Non-mesh sling procedures for stress incontinence
A non-mesh sling treats stress urinary incontinence using a strip of your own tissue instead of synthetic mesh. Surgeons also call it an autologous fascial sling or a pubovaginal sling. It is a good option if you want to avoid mesh, if you have had a mesh complication before, or if a previous incontinence surgery has failed.
The tissue forms a supportive hammock under the urethra. When you cough, laugh, or lift, the pressure in your belly rises, presses the urethra against that support, and keeps urine from leaking. That is the same problem a mesh sling solves; the difference is the material.
What the sling is made of
The strip is usually your own fascia, the tough connective tissue that wraps muscle:
- Rectus fascia, taken from the sheath over the abdominal muscles. This is the most common source.
- Fascia lata, taken from the outer thigh through a smaller incision.
Donor tissue (cadaveric fascia) and animal-derived grafts exist, but they are used less often because they do not last as well as your own tissue. When people say non-mesh sling, they almost always mean an autologous rectus fascia sling, which has been the standard for decades.
How the surgery works
I make a small incision to harvest the fascial strip, then a separate incision inside the vagina under the urethra. The strip passes beneath the urethra, and its ends are brought up behind the pubic bone and anchored to the strong abdominal wall tissue. I check the bladder with a small camera before closing. The goal is enough support to stop leakage without making the urethra so tight that you cannot empty.
It is done under general or regional anesthesia. Most women go home the same day or after one night.
Where it fits among stress incontinence treatments
Stress incontinence has several good surgical answers. The AUA guideline lists four first-line surgical options, all backed by strong evidence: the synthetic midurethral sling, the autologous fascial sling, the Burch colposuspension, and urethral bulking. Your insurance may ask you to try conservative measures first, but that is an insurance policy, not a medical requirement.
Which one fits you is a shared decision. It depends on how you feel about mesh, whether you have had incontinence surgery before, how your urethra moves, and what kind of recovery you want.
One thing to sort out first is what kind of leakage you have. A sling treats stress leakage, the kind tied to coughing, laughing, exercise, or lifting. It does not treat the sudden urge to go that comes with an overactive bladder. If you have both, which is called mixed incontinence, I treat the more bothersome type first. Stress incontinence surgery can make urge symptoms worse for a time, so this matters. In the ESTEEM trial, adding pelvic floor therapy around the time of a sling lowered that risk and reduced the need for more treatment later.
How well it works
The best comparison comes from the SISTEr trial, which randomized 655 women to an autologous fascial sling or a Burch colposuspension. At two years, the sling cured stress leakage in 66% of women versus 49% for the Burch, and only 2% of sling patients needed repeat surgery for stress incontinence, compared with 11% after the Burch. Five-year follow-up held the same pattern: repeat surgery stayed at 2% for the sling versus 12%, and 83% of sling patients were satisfied.
Single-center series report 85 to 92% success over 3 to 15 years of follow-up. Compared head to head with a synthetic midurethral sling, the fascial sling has a similar cure rate, about 67% versus 74%.
The tradeoffs
The fascial sling asks more of you than a mesh sling does. It needs an abdominal incision to harvest the tissue, and recovery runs about 6 to 8 weeks rather than the 2 to 4 weeks after a midurethral sling.
The main tradeoff is emptying the bladder. Because the support is your own firm tissue, some women have temporary trouble urinating afterward, reported in roughly 7.5 to 15% of cases. Most of this resolves, but a small number of women need a minor revision to loosen the sling. In the SISTEr trial, voiding trouble was more common after the sling than after the Burch (14% versus 2%). This is the tradeoff for the sling’s better cure and lower retreatment rate, and it is worth weighing openly.
What you avoid is mesh. There is no synthetic material to erode into the vagina or urethra, which is the specific complication that drives many women toward this operation.
Who it fits well
- You want to avoid synthetic mesh.
- You have had a mesh complication and need it addressed.
- A previous incontinence surgery has failed and you need a durable repair.
