Pubovaginal Fascial Sling: Dual Fixation Technique

INTRODUCTION: Autologous pubovaginal rectus fascial slings remain an important surgical option for the management of stress urinary incontinence, particularly in patients seeking to avoid synthetic mesh, in those with intrinsic sphincter deficiency, and in individuals who have failed prior sling procedures. Despite proven efficacy, fascial slings are performed less frequently than their mesh-based counterparts due to technical challenges, including risk of over tensioning, voiding dysfunction, and unpredictable fixation. We present an educational video demonstrating a novel two-surgeon approach to autologous rectus fascial sling placement with dual fixation at the level of the rectus fascia, emphasizing reproducible tensioning and secure support. OBJECTIVE: The objective of this educational submission is to demonstrate a practical, efficient technique for autologous fascial sling placement that addresses common pitfalls in sling surgery. Specifically, the video highlights a coordinated two-surgeon workflow to optimize operative efficiency. Methodical fascial harvest, preparation, and suture identification strategies. Dual-fascial fixation that ensures reliable sling positioning and tensioning. Our goal is to provide gynecologic surgeons with an instructional model that can be integrated into practice and improve confidence in non-mesh sling techniques. METHODS: A stepwise demonstration was performed on a patient with mild stress urinary incontinence and prior mesh sling exposure. A 4-cm transverse suprapubic incision was made 2 cm above the pubic symphysis to harvest rectus fascia, with apical fascial sutures placed to facilitate closure. Simultaneously, the second surgeon created periurethral tunnels to expedite operative flow. The harvested fascia was tagged and prepared with Gore-Tex suspension sutures, uniquely dyed and paired for clear intraoperative identification. Forceps were passed through the retropubic space under tactile guidance from the assistant’s finger to minimize the risk of bladder injury, and suspension sutures were retrieved bilaterally. The sling was positioned at the mid-urethra and secured with sequential fascial fixation to achieve a reproducible, flush placement without undue tension. Demonstration of the suturing pattern is provided so that these steps can be easily replicated. RESULTS: The two-surgeon approach facilitated efficient simultaneous dissection and harvest, reducing operative redundancy. The demonstrated fascial preparation allowed for unambiguous identification during placement, streamlining the passage process. Sequential knot-tying above the rectus fascia provided secure dual fixation and is designed to prevent sling malpositioning or overtensioning. The final surgical result achieved midurethral support with reliable and predictable tensioning, optimizing urethral coaptation while minimizing the risk of voiding dysfunction or retention. The educational format underscored strategies to avoid complications and improve reproducibility of this technique. CONCLUSIONS: This video demonstrates a reproducible two-surgeon technique for autologous rectus fascial sling placement with dual fixation. The method emphasizes efficiency, safety, and predictable sling tensioning, which are key educational objectives for gynecologic surgeons. By addressing technical pitfalls inherent to fascial sling procedures, this approach provides an instructive model that may enhance adoption of autologous sling surgery, particularly for patients or providers seeking mesh-free alternatives.