Non-mesh stress incontinence surgery review: Bulking agents, autologous fascial slings and colposuspension

Increasing concerns over pelvic mesh procedures have resulted in a revival, development and modifications of older procedures. In this review we will discuss indications, procedure details, as well as risks and benefits of non-mesh alternative procedures. This review covers bulking agents, autologous fascial slings and colposuspension. Urethral bulking agent injections offers the lowest risk and quickest recovery, often performed with local anaesthetic in the out-patient setting, making it suitable even for the most frail and elderly patients. The evolution of technique in autologous fascial slings is described: from an obstructive continuous loop, to the current technique that is less invasive; with likely better safety profile. Graft can be harvested from the rectus sheath or the fascia lata. ‘Colposuspension’ constitutes of a constellation of retropubic urethropexy procedures that are technically different, in terms of approach,e.g. open/ laparoscopic, access, e.g. intra- or extra peritoneal, as well as suture placement characteristic to named techniques. The evidence on safety and efficacy presented in Cochrane reviews is summarised. The efficacy data from the randomised controlled trials comparing bulking agents, autologous fascial slings,and colposuspension techniques at long term follow up is discussed.