Effect of Preoperative Voiding Mechanism on Success Rate of Autologous Rectus Fascia Suburethral Sling Procedure CHERYL B. IGLESIA, MD, SUSAN SHOTT, PhD, DEE E. FENNER, MD, AND LINDA BRUBAKER, MD Objective: To evaluate the efficacy of the rectus fascia sub- urethral sling procedure and to determine whether preoper- ative voiding caused by the Valsalva maneuver is a risk factor for short-term objective failure. Methods: This study is a retrospective chart review of 50 patients who underwent the suburethral sling procedure with rectus fascia at our institution between March 1994 and August 1996. All patients had genuine stress incontinence with intrinsic sphincteric deficiency or urethral hypomobil- ity. Preoperative multichannel urodynamics were measured in all patients, and postoperative urodynamic testing was done at 3 months in 48 patients. Results: Ninety-four percent of patients were cured sub- jectively of stress urinary incontinence at 3 months. Objec- tive cure was found by urodynamic measurements in 73% of the 48 patients who underwent postoperative testing. There was an increased risk of objective failure in patients whose voiding preoperatively was caused by the Valsalva maneu- ver. Objective failure was found at 3 months in 54% of the 13 patients in the Valsalva group, compared with 17% of the 35 in the non-Valsalva group (P  .011). Patients in the Val- salva group also tended to have longer durations of postop- erative catheterization than did patients in the non-Valsalva group (P  .049). Conclusion: The rectus fascia suburethral sling procedure appears to be an effective operation for the treatment of genuine stress incontinence in carefully selected patients. However, patients who are identified preoperatively as void- ing because of the Valsalva maneuver have a higher failure rate for this procedure. (Obstet Gynecol 1998;91:577– 81. © 1998 by The American College of Obstetricians and Gynecologists.) The suburethral sling procedure is an established oper- ation for the treatment of genuine stress incontinence. 1 This operation has been used in patients with recurrent genuine stress urinary incontinence, urethral hypomo- bility, or urethral hypermobility with intrinsic sphincter deficiency, as defined by low leak-point pressures or low maximal urethral closure pressures. 2–6 Patients with low–leak-point-pressure and low– closure-pres- sure urethras may have a higher risk of failure when standard urethropexy procedures are done. 7 Intrinsic urethral sphincter deficiency may be caused by exten- sive perineal nerve damage to the striated urethral sphincter through vaginal delivery, chronically in- creased pressure on the pelvic floor from severe asthma, chronic cough, obesity, constipation, and previous anti- incontinence procedures that include anterior vaginal wall dissection. 8 –11 The purpose of this study was to evaluate the efficacy and side effects of the rectus fascia suburethral sling and to determine whether preopera- tive urodynamic or clinical variables are related to objective outcome. Materials and Methods From March 1994 to August 1996, suburethral sling procedures were performed in 50 patients at Rush- Presbyterian-St. Luke’s Medical Center by three attend- ing surgeons and fellows under the direct supervision of the attending surgeons. A retrospective review of these patients’ charts was performed. All patients un- derwent a preoperative directed urogynecologic history and physical examination, review of a 24-hour urinary diary, postvoid residual check within 10 minutes of a spontaneous void, cotton-swab test for urethral hyper- mobility, and multichannel urodynamic evaluation re- corded on the Life-Tech (Model 1106 Urolab; Life-Tech, Inc, Houston, TX) or Wiest-Merkur (Model 4000; Wiest- Merkur, Munich, Germany). All terminology conforms From the Sections of Urogynecology and Reconstructive Pelvic Sur- gery, Department of Obstetrics and Gynecology, and Biostatistics, Department of Neurosurgery, Rush-Presbyterian-St. Luke’s Medical Center, Chicago, Illinois. 577 VOL. 91, NO. 4, APRIL 1998 0029-7844/98/$19.00 PII S0029-7844(98)00029-5