Schematic model.

Operative animation, Autologous pubovaginal sling

Autologous pubovaginal sling: a strip of her own rectus fascia under the bladder neck

A strip of the patient's own anterior rectus sheath is placed under the bladder neck and proximal urethra for stress incontinence, often after a failed mid-urethral sling or where synthetic material is not wanted.

Its two sutures are passed behind the pubis from the vagina to the suprapubic wound and tied loosely over the sheath. The lesson is the corridor behind the pubis, the cystoscopy before anything is tied, and the slack in the knot.

Advanced tier FRCS female urology, stress urinary incontinence, failed sling Interactive 3D
Schematic scene preview: Autologous pubovaginal sling
Preparing the 3D anatomy…

UrOops3D · UroRef · © Nity G

How to use this module. Play through the ten steps, or use Back and Next. Watch the strip lift off the muscle, the finger run up the back of the pubis, the carrier come down on to it and the sling settle under the bladder neck. The triggers show a carrier in the bladder, retropubic bleeding and a sling tied too tight.

Click me next Section 2 of 8 Anatomy The structures this operation works between, and the one it must not cross.

The structures in the scene

Autologous pubovaginal sling: how the structures relateThe corridor behind the pubis, from the vaginal field up to the rectus sheath. Retropubic tunnel: finger, carrier, sling arm: runs on its back surface all the way Back of the pubic symphysis. Retropubic tunnel: finger, carrier, sling arm: lies medial and behind; entered if the pass drifts Bladder, kept empty (danger). Retropubic tunnel: finger, carrier, sling arm: opened sharply each side to enter it Endopelvic fascia under the pubic margin. Retropubic tunnel: finger, carrier, sling arm: ends at it; the sutures are tied loosely on it Anterior rectus sheath: donor and tie point. Retropubic tunnel: finger, carrier, sling arm: the sling arms meet under them Bladder neck and proximal urethra. Retropubic tunnel: finger, carrier, sling arm: bleed when the tunnel leaves the bone Retropubic veins (danger).Retropubic tunnel:finger, carrier, slingarmBack of the pubicsymphysis!Bladder, kept emptyEndopelvic fasciaunder the pubicmarginAnterior rectussheath: donor andtie pointBladder neck andproximal urethra!Retropubic veinsruns on its backsurface all the waylies medial andbehind; entered ifthe pass driftsopened sharply eachside to enter itends at it; thesutures are tiedloosely on itthe sling arms meetunder thembleed when thetunnel leaves theboneTargetDangerLandmarkContext
The corridor behind the pubis, from the vaginal field up to the rectus sheath. Schematic, not to scale; relationships only.
  • In lithotomy the operation has two fields joined by a corridor.
  • Above, the rectus sheath lies under the suprapubic fat and the strip comes from its lower leaf.
  • Below, the anterior vaginal wall is opened over the bladder neck and the proximal urethra.
  • Between them, on each side, a tunnel runs from the endopelvic fascia under the pubic margin up the back of the symphysis to the sheath, with the empty bladder medial and behind.
  • ›Anterior rectus sheath - the donor tissue; the strip is taken from its inferior leaf and the defect closed without tension.
  • ›Rectus abdominis - lies under the sheath; the strip is lifted off it and it is left intact.
  • ›Pubic symphysis - the finger, the carrier and the arms of the sling all run on its back surface.
  • ›Space of Retzius - between the back of the pubis and the bladder; the corridor for each tunnel.
  • ›Endopelvic fascia - perforated on each side under the inferior margin of the pubis to enter the retropubic space.
  • ›Bladder - kept empty and medial to the corridor; the structure at risk from the carrier.
  • ›Bladder neck and proximal urethra - where the sling lies, on the periurethral fascia.
  • ›Periurethral and pubocervical fascia - the plane under the vaginal flap; the centre of the sling is stitched to the periurethral fascia.
  • ›Ischiopubic rami - the lateral limit of the vaginal dissection.
  • ›Ureteric orifices - efflux from both is seen at cystoscopy before the sling is tied.
Click me next Section 3 of 8 Steps The operation in order, with the landmark that guards each move.

