Stress urinary incontinence occurs in a fifth of adult women, having a significant impact on the quality of life in about half [
1]. A wide range of surgical procedures have been described for the treatment of stress urinary incontinence. Synthetic mid-urethral slings have become the ‘gold standard’ treatment since their introduction in 1995 by Ulmsten and Petros [
2]. Currently, the use of synthetic slings for the treatment of stress urinary incontinence is under intense scrutiny. Despite the evidence to support the high success rates and the safety of the synthetic slings, the general public and some health care bodies are expressing concerns regarding the long-term complications and seeking alternative surgical options. In 1933, Philip and Prince first described the autologous sling procedure [
3]. Aldridge described an autologous sling using a long piece of fascia that extended from the mid-urethra to the rectus sheath bilaterally [
4]. The technique described here was developed by Emery and Lucas in Swansea, UK, in 1990 and was employed in a large randomized controlled trial and other studies [
5‐
8]. It is based on the Aldridge technique. The ‘sling on a string’ uses a small detached piece of fascia, which requires less dissection and is less traumatic [
5]. The technique shown in this video uses a bottom-to-top approach, with the sutures tied on either side to the rectus sheath separately instead of in the middle. The sling is adjusted with control and secured tension-free. This is the technique employed in the large randomized controlled trial comparing autologous, xenograft and synthetic slings [
6‐
8]. This technique has been shown to have equivalent outcomes to a synthetic transvaginal tape at over 10 years of follow-up [
6]. In 2017, Fusco et al. published a meta-analysis of 15,855 patients having synthetic and autologous fascial slings. They reported similar objective cure rates for both mesh and autologous slings, which were superior to a Burch colposuspension [
9].
In the UK, all stress incontinence surgery operations are high-vigilance procedures [
10]. Data from these operations should be entered on a national audit database. In the UK, these procedures should be recorded on the British Society of Urogynaecology database (BSUG). Urodynamics should be performed to confirm the diagnosis. The National Institute of Clinical Excellence (NICE) recommends to discuss all the available operations with the patient with the aid of the Patient Decision Tool in the clinic [
10]. If the patient chooses a surgical procedure that is not offered locally, then the patient should have the option of being referred to another unit. The patient needs to be fully informed of the short- and long-term outcomes of the procedure, understand what is involved and have enough time to weigh this information and ask questions. Informed consent is a particularly important step of high-vigilance surgery.