Resurgence of Autologous Fascial Slings in a Challenging Climate for Sling Surgery: A 20-Year Review of Comparative Data

Abstract

Importance: Since the US Food and Drug Administration's 2016 ban of transvaginal mesh use in vaginal prolapse surgery, there has been growing public scrutiny over the use of synthetic mesh slings (SSs) for the surgical management of female stress urinary incontinence (SUI). Although long considered the mainstay of current practice, interest in biological alternatives has grown.Objectives: This article reviews the last 20 years of data comparing the success of autologous fascial slings (AFSs) and SSs in the treatment of female SUI.Evidence Acquisition: We reviewed the literature for randomized controlled trials comparing autologous pubovaginal sling and SS for the primary surgical treatment of female SUI using several search engines and databases between January 1, 2000, and March 31, 2020.Study Appraisal and Synthesis Methods: Data were retrieved and compared across studies. Trials were evaluated for study setting, type, population characteristics, sample size, success definition and rate, recurrence rate, operative time, length of hospital stay, complications, and quality of life.Results: Of the 1382 articles reviewed, 8 met eligibility criteria, representing 6 distinct cohorts and 726 subjects. Synthetic slings available for review were either tension-free vaginal tape (TVT) or minisling. The vast majority of studies demonstrated similar short-and long-term success rates of AFS and SS procedures utilizing a range of outcome measures. Both AFS and TVT sling had low recurrence rates in short-and long-term followup. However, AFS had significantly longer operative time, and longer hospital stay. Bladder perforation, on the other hand, occurred more commonly in TVT sling. Health-related quality-of-life scores, including sexual function, were similar between groups.Conclusions: Autologous fascial sling and SS are both highly effective surgical procedures for the treatment of female SUI. Although success rates are comparable, AFS is associated with less favorable operative measures.Relevance: This review supports the effectiveness of AFS in treating female SUI as concerns over the use of synthetic materials in vaginal surgery rise. However, clinicians must weigh the risks conferred by this nonsynthetic alternative.Target Audience: Obstetricians and gynecologists, family physicians Learning Objectives: After participating in this activity, the learner should be better able to compare the benefits and drawbacks of available sling types for the surgical management of female stress urinary incontinence; discuss complication rates related to each sling type; and explain their impact on quality of life. This study has not been presented in any meeting prior to this submission.All authors, faculty, and staff have no relevant financial relationships with any ineligible organizations regarding this educational activity.

Cosmetic and functional impact of fascia lata harvest for use in surgery for stress urinary incontinence

“…3 During this time, there has been increasing apprehension about the use of synthetic mesh for POP and stress urinary incontinence (SUI) procedures. 4,5 This growing concern has renewed interest in alternative approaches to surgery for POP 5,6 and SUI, 4 including the use of autologous fascia. 4,5 Autologous slings date back to 1907, when Dr.…”

“…4,5 This growing concern has renewed interest in alternative approaches to surgery for POP 5,6 and SUI, 4 including the use of autologous fascia. 4,5 Autologous slings date back to 1907, when Dr. Von Giordano described a pubovaginal sling (PVS) using a gracilis muscle graft.…”

“…Von Giordano described a pubovaginal sling (PVS) using a gracilis muscle graft. 4 In recent decades, retropubic colposuspensions (e.g., Burch procedure), autologous fascial PVSs (using autologous rectus fascia or fascia lata), and synthetic mesh mid-urethral slings (MUS) have been widely used. 7 Autologous fascial PVSs are highly effective with cure rates similar to MUS.…”

“…7 Autologous fascial PVSs are highly effective with cure rates similar to MUS. 4,8 However, autologous fascial PVS may come at the expense of longer operating time and hospital stay, potentially higher mean catheterization time, and wound complications. 4 Authors have reported outcome data on the graft harvest donor site for use in other procedures such as endoscopic endonasal transsphenoidal surgery 9 and arthroscopic shoulder procedures.…”

“…4,8 However, autologous fascial PVS may come at the expense of longer operating time and hospital stay, potentially higher mean catheterization time, and wound complications. 4 Authors have reported outcome data on the graft harvest donor site for use in other procedures such as endoscopic endonasal transsphenoidal surgery 9 and arthroscopic shoulder procedures. 10 However, there is a distinct lack of studies evaluating the fascia lata harvest donor site for female pelvic reconstruction procedures.…”