Risks
Every surgery carries risk. For a fascial sling the main ones are:
- Trouble emptying the bladder, usually temporary
- Bleeding, infection, and the usual risks of anesthesia
- Pain or weakness at the site where the fascia was taken
- A sling set too tight, which can require another operation
- New or worsened urgency, reported in roughly 9% of women
- A small chance that leakage returns over time
I go through all of these with you before you decide, along with what each one would mean for you specifically.
How a non-mesh sling compares with a mesh sling
| Non-mesh (fascial) sling | Mesh midurethral sling | |
|---|---|---|
| Material | Your own fascia | Synthetic mesh |
| Cure rate | About 67%; 85 to 92% in single-center series | About 74% |
| Recovery | 6 to 8 weeks | 2 to 4 weeks |
| Incision | Abdominal plus vaginal | Small vaginal only |
| Mesh exposure | Not possible | Possible |
| Trouble emptying | Higher (about 7.5 to 15%) | Lower |
| Revision surgery | More involved | Simpler |
Other options for stress incontinence
A sling is not the only way to treat stress leakage.
- Urethral bulking is a quick office injection under local anesthesia that plumps the tissue around the urethra. It is less effective than a sling, with cure rates around 20 to 30% in the first few years, but it avoids surgery entirely, and one large group of women followed for seven years kept their improvement or cure about 65% of the time. It is a strong choice if you want to avoid the operating room, are frail or elderly, are on blood thinners, or have had pelvic radiation.
- The Burch colposuspension lifts the tissue beside the urethra without any sling. It is a reasonable mesh-free option, though the SISTEr trial found the fascial sling cured leakage more often.
- The synthetic midurethral sling is the most common stress incontinence surgery and has the shortest recovery.
- An artificial urinary sphincter is reserved for severe leakage after other surgeries have failed.
- Pelvic floor physical therapy, which I can offer in the office, helps some women enough to postpone or avoid surgery, and it is worth adding around the time of surgery if you also have urgency.
Recovery
You will go home with a catheter for a day or two while the swelling settles. Full healing takes about 6 to 8 weeks, and continence can keep improving for several months. Let comfort guide your return to activity: if a movement hurts, hold off. Come to your follow-up visits, stay hydrated, and call if anything worries you.
How I think about this
I reach for a fascial sling when a woman wants to avoid mesh, when mesh has already caused a problem, or when the urethra is fixed and a mesh sling is less likely to hold. It is a durable, well-studied operation with a track record measured in decades.
I am honest about the tradeoff. You are trading a longer recovery and a somewhat higher chance of temporary trouble emptying for a mesh-free repair with strong long-term cure rates. For many women that trade is clearly worth it; for others, a midurethral sling or an office bulking injection fits their life better. There is no single right answer, and the choice is yours to make once you know what each option asks of you.
References
- Albo ME, Richter HE, Brubaker L, et al. Burch Colposuspension versus Fascial Sling to Reduce Urinary Stress Incontinence. New England Journal of Medicine. 2007. doi:10.1056/NEJMoa070218
- Brubaker L, Richter HE, Norton PA, et al. Five Year Continence Rates, Satisfaction and Adverse Events of Burch Urethropexy and Fascial Sling Surgery for Urinary Incontinence. Journal of Urology. 2012. doi:10.1016/j.juro.2011.11.087
- Kobashi KC, Albo ME, Dmochowski RR, et al. Surgical Treatment of Female Stress Urinary Incontinence: AUA/SUFU Guideline. The Journal of Urology. 2017. doi:10.1016/j.juro.2017.06.061
- Wu JM. Stress Incontinence in Women. New England Journal of Medicine. 2021. doi:10.1056/NEJMcp1914037
- Collins SA, Swift S, Jha S, et al. Joint Report on Terminology for Surgical Procedures to Treat Stress Urinary Incontinence in Women. Female Pelvic Medicine & Reconstructive Surgery. 2020. doi:10.1097/SPV.0000000000000831
- Fleischmann N, Chughtai B, Plair A, et al. Urethral Bulking. Urogynecology. 2024. doi:10.1097/SPV.0000000000001548
- Lukacz ES, Santiago-Lastra Y, Albo ME, et al. Urinary Incontinence in Women: A Review. JAMA. 2017. doi:10.1001/jama.2017.12137