String' modification, the surgical site morbidity was minimized. Clinical Follow-up: At the post-operative evaluation, the patient reported complete dryness during provocative maneuvers (walking, lifting). Functional Recovery: Post-operative uroflowmetry remained within normal limits, and no de novo urgency or voiding dysfunction was observed. The patient’s Grade 2-3 cystocele symptoms were also addressed during the same surgical session, leading to overall pelvic floor restoration.

The Autologous Rectus Fascial Sling remains a highly effective "gold standard" alternative, especially for patients who wish to avoid synthetic mesh or those with significant urethral hypermobility. The 'Sling on a String' technique offers: Biocompatibility: Eliminates the risk of mesh erosion or chronic inflammation. Durability: Provides long-lasting mechanical support using the patient's own high-tensile strength tissue. Versatility: Allows for precise tension adjustment to balance continence and efficient voiding.

Blaivas, J. G., et al. (2011). "The Classic Autologous Fascial Sling: Indications and Outcomes." Urologic Clinics of North America.
Fusco, F., et al. (2017). "Autologous Fascial Sling for Female Stress Urinary Incontinence: A Systematic Review and Meta-analysis." European Urology.
Guerette, N. L., et al. (2007). "Short-term outcomes of the 'Sling on a String' procedure for SUI." International Urogynecology Journal.