The autologous pubovaginal fascial sling (AFPVS) has been used for several decades and is usually regarded as the best autologous option for the surgical treatment of female stress urinary incontinence (SUI). This study aimed to compare the outcomes of the traditional autologous pubovaginal sling vs a novel robot-assisted bladder neck fascial sling technique for female patients with SUI

A retrospective study was conducted, including all patients treated with either a pubovaginal sling or a bladder neck robotic fascial sling for SUI at an academic center between April 2019 and April 2023. The use of fascial slings was offered in specific situations: for neurological patients requiring self-catheterization, individuals with urinary incontinence due to persistent sphincter failure post-ileal neobladder, patients with urethrovesical fistula or diverticulectomy, and females with urethral or bladder extrusion of synthetic materials intended for SUI treatment (e.g., synthetic midurethral slings, ACT balloons, or artificial urinary sphincters). In the latter cases, the sling was inserted concurrently with the removal of the existing device/material. The fascial sling was harvested from the rectus fascia or the fascia lata (for obese patients or those with a history of multiple previous abdominal incisions). It was placed at the bladder neck through an inverted U-shaped vaginal incision and passed retropubically via a Pfannenstiel incision. The robotic approach was preferred when concomitant abdominal surgical procedures were necessary (such as vesico-vaginal fistula repair or material explantation).

Twenty-nine patients were included over the study period: 21 received a pubovaginal sling, and 8 underwent robotic bladder neck fascial sling insertion. The indications were neurological conditions with clean intermittent catheterization (CIC) in 7 cases (24.1%), extrusion/exposure of a prior anti-incontinence material in 17 cases (58.6%), urethrovesical fistula in 3 cases (10.3%), and ileal neobladder in 2 cases (7.9%).
The incidence of major complications was similar between patients who underwent a pubovaginal or robotic fascial sling insertion  (14.3% vs.25% p = 0.59). The success rate, defined as complete stress urinary incontinence cure, was 52.4% for the pubovaginal sling versus 50% for the robotic sling. At 3 months, 19 patients showed either dry or improved SUI: 75% vs. 100%. Eleven patients had a significant post-void residual (PVR) postoperatively, predominantly managed via transient self-catheterization. Five patients required another procedure on the sling: 4 in the pubovaginal group and 1 in the robotic sling group (p = 0.61).

Both the pubovaginal and robotic bladder neck fascial slings demonstrated similar perioperative and functional outcomes.

The robotic sling could thus be considered an alternative to the pubovaginal sling, especially when a concomitant abdominal surgical procedure is necessary. Further studies are essential to determine the roles of pubovaginal and robot-assisted approaches for the fascial sling.