A pubovaginal sling (PVS), commonly known as a fascial sling because it is made of body tissue rather than a synthetic material. This is a non-mesh or mesh-free sling that can be harvested from the patient’s own rectus fascia (layer of tough abdominal wall tissue). Occasionally fascia can also be harvested from a patient’s leg (fascia lata).
The results are excellent and durable (80% to 90% at 10 years). Most importantly, it has zero risk of erosion and a very low risk of infection, as it is the patient’s own body tissue which will never be rejected. This surgery has been around for many decades and initially took a back seat when the mid-urethral mesh sling was at its peak in popularity. However, with the recent mesh concerns, the PVS has now become a more appealing treatment option.
Even though the lower abdominal incision can cause some post-op discomfort, patients often view it as ‘short-term pain, long-term gain’, as they do not have to worry about mesh problems in the future.
It is a treatment option for female stress urinary incontinence. Women with this condition suffer from involuntary loss of urine during activities involving physical exertion such as coughing, sneezing, laughing, and exercising.
It is a very versatile sling, and is suitable for:
- Patients who do not want mesh material in their body.
- Primary (first) treatment of patients with stress urinary incontinence (SUI).
- Salvage (repeat) treatment of patients who have failed other SUI treatments.
- Patients with poor vaginal tissue who are at higher risk of erosion (e.g., radiotherapy, previous vaginal surgery).
- Patients at higher risk of infection (e.g., diabetic, immuno-compromised).
- Patients with all types and severity of SUI (including hypermobility and intrinsic sphincter deficiency).
- As an additional protective layer in vaginal reconstruction surgery (e.g., urethral diverticulum, vaginal fistula surgery).
If you are taking blood thinners or certain newer diabetic medications, please inform your doctor as these may have to stopped before the surgery.
You will need to fast for at least 6 hours before the surgery.
Your doctor may require you to have blood tests or a urine test prior to the surgery.
See preparing for surgery, for more detailed instructions.
The surgery is done under general anaesthesia and takes about 1.5 to 2 hours. Antibiotics are given through the drip. There are two incisions. A 6cm to 8cm horizontal lower abdominal incision, 2 – 3 fingerbreadths above the pubic bone, is first done. This allows the harvesting of a small strip of fascia to be used as the sling. The fascia is a strong sheath of tissue that lies above the abdominal muscles (rectus muscle). The small gap in the fascia will eventually be approximated and closed together with sutures.
Another smaller incision (about 2cm) is done at the anterior wall of the vagina. Through this incision, the sling arms are passed upwards to the abdominal area where they will eventually be tied down on top of the abdominal wall under the skin. The sling therefore supports the urethra and bladder neck in a U-shaped configuration, with the sling knot at the top.
A cystoscopy is done to check for any bladder injury during the passage of the sling arms.
Both wounds are then closed with absorbable sutures. A catheter is inserted to drain the bladder for 2 days. A small pack is placed in the vagina. Some patients may need a drain tube adjacent to the abdominal wound.
Most patients stay in the hospital for 2 days. The vaginal pack is removed on day 1. Patients are encouraged to mobilise. The catheter is then removed on day 2. Each time the patient passes urine, the amount that is passed is measured. A bladder scan is also done to check if the patient is emptying the bladder properly. These volumes are documented. If the patient is voiding satisfactorily, she can then go home.
The vaginal incision usually does not cause much post-op pain. Some creamy white vaginal discharge may be expected for the first few weeks. This is due to the presence of dissolvable sutures in the vagina. About a week post-op, some blood-stained vaginal discharge may happen. This is due to the breakdown of old blood trapped under the skin. If the discharge is offensive-smelling, see your GP in case you need to go on oral antibiotics.
