The patient is placed in the dorsal lithotomy position and examined under anesthesia. The degree of cystourethrocele is assessed.

The patient is changed to the right or left lateral decubitus position with flexion of both the hip and the knee at approximately 60°. A pillow should be placed between the knees in order to elevate the thigh to a level position. Two large pieces of tape are used to stabilize the patient and prevent her from moving to either side. The lateral thigh is prepped and draped. The solid line marks the site of the initial incision, and the dotted line marks the direction of the incision in the fascia lata.

The Masson fascia stripper consists of two hollow metal tubes-one inside the other. The inner tube has a narrow opening near one end; the edge of the outer tube is sharpened to allow cutting of the fascia strip at the desired level.

A longitudinal incision of 5 cm is made approximately 4 cm above the knee. This incision is carried down to the fascia lata. Small rake retractors are used to expose the fascia lata.

The strap is started with the scalpel blade and should be approximately 3 cm wide. It is dissected off the muscle and the subcutaneous fat for a distance of at least 10-12 cm with the handle of the knife and index finger.

The hand-carved portion of the strap is fed through the eye of the inner tube of the Masson fascia stripper. A 2-0 suture is placed through the fascia at the level of the eye to be used as a retriever in case the strap is inadvertently cut up inside the thigh. Two straight Kocher clamps are applied to the end of the strap for countertraction. The outer tube of the Masson fascia stripper is inserted over the inner tube, and they are locked together with a bolt action.

With countertraction on the two Kocher clamps placed across the end of the strap, the Masson fascial stripper is advanced up the fascia lata until the desired length of fascia is obtained. At that point, the outer tube of the Masson fascia stripper is disengaged from the inner tube, and with a sudden shearing motion the inner tube is withdrawn from the outer tube, cutting the proximal end of the fascia strap.

On occasion, the fascia strap will be too short, particularly in obese patients. Therefore, one end of the strap may be folded on itself, and several interrupted 2-0 Prolene sutures will need to be placed to anchor it. From the opposite end, and incision can be made down the length of the strap, thereby doubling the overall length.

The incision in the thigh is closed with two layers-the inner layer with 3-0 synthetic absorbable suture and the outer layer with fine monofilament suture such as nylon or Prolene.

The patient is now changed from the lateral decubitus position to the dorsal lithotomy position. The vulva, vagina, and lower abdomen are prepped and draped.

With the labia minora tacked to the perineum with interrupted sutures, a Foley catheter is inserted into the bladder, and tension is applied to define the urethrovesical angle.

Two Allis clamps are applied at the urethrovesical angle, and a linear incision is made in the vaginal mucosa. This is carried down to the pubovesical cervical fascia.

After sharp dissection has separated the vaginal mucosa from the pubovesical cervical fascia, blunt dissection with the finger can usually be carried out without difficulty lateral to the urethra up to the urogenital diaphragm. The same dissection should be carried out on the opposite side.

The surgeon should make an 8-cm transverse incision approximately 8 cm above the pubic bone.

This incision should be carried down to the rectus fascia, and two small oblique incisions large enough to admit a finger should be made in the rectus fascia.

Blunt dissection with a finger is used to create a space behind the pubic bone down to the urogenital diaphragm lateral to the urethra.

A finger is inserted through the vaginal mucosa lateral to the urethra and up to the urogenital diaphragm. At the same time, a large Kelly clamp can be inserted through the rectus incision down to the point where it touches the finger.

The Kelly clamp is then pushed through the urogenital diaphragm and out into the vagina. The clamp is used to grasp one end of the fascia strap.

The strap is pulled up to the rectus abdominis incision and held with a small hemostat. A similar technique of dissection and strap pull-through is performed on the opposite side. A strap now is through both incisions in the rectus fascia and is around the urethrovesical angle.

Tension on the strap is adjusted so that there is enough space between the urethrovesical angle and the strap to easily insert a Kelly clamp.

At this point, two 3-0 synthetic absorbable sutures are placed between the strap and the pubovesical cervical fascia at the urethrovesical angle. In addition, sutures are placed in the strap and rectus fascia.

A suprapubic Foley catheter is inserted in the bladder as shown in Bladder and Ureter. The abdominal incision is closed in layers; the vaginal mucosa is closed with interrupted 0 synthetic absorbable suture. The Foley catheter is left in place for at least 5 days, after which clamping of the catheter is started and the patient is encouraged to void.

Figure 22 shows the physiologic changes in the anatomy that allow the Goebell-Stoeckel fascia lata sling procedure to correct urinary incontinence.

The central alteration in the anatomy is a reduction in size in the proximal and middle third of the urethral lumen, as noted in the insert to Figure 22 of the bladder and urethra. Continence is achieved by elevating the pressure inside this area above the pressure inside the bladder (B). S identifies the symphysis pubis.

It is important to note that unlike the retropubic "pin-up operations" (Marshall-Marchetti-Krantz, Burch, and Tenagho), the Goebell-Stoeckel fascia lata sling procedure does not make the bladder into an intra-abdominal organ. Instead, it increases the intra-urethral  pressure (pIU) so that it becomes higher than the intravesical pressure (pIV) except when, on command, there is massive contraction of the detrusor.

Figure 22 illustrates a key point in this procedure. If the fascia strap is pulled too tightly, the chance of postoperative urinary retention will be greater than 30%. This is not a procedure to correct pelvic prolapse. The strap should not be used to bring the bladder back to an intra-abdominal organ like the Marshall-Marchetti-Krantz, Burch, and Tenagho procedures. Failure to recognize this point results in an unacceptable level of postoperative urinary retention.