Table of Contents
- Procedure Summary
- Authors
- Youtube Video
- What is Laparoscopic Retropubic Urethropexy?
- What are the Risks of Laparoscopic Retropubic Urethropexy?
- Video Transcript
Video Description
This video demonstrates a laparoscopic retropubic urethropexy for stress urinary incontinence, focusing on key anatomy, dissection, and precise suture placement. It highlights a minimally invasive, mesh-free surgical option for effective urethral support.
Presented By
Affiliations
University of British Columbia
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What is Laparoscopic Retropubic Urethropexy?
Laparoscopic retropubic urethropexy is a minimally invasive surgical procedure used to treat stress urinary incontinence by restoring support to the urethra. It is a mesh-free alternative to mid-urethral slings, using sutures to elevate the pubocervical fascia and secure it to the pectineal (Cooper’s) ligament, improving urethral stability and continence.
- Preoperative Planning: Involves patient selection and understanding pelvic anatomy, with consideration for those seeking a non-mesh surgical option.
- Retropubic Space Dissection: Requires careful entry into the retropubic space while identifying and protecting key structures such as the bladder, obturator vessels, and surrounding neurovascular anatomy.
- Anatomical Landmark Identification: Focuses on structures like the pectineal ligament, pubocervical fascia, and urethrovesical junction to guide safe and accurate suture placement.
- Suture Placement Technique: Involves placing sutures lateral to the mid-urethra and securing them to the pectineal ligament to elevate and support the urethra.
- Precise Tensioning: Ensures appropriate urethral support without overcorrection, which could lead to obstruction.
What are the Risks of Laparoscopic Retropubic Urethropexy?
While this is an effective minimally invasive, mesh-free option, it carries several surgical risks:
- Bleeding and Vascular Injury: Dissection near the pectineal ligament and retropubic space can risk injury to vessels such as the corona mortis or obturator vessels.
- Bladder Injury: Due to the proximity of the bladder during dissection and suture placement, there is a risk of perforation or inadvertent suture placement.
- Urethral Obstruction: Over-tightening sutures can lead to voiding dysfunction or urinary retention.
- Injury to Neurovascular Structures: Structures within the retropubic and obturator regions are at risk if anatomical landmarks are not clearly identified.
- Anesthesia and Operative Risks: Includes risks related to laparoscopic surgery such as longer operative time or complications from pneumoperitoneum.
- Postoperative Complications: May include infection, urinary retention, or persistent/recurrent incontinence if support is inadequate.
Careful surgical technique, strong anatomical knowledge, and appropriate tensioning are critical to achieving successful outcomes while minimizing complications.
Video Transcript: Laparoscopic Retropubic Urethropexy?
Stress urinary incontinence affects 1 in 3 women, negatively impacting work, socializing, and overall health. The retropubic urethropexy is a well-established surgical treatment that fell out of favour after the introduction of the mid-urethral sling in the nineties. However, some women suffering from stress incontinence are wary of surgical mesh, and prefer a treatment that avoids the mesh sling. The laparoscopic retropubic urethropexy provides an effective minimally invasive surgical repair with comparable results to the mid-urethral sling, although few surgeons know the technique.
The objective of this video is to review the surgical approach to the laparoscopic retropubic urethropexy. We will demonstrate a laparoscopic version of the retropubic urethropexy as described by Tanagho, and review relevant anatomy.
Proper port placement is essential to facilitate suturing to the Cooper’s ligaments. We use an 5 mm, umbilical port for the laparoscope, a 10mm, left paramedian port for passing sutures, and bilateral, 5 mm, lateral ports placed one third of the distance from the anterior iliac crest to the umbilicus. These lateral ports allow the needle driver to approach the pubic ramus parallel to the Pectineal or Cooper’s ligament, simplifying needle placement.
The dissection begins with a transverse incision in the parietal peritoneum, medial to the obliterated umbilical arteries. This incision should be high on the peritoneum, approximately halfway between the symphysis and the umbilicus. We fill the bladder retrograde using an indwelling three-way Foley, to optimize identification and assist with the dissection of the retropubic space.
Blunt dissection is effective to open the retropubic space. Key anatomical landmarks to avoid are the dorsal vein of the clitoris, posterior to the symphysis pubis, and the obturator neurovascular bundle, that exits the retropubic space through the obturator foramen on the lateral aspect of the pectineal ligament. Dissecting above the parietal fat and between these two landmarks provides visualization of the pectineal ligament with tactile confirmation as a hard boney structure. Continuing the dissection posterior to the pectineal ligament, with blunt dissection down the obturator internus muscle and medially, opens the retropubic space and protects the bladder. This dissection should be continued to the arcus tendineus fascia pelvis, or white line, which runs from the posterior aspect of the symphysis pubis to the ischial spine.
The ischial spine is a useful anatomical landmark that can be recognized both by its location at the end of the white line and its hard tactile sensation. It is a safe structure to identify and reliably leads the surgeon to the obturator foramen, which is 3-4 cms anterior to the ischial spine. The obturator foramen deserves special care, not only for the obturator neurovascular bundle that courses posteriorly and laterally through the para-vesical space, but also for the corona mortis, a communication between the obturator artery and external iliac artery found in 25-30% of women that is vulnerable on the lateral pectineal line.
The Tanagho technique uses two sutures on each side to elevate the pubocervical fascia lateral to the mid-urethra and lateral to the urethrovesical junction. These sutures are elevated to the pectineal ligament.
To place the knot at the pectineal ligament, the suture is initially brought through the pectineal ligament just lateral to the midline. Throwing this stitch in an anterior to posterior direction is easiest using the needle driver through the ipsilateral lateral port. The needle driver is then moved to the contra-lateral port to throw the needle through the pubocervical fascia, 1 cm lateral to the mid-urethra.
The needle should get a good purchase of the pubocervical fascia without traversing the vaginal mucosa. This is facilitated by an assistant’s finger in the vagina lateral to the Foley catheter to elevate the vaginal wall. Care or a sterile thimble protects the assistant during this maneuver. A figure of eight stitch is used in the pubocervical fascia to prevent bleeding. Finally, the suture is brought back through the pectineal line in a posterior to anterior direction, using a needle driver in the ipsilateral lateral port. The knot is then tied down on the anterior aspect of the ligament using an extracorporeal technique.
The anatomical goal of the retropubic urethropexy is to use the pubocervical fascia to support the urethra, but over-elevation can result in obstruction rather than support. This illustrates the importance of suture tensioning to achieve optimal results. Studies show that the most effective method to judge tension is a surgeon’s finger in the vagina that should feel a minimal lift, similar to the lifting of a surgical glove off the fingertip. Once the assistant feels this degree of elevation. The knot is tied down on the pectineal ligament without further elevation.
The same approach is used to place the second urethrovesical junction stitch, which enters the pectineal line 1 cm lateral to the mid-urethral knot, and enters the pubocervical fascia 1 cm above and 1 cm lateral to the mid-urethral stitch. Finally, after placing the sutures on one side, the two stitches should be placed on other side.
Cystoscopy is essential to confirm ureteral patency and that sutures have not entered the bladder. Closing the retropubic space is prudent to prevent postoperative bowel adhesions within the space. This can usually be accomplished with 3 interrupted stitches placed using an extracorporeal or intracorporeal technique. A CTX needle is useful to bridge the gap.
The laparoscopic retropubic urethropexy is a straight forward surgical technique easily mastered by surgeons skilled in minimally invasive reconstructive surgery techniques. It offers an effective minimally invasive surgical treatment for stress urinary incontinence that avoids the use of mesh and risks of autologous fascia harvest.