Operative steps

  1. Suprapubic incision After counselling and consent, antibiotics, and compression devices on the legs, she is placed in dorsal lithotomy with the abdomen, genitalia and perineum prepared in one field. A low transverse incision above the pubic symphysis is carried through the subcutaneous tissue to the anterior rectus sheath, and a self-retaining retractor is placed.
    where it bites: the strip comes from the sheath; the wound is taken cleanly down to it over its whole length.
  2. Harvest the strip The sheath is incised in the bed of the wound and a strip is raised from the inferior leaf by lifting the fascia off the rectus muscle. Haemostasis is secured with diathermy. A long suture is placed through each end of the strip in a figure of eight and each is clamped; the strip is kept in saline.
    where it bites: the muscle under the fascia is left intact; the strip is lifted off it, not cut out of it.
  3. Close the sheath The cut edges of the sheath are mobilised and the defect is closed without tension with a running suture. The wound is irrigated and the self-retaining retractor removed.
    where it bites: a closure under tension tears out and leaves a hernia; mobilise the edges first.
  4. Vaginal flap A urethral catheter drains the bladder, which is kept empty from here on. A weighted speculum and a vaginal self-retaining retractor give exposure, and the anterior wall is hydrodissected with dilute local anaesthetic and adrenaline. An inverted-U incision from just below the meatus to the bladder neck raises a flap off the periurethral and pubocervical fascia, and the dissection is carried laterally to the ischiopubic rami to expose the endopelvic fascia on each side.
    where it bites: the bladder neck lies under the top of the flap; an empty bladder falls away from the dissection.
  5. Into the retropubic space Metzenbaum scissors perforate the endopelvic fascia on each side at the level of the rami, entering the retropubic space below the inferior margin of the pubis. Blunt finger dissection develops a tunnel from the vagina through the space of Retzius to the back of the rectus fascia, hugging the back of the symphysis throughout.
    where it bites: the bladder lies medial and behind; the finger keeps on the bone.
  6. First pass A ligature carrier perforates the rectus sheath just to one side of the midline, above the pubis. With a finger in the retropubic space from the vagina, it is angled down and advanced through the endopelvic opening of that side into the vagina, again closely hugging the symphysis. The strip is brought into the vaginal field, the suture of that end is loaded on the carrier and drawn back up into the suprapubic wound, and its ends are clamped.
    where it bites: the tip of the carrier is guided on to the finger; a tip that leaves the bone can enter the bladder.
  7. Second pass The identical procedure on the other side: the finger in the tunnel, the carrier through the sheath just off the midline, down on the back of the pubis into the vagina, and the second suture loaded and drawn up. Both pairs of ends are clamped above the sheath.
    where it bites: the second side carries the same risk as the first; the finger guides it as before.
  8. Cystourethroscopy The catheter is removed and cystourethroscopy is performed with a flexible scope or a rigid scope with angled lenses. The proximal urethra and bladder are intact, clear efflux is seen from both ureteric orifices, and there is no suture inside the bladder. The catheter is replaced.
    where it bites: this is the check before anything is tied; a suture in the bladder is found now or not at all.
  9. Set the sling Gentle traction on both sutures brings the sling to the bladder neck and proximal urethra. Its centre is secured to the periurethral fascia with two fine absorbable stitches. The sutures at each end are then tied to each other above the rectus sheath, loosely.
    where it bites: too tight is the error that leaves her in retention; the knot is tied with slack.
  10. Closure Scarpa's fascia is approximated and the skin closed with a subcuticular suture, adhesive strips and a dressing. The vaginal retractor and the speculum are removed and the vaginal wall is closed with interrupted absorbable sutures. The catheter goes on free drainage and she is returned supine.
    where it bites: a vaginal pack may be placed for haemostasis; if so, its removal is written in the plan.
Click me next Section 4 of 8 Danger zones Where this operation bites, and why it bites there.
Critical relationship

Danger zones

The spatial relationships the animation is built to make automatic. Before you read each one, ask yourself: at this point in the operation, what is about to go wrong, and what is my first move? The save for each sits in the Complications tab.

