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Autologous Rectus Fascia

Autologous rectus fascia is a versatile native-tissue graft used across reconstructive urology and urogynecology — most prominently as the pubovaginal sling for female SUI, with growing applications in sacrocolpopexy, cystocele repair, Peyronie's disease, corporal reconstruction during penile prosthesis placement, pediatric neurogenic bladder neck procedures, and urethrocutaneous fistula repair. Its reuse has surged in the era of mesh restrictions.[1][2]

Why It Matters​

  • Immunologically inert — no rejection, no foreign-body reaction.
  • Durable — retains tensile strength long-term.
  • No mesh-erosion risk into urethra or vagina.
  • Reoperation-friendly — tissue planes heal predictably.
  • The reconstructive community's default when synthetic or xenogeneic alternatives are contraindicated or have failed.

Harvest Anatomy & Safety Zone​

  • Low transverse (Pfannenstiel) incision through skin and subcutaneous tissue; expose the anterior rectus sheath.
  • Standard sling graft: 10–12 × 2 cm; trapezoidal grafts up to 6 × 4 × 5 cm for cystocele repair.[3][16]
  • Safety zone (Cardenas-Trowers anatomic study): a graft harvested 5.4 cm superior to the pubic symphysis with inferior border ~9.4 cm minimizes injury to the ilioinguinal and iliohypogastric nerves. The closer to the symphysis, the narrower the safe graft width.[28]
  • Tag each end with nonabsorbable stay sutures; close the fascial defect with a running nonabsorbable or slowly absorbable suture.
  • Donor-site morbidity is generally mild: wound dehiscence without fascial involvement[16], rare ventral hernia[21], longer operative time. Prophylactic mesh reinforcement of the harvest site has been described in robotic approaches.[29]

Pubovaginal Sling for Female SUI​

The most established application and the gold-standard biologic sling; has experienced a resurgence after FDA restrictions on transvaginal mesh.[1][2]

Technique​

A 10–12 × 2 cm strip is harvested through a Pfannenstiel incision. Nonabsorbable stay sutures are tied at each end. The sling is passed retropubically (e.g., via Raz-Pereyra trocar) and positioned at the bladder neck (classic PVS) or midurethra (newer "sling on a string"), with tensioning confirmed cystoscopically.[3][4]

Efficacy​

StudyComparisonOutcome
Grigoryan 2024 SR + meta-analysisAutologous fascia vs SMUSNo significant difference in cure; SMUS had significantly more long-term complications (RR 0.12, p = 0.004).[5]
Khan 2015 multicenter RCT, 10-yrAutologous fascia vs TVT vs xenograftSuccess 75.4% autologous vs 73% TVT; "dry" rates 50.8% vs 31.7% (p = 0.036); zero reoperations in autologous arm.[6]
Athanasopoulos 2011 (n = 264)Single-arm85% success, 75.8% completely dry.[7]
Wu NEJM 2021Pooled (6 trials)PVS vs SMUS cure 67% vs 74% (moderate-quality); PVS — more perioperative complications, urgency/frequency, longer LOS; lower bladder/urethral perforation.[8]

Tradeoffs vs Synthetic Slings​

  • Longer OR time (~91 vs ~32 min) and longer LOS.[9][5]
  • Higher de novo urgency (~18.5% in one series; RR 2.84 vs SMUS).[7][5]
  • Lower long-term complications (no erosion / extrusion).[5]
  • Lower bladder/urethral perforation risk.[8]

Preferred Populations​

  • High mesh-erosion risk (immunocompromised, chronic steroid use, prior radiation, prior mesh complications).
  • Prior mesh-sling failure or mesh complications.
  • Failed Burch colposuspension.
  • Intrinsic sphincter deficiency (ISD).
  • Neurogenic bladder-neck incompetence.
  • Patients declining synthetic mesh.
  • Severe SUI.[4][10]

Midurethral Fascial Sling ("Sling on a String")​

Newer modification placing the autologous fascia loosely at the midurethra rather than the bladder neck.[2]

  • Subjective cure 87.8% in primary SUI.
  • De novo storage symptoms reduced (~8.2%).
  • ISC beyond 2 weeks needed in only 2.0%.
  • A laparoscopic mid-urethral fascial sling has been described with 100% cure at 12 mo in a small series (Fayyad 2024).[11]