The lower abdominal incision takes a bit longer to recover from. Most patients get discomfort for 3 to 4 weeks, occasionally up to 6 weeks. This is due to the body re-adjusting to the tightness of the fascia when they are approximated together to close the gap from the harvesting of the sling. The discomfort is felt more when the patient goes on a full stretch. You can do light duties at home including walking up 1-2 flights of stairs, going for short walks, and going to the shops (but no heavy lifting) in the first few weeks. Slowly increase your activity level as you become more comfortable.
Take your pain medication as directed. You may need to take it as soon as you start feeling uncomfortable (before the pain gets severe).
Remove the abdominal wound dressing in 5 to 7 days post-op. The skin sutures are dissolvable. If the abdominal wound becomes red and inflamed looking, see your GP in case it is an infection, and you need antibiotics.
Do not drive for at least 2 weeks as you may still have some post-op pain.
No sexual intercourse for 6 weeks as the vaginal wound needs time to heal.
Check with your doctor when you can go back to work as the type of work that you do will determine this. In general, if your work is not too physically demanding, you can go back to work in 3 to 4 weeks. If it is more demanding, you may need about 6 weeks off work.
You should attend your post-op appointment so your doctor can check for any complications.
- Anaesthetic risks such as heart or lung problems.
- Wound infection – you will be covered with antibiotics during the surgery.
- Bleeding – it is uncommon to need a blood transfusion for this surgery.
- Clots in the legs (DVT) or pulmonary emboli.
- Chest infection, urinary tract infection.
- Allergic reactions (e.g., to dressings, drugs etc.) – inform us if you have any known allergies.
- Risk of death is a very rare complication that may arise from any surgery or anaesthetic. Modern medicine and anaesthesia have made this extremely rare. The risk varies with each individual’s general health conditions and the complexity of the surgery. Pubovaginal fascial surgery is not considered to be a major surgery.
- Bladder injury: this is an uncommon injury that may occur during the passage of the sling arms. A cystoscopy is usually done during the surgery to check for this. If it happens, some patients may need to have a longer period of post-op indwelling catheterization to allow the bladder to heal. Instead of the catheter being removed on day 2, it may have to stay in for 7 to 10 days. Most patients can still go home as planned around day 2, with instructions on how to look after the catheter.
- Abdominal wound swelling from seroma formation: About 10% – 15% of patients may get a seroma, which is a build-up of fluid under the skin. This can contribute to the overall discomfort due to the swelling. The vast majority of seromas do not get infected and do not need antibiotics. It will get re-absorbed by the body in a few weeks. Very rarely, it may discharge itself at one corner of the skin incision, or need drainage by a doctor. Seek medical attention if you are concerned.
- New onset bladder urgency (9%): this is also called de novo urgency. It is due to the bladder adjusting itself to the newly supported angle at the bladder neck. The vast majority of this will settle down after a few weeks.
- Sling is too tight: Uncommonly, the sling may be too tight and can cause difficulty passing urine. Sometimes this is due to post-op swelling and will resolve spontaneously. Some patients can be observed during this period, and a minority will need to do intermittent self-catheterisation for a few weeks. In patients with persistent tight slings, another operation may be needed to loosen the tension. A/Prof Gani’s sling tensioning technique has significantly reduced this risk, see below.
- Persistent incontinence: The initial success rate is excellent. In our published results, 87% of women are ‘very much better’ or ‘much better’, 11% are ‘a little better’ and the failure rate is 2%. Many patients with mild residual stress incontinence are using 1 pad or less per day. Occasionally, a second minor procedure such as transurethral bulking agent, may suffice to make them continent.
For other treatment alternatives, see female stress urinary incontinence.
A/Prof Gani has extensive experience with the pubovaginal fascial sling and is one of the highest volume surgeons in the country doing this. See his publication on his technique to achieve the best sling tension with a lower risk of complication. He has run workshops and been invited to multiple conferences to give talks on this technique.
Read A/Prof Gani’s publication:
Download Optimising the tension of an autologous fascia pubovaginal sling to minimize retentive complications - PDF (538 Kb)