  • RiskBack of the symphysis - the finger and the carrier stay on the bone; a pass that drifts medially enters the bladder.
  • RiskRetropubic veins - a tunnel off the bone bleeds from the space of Retzius; pressure first.
  • RiskBladder neck under the flap - the top of the inverted U reaches the bladder neck; the bladder is kept empty.
  • RiskThe knot over the sheath - tied loosely; tension is what turns a continent woman into one who cannot void.
  • RiskUreteric orifices - efflux from both is seen before the sling is tied.
Practise it Take me into the scene Opens the animation at a danger moment and asks you to predict the mechanism and your first move before it reveals.
Click me next Section 5 of 8 Complications The save for each one: the first move, the escalation trigger, the op-note line.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

Bladder perforation by the carrier

  • the tip of the ligature carrier leaves the back of the pubis and enters the bladder; bladder perforation is a listed complication of this operation.
The save
  1. Withdraw the carrier and do not load a suture on it. first move
  2. Pass it again on the back of the symphysis with the vaginal finger guiding the tip, and look again at cystoscopy before anything is tied.
  3. A large hole, a second entry or a suture that cannot be cleared from the bladder needs senior help in theatre. escalation trigger
  4. Leave the catheter in for a longer period of drainage, as the operating surgeon decides.
  5. Op note: the side, what cystoscopy showed, how it was dealt with and the catheter plan. document

Retropubic bleeding

  • venous bleeding from the space of Retzius into the tunnel and the vaginal wound.
The save
  1. Pressure: a pack in the vagina up against the back of the pubis, with a hand on the abdomen above it, and time. first move
  2. Complete the passes on the bone and set the sling; a rolled vaginal pack at the end is a described option for haemostasis.
  3. Bleeding that does not settle with pressure, or a change in pulse or blood pressure, needs senior and anaesthetic help now. escalation trigger
  4. Check haemoglobin after operation if the loss was more than expected.
  5. Op note: the estimated loss, what controlled it, any pack left and when it comes out. document

Urinary retention

  • the sling tied too tight obstructs the urethra and she cannot empty her bladder.
The save
  1. Drain the bladder by catheter and record the volume. first move
  2. A trial without catheter, with residual volumes measured; intermittent self-catheterisation while the outlet settles.
  3. Retention or a high residual that persists goes back to the operating surgeon for the sling to be loosened or divided. escalation trigger
  4. New urgency after the operation is asked about at every review; it can be a sign of obstruction.
  5. Notes: residual volumes, the catheter or self-catheterisation plan and the review date. document
Click me next Section 6 of 8 Troubleshooting When the case turns: the problem, then the next move.

Intra-operative troubleshooting

When the case turns: the problem, then the next move.

  • ActionThe rectus fascia is unsuitable after previous major abdominal surgery - fascia lata harvested from the lateral thigh is the autologous alternative the operative text names.
  • ActionAn inverted-U flap is not wanted - the operation can also be done through a midline vertical vaginal incision, a variation the operative text allows.
  • ActionUreteric efflux is hard to see at cystoscopy - intravenous indigo carmine or methylene blue before the cystoscopy is the described way to confirm ureteric patency.
  • ActionA difficult voiding trial is expected - a suprapubic catheter can be placed as well as the urethral catheter to help the voiding trial afterwards.
  • ActionThe finger cannot find the back of the pubis - stop and go back to the opening in the endopelvic fascia under the pubic margin; develop the tunnel from there on the bone. Do not pass the carrier blind.
  • ActionOoze from the vaginal wound at the end - a sterile rolled gauze pack in the vagina after operation is the described option for haemostasis.
Click me next Section 7 of 8 FRCS viva Say it out loud, then mark yourself against the model answer.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

QA woman whose mid-urethral sling has failed asks about her own-tissue options. What do you tell her?reveal answer
  • I would first confirm that the leak is stress incontinence and not urgency or overflow, and look at what the previous operation was and whether there is any mesh complication.
  • I would then explain the options together.
  • The European guideline on non-neurogenic female lower urinary tract symptoms lists a secondary synthetic sling, bulking agents, Burch colposuspension, an autologous sling and an artificial urinary sphincter as options for complicated stress incontinence, a weak recommendation, and says that any second-line operation is generally less effective than a first one.
  • It also recommends that complicated cases are managed in centres with appropriate experience.
  • For an autologous sling I would explain the abdominal wound, the passes behind the pubis, the catheter afterwards, and that voiding difficulty is more common than after a retropubic mid-urethral sling, so she must be willing to self-catheterise.
Strong pass