Autologous Transobturator​

Kilinc 2022 RCT: autologous rectus fascia transobturator sling vs TVT-O — equivalent objective and subjective success at long-term follow-up.[12] Vasudeva 2024 SR/meta: equivalent success across objective and subjective measures.[13]

Sacrocolpopexy for POP​

StudyApproachOutcome
Wang 2022 cohort (n = 132)Abdominal sacrocolpopexy with autologous rectus fasciaAnatomic failure 0% at 12 mo, 6.8% at 5 yr; retreatment 13% at 5 yr.[14]
Bock 2021Robotic sacrocolpopexy with autologous fascia lata vs meshEquivalent short-term anatomic outcomes; donor-site morbidity non-trivial.[15]

ACOG 214: sacrocolpopexy with biologic grafts may be considered in patients at increased risk of mesh-related complications (chronic steroid use, current smokers).[10]

Cystocele Repair — Pubovaginal Cystocele Sling​

Cormio 2015 modification: trapezoidal 6 × 4 × 5 cm rectus fascia graft with 4 suspension sutures, simultaneously correcting cystocele and SUI. At 62.6 mo mean (n = 30): no anterior compartment recurrence; resolution of SUI, PVR, and UTI in all affected.[16]

Peyronie's Disease — Tunical Substitute​

The dorsal lamina of the rectus sheath has a 3D meshwork of collagen and elastic fibers histologically similar to tunica albuginea, making it a morphologically ideal autologous tunical graft (Craatz / Spanel-Borowski).[17] Successful curvature correction in 10/12 patients in the original series.[17]

Corporal Reconstruction During Penile Prosthesis Placement​

Pathak 2005: rectus fascia graft for corporal reconstruction in patients with severe corporal fibrosis during IPP placement — 100% success at 18 months with no graft-related complications.[18] Adopted into the toolkit for the difficult IPP / Peyronie's reconstructive series (Kadioglu).[19]

Pediatric Neurogenic Bladder Neck Procedures​

ApplicationDescriptionReference
Rectus fascial slingSphincteric incontinence in myelodysplasia, exstrophy, epispadias — effective in girls and boysBauer 1989; Nguyen 2001[20][21]
Rectus fascial wrap / cinchCircumferential bladder-neck wrap as adjunct to augmentation cystoplasty — continence 60–75%Walker 1995; Bugg 2003[22][23]
Myofascial wrapFull-thickness pedicle (anterior sheath + rectus muscle + posterior sheath) — continence in 6/8 with intractable incontinenceKolligian 1998[24]
Rectus abdominis muscle flapInterposition during bladder neck closure to prevent vesicoureteral fistulaSmith 2010[25]
Fascial flapsAbdominal wall + bladder / bladder neck coverage in epispadias/exstrophyHorton 1988[26]

Urethrocutaneous Fistula Repair​

Johnsen 2018: autologous rectus fascia interposition graft for recurrent urethrocutaneous fistulae after metoidioplasty in transmasculine patients — no recurrence in a small series (mean 3 prior failed repairs).[27]

Urethral Tube Substitute (Investigational)​

Sade 2007 rabbit model: autologous fascial tube graft as urethral substitute — rapid epithelialization and low contraction in animals, not translated to clinical use.

Summary​

ApplicationGraft sizeOutcome
Pubovaginal sling (SUI)10–12 × 2 cm75–94% cure; comparable to synthetic slings; fewer long-term complications
Midurethral fascial sling~7–10 × 1 cm80–88% cure; lower de novo urgency than classic PVS
SacrocolpopexyVariable93%+ anatomic success at 3–5 yr
Cystocele repairTrapezoidal 6 × 4 × 5 cm100% anterior-compartment success at 5 yr
Peyronie's graftingVariable~83% curvature correction
Corporal reconstruction (IPP)Variable100% success at 18 mo
Pediatric bladder neck sling / wrap / cinch1–1.5 cm widthContinence 60–75%
Urethrocutaneous fistula (metoidioplasty)Variable100% in small series

Tradeoffs​

  • Longer operation than mesh sling.
  • Additional abdominal incision with associated wound risk.
  • Rare ventral hernia at the harvest site — minimizable by respecting Cardenas-Trowers safety zone.[28]
  • Higher technical demand than midurethral mesh sling placement.

