While midurethral synthetic sling placement is the current treatment modality of choice for the surgical management of stress urinary incontinence (SUI) in women, the approach is plagued by complications related to the use of polypropylene mesh. Furthermore, de-novo voiding dysfunction may occur due to inappropriate and fixed tension in the sling. Historically, pubovaginal slings (PVS) offered an autologous alternative to synthetic mesh but were similarly limited. Herein, we describe a modified approach to PVS placement that incorporates autologous fascial sling with the adjustable Remeex varitensor.

A 46-year-old female presented to our clinic due to mixed incontinence with a more significant and bothersome stress component. She had undergone total abdominal hysterectomy for cervical cancer in 2013 after which SUI worsened. Cervical cancer was in remission since then. She now used 8 pads daily and her symptoms had been refractory to pelvic floor physical therapy. Cough stress test was positive. SUI was also confirmed on urodynamic study. Based on these findings; she was scheduled for autologous fascial pubovaginal sling placement with an adjustable mechanism.

The patient was positioned in dorsal lithotomy and a suprapubic low Pfannenstiel incision was made. Following dissection to the rectus fascia, we harvested a 2 x 6 cm autologous graft. The fascial sling was then defatted and pierced with PDS sutures, replacing the synthetic mesh of the Remeex system. A vertical incision was made on the anterior vaginal wall and periurethral dissections were advanced toward the pubic bone. Trocars were then passed through the retropubic space to the suprapubic incision. Flexible cystoscopy was then performed to assess possible bladder injury. There was a small area of trocar infiltration on the left bladder wall, visible only when the scope was in maximal deflection. The perforating trocar was adjusted for appropriate positioning under cystoscopic guidance. The PDS sutures were then passed to the suprapubic incision and integrated into the varitensor. All incisions were then closed, the vagina was packed, and a urethral catheter was left indwelling. The sling tension was assessed on postoperative day 1 with a cough stress test, however there was no evident leak to indicate further adjustment to the sling tension. After ensuring efficient bladder emptying via serial post-void residual measurements, the adjuster was removed.

The integration of autologous fascia with an adjustable tensioning mechanism in a pubovaginal sling offers a potentially feasible approach and provides an alternative to midurethral synthetic mesh placement in the surgical treatment of female SUI. The availability of bidirectional adjustment in the postoperative setting in case of SUI recurrence or voiding dysfunction and the avoidance of synthetic mesh-related complications seem to be the major advantages. Further research is warranted.