Say both

  • Counselling that second-line surgery does less well than first-line surgery
  • That voiding difficulty and self-catheterisation are part of the consent for this operation
Examiner note
Counselling that second-line surgery does less well than first-line surgery, and that voiding difficulty and self-catheterisation are part of the consent for this operation.
QTalk me through an autologous pubovaginal sling.reveal answer
  • Antibiotics and compression devices, then dorsal lithotomy with the abdomen and perineum in one field.
  • I make a low transverse incision above the symphysis, take it down to the anterior rectus sheath and place a self-retaining retractor.
  • I incise the sheath and raise a strip from the inferior leaf off the muscle, put a long figure-of-eight suture on each end, clamp them and keep the strip in saline.
  • I mobilise the sheath edges and close the defect without tension.
  • Vaginally, I pass a catheter and keep the bladder empty, place a weighted speculum and a retractor, hydrodissect, and make an inverted-U incision from below the meatus to the bladder neck.
  • I raise the flap off the periurethral and pubocervical fascia out to the ischiopubic rami, perforate the endopelvic fascia under the pubic margin with scissors, and develop a tunnel with my finger up the back of the symphysis to the rectus fascia.
  • I pass the carrier through the sheath just off the midline, down on the bone on to my finger and into the vagina, load the suture and draw it up; then the same on the other side.
  • I do a cystourethroscopy, replace the catheter, draw the sling to the bladder neck and proximal urethra, tack its centre to the periurethral fascia and tie the sutures loosely over the sheath.
  • Then I close both wounds.
Strong pass

Say both

  • Cystoscopy after both passes and before the sling is tied
  • A loose tie over the sheath
Examiner note
Cystoscopy after both passes and before the sling is tied, and a loose tie over the sheath.
QHow does an autologous sling compare with a mid-urethral sling or colposuspension?reveal answer
  • I would quote the European guideline, which recommends offering an autologous sling to women seeking surgery for stress incontinence after a thorough discussion of its risks and benefits against the other operations, a strong recommendation.
  • Its summary of the evidence is that autologous slings have high cure rates and are more effective than colposuspension, with adverse events similar to colposuspension overall but more voiding dysfunction and more urinary infection, and less prolapse and fewer bladder or urethral perforations.
  • In the network meta-analysis it quotes, the pooled one-year cure estimate favoured the autologous sling over open colposuspension, but the evidence was of very low quality and the difference was not statistically significant.
  • I would give her the figures the guideline quotes for voiding difficulty: 15.4 per cent after autologous slings and 10.2 per cent after retropubic mid-urethral slings.
  • In the United Kingdom I would add that NICE says that when conservative treatment has failed a woman should be offered the choice of colposuspension or an autologous rectus fascial sling, with a retropubic mesh sling also included in that choice.
Strong pass

Say both

  • Knowing that the cure advantage over colposuspension in that analysis is not statistically significant and rests on very low-quality evidence
  • While the excess voiding dysfunction is the consistent trade-off
Examiner note
Knowing that the cure advantage over colposuspension in that analysis is not statistically significant and rests on very low-quality evidence, while the excess voiding dysfunction is the consistent trade-off.
QOn the second pass the carrier tip leaves the bone and you suspect it has entered the bladder. What do you do, and how do you prevent it?reveal answer
  • I would withdraw the carrier without loading the suture, pass it again on the back of the symphysis with my finger guiding the tip, and repeat the cystoscopy to be sure the bladder and urethra are intact and no suture lies inside before I tie anything.
  • A large hole, more than one entry or a suture I cannot clear would make me ask for senior help, and I would leave the catheter in longer.
  • I would record the side, the finding and the plan in the note and tell her afterwards.
  • Prevention is in the steps: the bladder kept empty throughout, the endopelvic fascia opened under the pubic margin, the tunnel made with a finger hugging the back of the bone, the carrier passed on to that finger and never blind, and the cystoscopy done after both passes and before the sling is set.
Strong pass

Say both

  • Saying that the cystoscopy before tying is what finds the perforation
  • That the finger guiding the tip on the bone is what prevents it
Examiner note
Saying that the cystoscopy before tying is what finds the perforation, and that the finger guiding the tip on the bone is what prevents it.
Click me next Section 8 of 8 Evidence The guidance each of these answers is built on.

