The autologous fascial pubovaginal sling (AFPVS), long considered the gold standard for the treatment of stress urinary incontinence (SUI) has been largely replaced by synthetic midurethral slings (SMUS) in current practice because SMUS are considered to have less morbidity with equal or better efficacy and have a much shorter learning curve for surgeons to master [1] [2] [3]. The safety of SMUS, though, has been the subject of controversy. The aim of this study is to perform a literature review of the safety of AFPVS and to compare the results to reviews of SMUS.

A systematic literature search of PubMed, Science Direct, Web of Science, and articles mentioned in the reference pages, was conducted between March 2017 and September 2017 for English language, full text articles published between 1978 and 2017. The search utilized free text terms on autologous and pubovaginal sling complications. Articles with a follow up less than one year and/or studies on prior synthetic, allograft and xenograft slings were excluded. For complications, there were no exclusions. Complications were limited to serious ones (see table 1). For data analysis, for the numerator, we used the sum of the number of patients cited in each study and, for the denominator, the sum of the total number of patients in each study from which meaningful data could be extracted. For the SMUS comparison we used the data from a literature review that uses the same criteria [2], and for the AFPVS reference, we used evidence-based guidelines for SUI [3].

105 articles were identified that met the inclusion criteria and 44 were excluded, leaving 61 for analysis. The nature and prevalence of complications due to AFPVS and SMUS are depicted in table 1. Range of follow up was 12-190 months. P values were determined using a two tailed Z test and values less than 0.05 are bolded.

Despite many reports to the contrary, these data do not show a higher rate of serious complications for AFPVS compared to SMUS. Rather, sling erosion, refractory pelvic pain, dyspareunia, de novo overactive bladder (OAB), and bowel perforation are more common after SMUS, while wound complications are more common after AFPVS. Bladder perforation and urethral obstruction are equally common in both procedures. However, the most daunting complications of sling surgery were the unique SMUS complications - pelvic pain and dyspareunia which were truly refractory in the majority of cases. Because of woefully inadequate follow up studies after treatment of complications, it is not possible to capture the full extent of these complications.

SMUS have a complicated safety profile; they are not as safe as are believed and are accompanied with a risk of complications that are unique to mesh slings, including erosions, fistula, dyspareunia and pelvic pain which are often refractory to treatment and lifestyle-altering. Complications after AFPVS surgery are rarely lifestyle-altering in nature.

Nager C, Tulikangas P, Miller D, Rovner E, and Goldman H. Position Statement on Mesh Midurethral Slings for Stress Urinary Incontinence. Female Pelvic Medicine & Reconstructive Surgery (2014) 20(3): 123-5.
Blaivas, JG, Purohit RS, Benedon, MS, et al. Safety considerations for synthetic sling surgery. Nature Reviews Urology (2015) 12(9): 481-509.
American Urological Association (2009). Guideline for the Surgical Management of Female Stress Urinary Incontinence: 2009 Update. Retrieved from https://www.auanet.org/guidelines.