Objective: To evaluate the efficacy of the rectus fascia suburethral sling procedure and to determine whether preoperative 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 hypomobility. 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 subjectively of stress urinary incontinence at 3 months. Objective 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 maneuver. 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 Valsalva group also tended to have longer durations of postoperative 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 voiding because of the Valsalva maneuver have a higher failure rate for this procedure. (C) 1998 by The American College of Obstetricians and Gynecologists.