Evidence and guidance

Operative Dictations in Urologic Surgery
Armenakas NA, Fracchia JA, Golan R. Autologous pubovaginal sling. Chapter 92. Wiley, 2019
The indications, the nine essential steps and their order, the template dictation followed step by step here, the variations (other sling materials, fascia lata harvest, a midline vertical vaginal incision, intravenous dye before cystoscopy, a suprapubic catheter, a vaginal pack) and the complication list: bleeding, infection, bladder perforation, ureteric injury, urinary retention, urgency, recurrent incontinence, dyspareunia, fistula and erosion. The chapter describes a “longitudinal” incision just above the symphysis and also calls it a modified Pfannenstiel, and takes the strip from the inferior fascial leaf. A fascial leaf below the incision exists only if the incision is transverse, so it is drawn as a low transverse incision with the strip cut along it. The scene is schematic: the abdominal wall is a patch over the pelvis and the sling is drawn on a model, not to the chapter's sizes. The chapter lists complications without their management; the first, escalate and document steps are general surgical practice.
Open guideline
EAU Guidelines
Non-neurogenic Female LUTS, 2026: Disease management, sections 4.2.4.c.2.b, 4.2.4.c.3.a and 4.2.4.c.3.d, read 14 October 2026
Offer autologous sling placement to women seeking surgery for stress incontinence after a thorough discussion of risks and benefits against other operations (strong). Summary of evidence: high cure rates; more effective than colposuspension; adverse events similar to colposuspension with more voiding dysfunction and urinary infection and fewer bladder or urethral perforations. The network meta-analysis estimate favoured autologous slings over open colposuspension, very low-quality evidence, not statistically significant. Voiding difficulty 15.4% against 10.2% for retropubic mid-urethral slings. For complicated stress incontinence: secondary synthetic sling, bulking, Burch colposuspension, autologous sling or artificial sphincter as options (weak); second-line outcomes generally inferior (weak); experienced centres (strong).
Open guideline
NICE
Urinary incontinence and pelvic organ prolapse in women: management. NICE guideline NG123, recommendation 1.5.2, read 14 October 2026
If non-surgical management has failed and the woman wishes to consider surgery, offer the choice of colposuspension (open or laparoscopic) or an autologous rectus fascial sling, also including the option of a retropubic mid-urethral mesh sling, subject to that guideline's mesh recommendations.
Open guideline

Curriculum. Supports learning relevant to the ISCP Urology Curriculum syllabus topic Stress urinary incontinence in men and women. Not a workplace-based assessment and not evidence of competence.

Two minutes

Close the lap: recall it before you leave.

Say it aloud, then reveal. Reading is not remembering.

  1. 01 The relationship Say the critical spatial relationship out loud, then reveal. reveal
    Memory frame

    In lithotomy the operation has two fields joined by a corridor.

    Why?
    Above, the rectus sheath lies under the suprapubic fat and the strip comes from its lower leaf. Below, the anterior vaginal wall is opened over the bladder neck and the proximal urethra. Between them, on each side, a tunnel runs from the endopelvic fascia under the pubic margin up the back of the symphysis to the sheath, with the empty bladder medial and behind.
  2. 02 The first move Bladder perforation by the carrier. Your first move? reveal
    First move

    Withdraw the carrier and do not load a suture on it.

  3. 03 The escalation trigger Bladder perforation by the carrier. What makes you call for help? reveal
    Escalate when

    A large hole, a second entry or a suture that cannot be cleared from the bladder needs senior help in theatre.

  4. 04 The discriminator What turns a pass into a strong pass? reveal
    Strong pass

    Say both

    • Counselling that second-line surgery does less well than first-line surgery
    • That voiding difficulty and self-catheterisation are part of the consent for this operation
    Examiner note
    Counselling that second-line surgery does less well than first-line surgery, and that voiding difficulty and self-catheterisation are part of the consent for this operation.
  5. 05 The pitfall Where does this operation bite first? reveal
    Pitfall

    Back of the symphysis

    Why?
    the finger and the carrier stay on the bone; a pass that drifts medially enters the bladder.

Revision practice with self-marked answers, not an assessment of clinical competence. Kept in this browser only; it does not sync between devices.