See also: Fascia Lata, Raz-Pereyra Trocar, Polypropylene Mesh, Porcine Acellular Collagen Matrix.

References​

1. Chen YA, Jean-Michel M. Resurgence of Autologous Fascial Slings in a Challenging Climate for Sling Surgery: A 20-Year Review of Comparative Data. Obstetrical & Gynecological Survey. 2022;77(11):696-706. doi:10.1097/OGX.0000000000001072

2. Osman NI, Hillary CJ, Mangera A, et al. The Midurethral Fascial "Sling on a String": An Alternative to Midurethral Synthetic Tapes in the Era of Mesh Complications. European Urology. 2018;74(2):191-196. doi:10.1016/j.eururo.2018.04.031

3. Miller AR, Linder BJ, Lightner DJ. Autologous Rectus Fascia Sling Placement in the Management of Female Stress Urinary Incontinence. International Urogynecology Journal. 2018;29(9):1403-1405. doi:10.1007/s00192-018-3643-1

4. Leow JJ, Gurbani C, Yeow S, Bang S. Autologous Pubovaginal Sling for the Treatment of Stress Urinary Incontinence in a Patient With High Risk of Mesh Erosion. Urology. 2020;143:266. doi:10.1016/j.urology.2020.05.031

5. Grigoryan B, Kasyan G, Pushkar D. Autologous Slings in Female Stress Urinary Incontinence Treatment: Systematic Review and Meta-Analysis of Randomized Controlled Trials. International Urogynecology Journal. 2024;35(4):759-773. doi:10.1007/s00192-024-05768-6

6. Khan ZA, Nambiar A, Morley R, et al. Long-Term Follow-Up of a Multicentre Randomised Controlled Trial Comparing Tension-Free Vaginal Tape, Xenograft and Autologous Fascial Slings for the Treatment of Stress Urinary Incontinence in Women. BJU International. 2015;115(6):968-977. doi:10.1111/bju.12851

7. Athanasopoulos A, Gyftopoulos K, McGuire EJ. Efficacy and Preoperative Prognostic Factors of Autologous Fascia Rectus Sling for Treatment of Female Stress Urinary Incontinence. Urology. 2011;78(5):1034-1038. doi:10.1016/j.urology.2011.05.069

8. Wu JM. Stress Incontinence in Women. The New England Journal of Medicine. 2021;384(25):2428-2436. doi:10.1056/NEJMcp1914037

9. Zargham M, Merasie R, Aghdas FS, et al. Comparing Mid-Term Outcomes of Pubovaginal Slings Using Rectus Autologous Fascia With Polyvinylidene Fluoride Tape Slings in the Management of Female Stress Urinary Incontinence. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2025;317:114843. doi:10.1016/j.ejogrb.2025.114843

10. Committee on Practice Bulletins—Gynecology and American Urogynecologic Society. Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214. Obstetrics and Gynecology. 2019;134(5):e126-e142. doi:10.1097/AOG.0000000000003519

11. Fayyad AM, Hasan MR. Novel Technique of Laparoscopic Mid-Urethral Autologous Rectus Fascial Sling for Stress Urinary Incontinence. BJOG. 2024;131(12):1587-1590. doi:10.1111/1471-0528.17877

12. Kilinc MF, Yildiz Y, Hascicek AM, Doluoglu OG, Tokat E. Long-Term Postoperative Follow-Up Results of Transobturator Autologous Rectus Fascial Sling Versus Transobturator Tension-Free Vaginal Tapes for Female Stress Urinary Incontinence: Randomized Controlled Clinical Trial. Neurourology and Urodynamics. 2022;41(1):281-289. doi:10.1002/nau.24813

13. Vasudeva P, Yadav S, Sinha S, et al. Autologous Versus Synthetic Midurethral Transobturator Sling: A Systematic Review and Meta-Analysis of Outcomes. Neurourology and Urodynamics. 2024;43(8):2017-2029. doi:10.1002/nau.25527

14. Wang R, Reagan K, Boyd S, Tulikangas P. Sacrocolpopexy Using Autologous Rectus Fascia: Cohort Study of Long-Term Outcomes and Complications. BJOG. 2022;129(9):1600-1606. doi:10.1111/1471-0528.17107

