Autologous pubovaginal fascial sling from external oblique muscle aponeurosis in the treatment of urodynamic stress urinary incontinence in women: a surgical technique.

Surgical treatment of female stress urinary incontinence (SUI) has been performed for over a century. Various techniques have been utilized, with retropubic colposuspension and sling procedures being the most prevalent. Among sling methods, the use of synthetic midurethral slings (MUS) gained widespread acceptance due to their effectiveness and ease of placement, becoming the gold standard for many practitioners. However, concerns regarding intermediate and long-term complications, including erosion, chronic pain, and dyspareunia, as well as challenges in removal, have led to increased scrutiny and restrictions on their use. Regulatory concerns by the Food and Drug Administration (FDA) and Health Canada regarding vaginal mesh have prompted urogynecologists to seek alternative methods, including autologous fascial pubovaginal slings as a first or second-line option. This video article presents a novel surgical technique utilizing strips from the external oblique muscle aponeurosis for the treatment of SUI. The procedure is performed in four key steps: (I) harvesting an at least 10-12 cm long, 5-7 mm wide fascial strip from the external oblique muscle aponeurosis; (II) preparing the anterior vaginal wall and creating a small vertical incision; (III) placing the sling via the retropubic space using an introducer needle; and (IV) securing the fascial strip under the bladder neck with Prolene 3-0 sutures, ensuring appropriate tension to avoid obstruction and maintaining a distance of one finger breadth of the strip under the bladder neck. The average operative time is approximately 90 minutes. While autologous fascial slings require longer operative time and technical expertise, they offer a viable alternative with potentially lower long-term complications. Encouraging long-term outcomes support their role in SUI management, particularly in light of the restricted use of synthetic slings in several countries. Understanding the technique of autologous fascial slings is essential for surgeons to provide safe and effective treatment options for SUI.