The surgical treatment of female stress urinary incontinence (SUI) has evolved over the last 3 decades. In recent years, higher quality outcomes research has shown that 3 procedures are superior to others based on level 1 evidence. Mid-urethral synthetic slings (MUS), autologous fascia pubovaginal slings (PVS) and Burch colposuspension are the procedures that are supported by the American Urological Association (AUA)/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) guideline on the surgical treatment of female stress urinary incontinence in the index patient as first line surgical therapy to treat SUI.¹ After being introduced in the late 1990s, MUS overwhelmingly became the most popular surgical procedure to treat SUI due to the excellent outcomes, low complication rates and short recovery time. However, since 2008, international regulatory agencies have increased regulation and issued warnings on vaginal mesh, and this has led to increased scrutiny of MUS by patients, surgeons and health care advocates. As such, the AUA/SUFU guideline recommends that all patients be counseled regarding the risks and benefits of the use of synthetic mesh to treat SUI, as well as understand alternatives to MUS. Increased concerns about synthetic mesh plus an increasing number of patients who have failed or suffered a complication from MUS have created and increased the need for surgical expertise in alternative procedures such as PVS. In our own Female Pelvic Medicine and Reconstructive Surgery specialty practice, we found that in women undergoing surgical treatment of SUI, the use of PVS went from 0% in 2010–2011 (before the 2011 FDA notification) to 6% to 20% per year from 2012 through 2017.² This included index patients with uncomplicated SUI who chose PVS over MUS.

The popularity and almost exclusive use of MUS to treat female SUI have left a large gap in the performance and surgical teaching of PVS. In 2012, urologists submitting surgical logs for certification or recertification reported that 86% of surgical and minimally invasive treatments for female SUI were MUS, and less than 1% were PVS.³ On the urogynecology side, a recent Internet based survey of members of the International Urogynecological Association found that 72% of members did not even offer PVS to their patients.⁴ Clearly, as we move into 2021, there will continue to be an increased demand for PVS to treat both simple and complex SUI in women. Thus, it is important that urologists and urogynecologists are adequately trained in the performance of these procedures. Appendix 1 lists the common indications for PVS.

Rectus Fascia vs Fascia Lata

The majority of level 1 evidence on PVS is for autologous fascia. Other biologics such as allographic fascia and various xenographs have been used, although the results are generally inferior. The sentinel study on PVS was the randomized controlled SISTEr (Stress Incontinence Surgical Treatment Efficacy) Trial, which compared autologous rectus fascia sling to Burch procedure in a large population.⁵ The majority of other series have also reported the use of autologous rectus fascia for PVS. However, in some women, the use of rectus fascia can be challenging, for example in those with extensive prior abdominal surgery, synthetic mesh in the abdominal wall, poor quality abdominal fascia or significant central obesity. In such cases, autologous fascia lata can be used as an alternative to rectus fascia with similar results. It has been our experience that in such patients, fascia lata harvest has a lower morbidity and a quicker recovery time than rectus fascia harvest. In a recent nonrandomized cohort study, we found overall complications were comparable between fascia lata and rectus fascia groups, although the proportion of Clavien grade 2 or greater complications was higher in the rectus fascia group (4.8% vs 20.2%).⁶ It has become our practice to offer both rectus fascia and fascia lata (when appropriate) to all women undergoing PVS, and to discuss the pros and cons of each. The relative indications for fascia lata are summarized in Appendix 2.

Summary

In 2021, PVS should be a valued option for the treatment of SUI in women. It is applicable to the index patient as well as women with more complicated SUI. One must, however, keep in mind that total complications of PVS in general are higher than for MUS. While the risks of mesh-specific complications (erosion, exposure, pain related to synthetic material) are eliminated, there is an approximately threefold higher risk of voiding dysfunction requiring a second procedure (eg sling revision or urethrolysis) and a higher incidence of wound complications (hernia, seroma, wound infection). Thus, thorough counseling and shared decision making are critical. With that said, it is vital that we continue to train the current and next generation of urologists in this time-honored procedure.