Patient selection for the creation of a fascial sling procedure to increase outlet resistance has been somewhat controversial. We review our experience with the fascial sling technique and report our patient selection process. Since 1991, 30 patients, including 6 males and 24 females aged 4-20 years (mean 10 years), underwent a rectus fascial sling procedure as part of their reconstructive efforts for continence. The underlying cause of incontinence was neurogenic in 28 patients. All males were prepubertal. Videourodynamics were performed in all patients preoperatively. Criteria for enhancement of bladder-outlet resistance included a detrusor leak-point pressure (LPPd) of < 50 cmH2O; a stress leak-point pressure (LPPs) of < 100 cmH2O; an open bladder neck, irrespective of LPP, and clinical evidence of stress incontinence, irrespective of videourodynamic parameters. Technical aspects of the procedure are discussed. Augmentation cystoplasty was performed in 29 patients with poor bladder compliance. In 18 patients a catheterizable stoma was also created. The period of follow-up currently ranges from 2 to 70 (mean 37) months. In all, 28 patients (93%) became continent and 2 female patients remain incontinent with a low LPP. All patients are on clean intermittent catheterization (CIC); 12 patients (40%) are catheterizing per urethra without difficulty. All prepubertal males are completely dry. The fascial sling repair has many advantages over other methods for increasing outlet resistance, including simplicity of technique, effectiveness, minimal likelihood of erosion, and low cost.