Fascial slings are a surgical treatment option for stress urinary incontinence (SUI) in female patients. While it is now recommended as a possible first-line treatment option by international guidelines in the current mesh controversy era, it remains of special interest in patients carrying a high risk of mesh-related or device (artificial urinary sphincter (AUS), adjustable continence therapy (ACT)) related complications.  Most of the existing case series include mixed populations, i.e. naive patients along with patients with failed previous anti-incontinence procedures. The aim of the present series was to report the outcomes of fascial pubovaginal sling in high-risk female SUI patients.

The charts of all female patients who underwent a fascial sling for SUI at a single academic center were reviewed retrospectively. Only patients deemed at high-risk of device/mesh related complications were included in the present analysis: female with a neurological condition who were doing clean intermittent catheterization (CIC), female with SUI after radical cystectomy and ileal neobladder, female with urethral/bladder extrusion of any synthetic material placed for SUI (ie synthetic midurethral sling, (ACT) balloons or artificial urinary sphincter). In the later cases, fascial sling was inserted at the time of material explantation. The fascial sling was taken in the rectus fascia or the fascia lata (for obese patients and/or those with history of multiple previous abdominal incisions). The fascial sling was placed at the bladder neck. Success was defined as complete resolution of SUI postoperatively.

Sixteen patients were included in this study : 13 rectus fascia slings and 3 fascia lata slings. The indications were : neurological condition with CIC for 7 patients (43.7%), ileal neobladder for 2 patients (12.6%)and extrusion / exposure of a previous anti-continence material in 7 cases (43.7%). All these later patients had concomitant mesh/device explantation and pubovaginal sling insertion. The success rate was 56.3% (9/16 patients). Four patients were improved but not completely dry (25%). The procedure failed in three patients (18.7 %). The overall post-operative complications rate was 56.3% but only two patients had a major postoperative complications (i.e. Clavien grade 3 or higher, 11.2%): one reintervention for early spontaneous sling loosening with reoperation at 1 months to tighten the sling and one urinoma with abdominal wound infection requiring reintervention. Four patients presented an abdominal wound complication (abscess or seroma), all after using a rectus fascia sling (4/13, 30.8%) all treated with nursing cares. Two patients had a persisting significant post-void residual (PVR) postoperatively, managed by self-catheterization (transition to self-catheterization at 3 months: 2/8, 25%). There was one urethrovaginal fistula at 2 months in a neurological patient who had resumed CIC. After a median follow-up of 8 months, there was no sling exposure or extrusion.

The use of autologous fascia pubovaginal sling is an interesting option in female SUI patients with high risk of device/mesh related complications with satisfactory functional outcomes and a relatively limited morbidity considering the surgical complexity of this patient population.

Autologous fascial bling is a difficult intervention, with related complications. Whenever it is needed, it can be done on patients with complicated incontinence.