15. Bock ME, Nagle R, Soyster M, et al. Robotic Sacral Colpopexy Using Autologous Fascia Lata Compared With Mesh. Journal of Endourology. 2021;35(6):801-807. doi:10.1089/end.2020.0537

16. Cormio L, Mancini V, Liuzzi G, Lucarelli G, Carrieri G. Cystocele Repair by Autologous Rectus Fascia Graft: The Pubovaginal Cystocele Sling. The Journal of Urology. 2015;194(3):721-727. doi:10.1016/j.juro.2015.03.104

17. Craatz S, Spanel-Borowski K, Begemann JF, et al. The Dorsal Lamina of the Rectus Sheath: A Suitable Grafting Material for the Penile Tunica Albuginea in Peyronie's Disease? BJU International. 2006;97(1):134-137. doi:10.1111/j.1464-410X.2006.05876.x

18. Pathak AS, Chang JH, Parekh AR, Aboseif SR. Use of Rectus Fascia Graft for Corporeal Reconstruction During Placement of Penile Implant. Urology. 2005;65(6):1198-1201. doi:10.1016/j.urology.2004.12.062

19. Kadioglu A, Sanli O, Akman T, et al. Surgical Treatment of Peyronie's Disease: A Single Center Experience With 145 Patients. European Urology. 2008;53(2):432-439. doi:10.1016/j.eururo.2007.04.045

20. Bauer SB, Peters CA, Colodny AH, Mandell J, Retik AB. The Use of Rectus Fascia to Manage Urinary Incontinence. The Journal of Urology. 1989;142(2 Pt 2):516-519. doi:10.1016/s0022-5347(17)38801-8

21. Nguyen HT, Bauer SB, Diamond DA, Retik AB. Rectus Fascial Sling for the Treatment of Neurogenic Sphincteric Incontinence in Boys: Is It Safe and Effective? The Journal of Urology. 2001;166(2):658-661.

22. Walker RD, Flack CE, Hawkins-Lee B, et al. Rectus Fascial Wrap: Early Results of a Modification of the Rectus Fascial Sling. The Journal of Urology. 1995;154(2 Pt 2):771-774.

23. Bugg CE, Joseph DB. Bladder Neck Cinch for Pediatric Neurogenic Outlet Deficiency. The Journal of Urology. 2003;170(4 Pt 2):1501-1503. doi:10.1097/01.ju.0000084145.34813.97

24. Kolligian ME, Palmer LS, Cheng EY, Firlit CF. Myofascial Wrap to Treat Intractable Urinary Incontinence in Children. Urology. 1998;52(6):1122-1127. doi:10.1016/s0090-4295(98)00490-7

25. Smith EA, Kaye JD, Lee JY, Kirsch AJ, Williams JK. Use of Rectus Abdominis Muscle Flap as Adjunct to Bladder Neck Closure in Patients With Neurogenic Incontinence: Preliminary Experience. The Journal of Urology. 2010;183(4):1556-1560. doi:10.1016/j.juro.2009.12.044

26. Horton CE, Sadove RC, Jordan GH, Sagher U. Use of the Rectus Abdominis Muscle and Fascia Flap in Reconstruction of Epispadias/Exstrophy. Clinics in Plastic Surgery. 1988;15(3):393-397.

27. Johnsen NV, Voelzke BB. Autologous Rectus Fascia Graft Interposition Repair of Urethrocutaneous Fistulae in Female-to-Male Metoidioplasty Patients. Urology. 2018;116:208-212. doi:10.1016/j.urology.2018.03.013

28. Cardenas-Trowers OO, Bergden JS, Gaskins JT, et al. Development of a Safety Zone for Rectus Abdominis Fascia Graft Harvest Based on Dissections of the Ilioinguinal and Iliohypogastric Nerves. American Journal of Obstetrics and Gynecology. 2020;222(5):480.e1-480.e7. doi:10.1016/j.ajog.2019.12.009

29. Davila AA, Goldman J, Kleban S, et al. Reducing Complications and Expanding Use of Robotic Rectus Abdominis Muscle Harvest for Pelvic Reconstruction. Plastic and Reconstructive Surgery. 2022;150(1):190-195. doi:10.1097/PRS.0000000000009233