CHAPTER 33 After the retropubic space is entered, the urethra and anterior vaginal wall are depressed. Dissection at the midline is avoided, thus protecting the delicate musculature of the urethra and urethrovesical junction from surgical trauma. Attention is directed to the tissue on either side of the urethra. The surgeon’s nondominant hand is placed in the vagina with the index and middle fingers on one side of the proximal urethra. Two sponge sticks are utilized to gently mobilize the bladder to the opposite side (Figs. 33–1 through 33–3). Most of the overlying fat can be cleared away with the use of a swab mounted on a curved forceps. This dissection is accomplished with forceful elevation of the surgeon’s vaginal finger until glistening, white periurethral fascia and vaginal wall are seen (see Figs. 33–1, 33–4, and 33–5). This area is extremely vascular, with a rich, thin-walled venous plexus, and should be avoided if possible. The positions of the urethra and the lower edge of the bladder are determined by palpating the Foley balloon, or by partially distending the bladder if necessary to find the rounded lower margins of the bladder as it meets the anterior vaginal wall. Dissection lateral to the urethra is completed bilaterally, and vaginal mobility is judged to be adequate by using the vaginal finger to lift the anterior vaginal wall upward and forward (see Figs. 33–1 and 33–5). Either 0 or 1 delayed-absorbable or nonabsorbable sutures are then placed lateral in the anterior vaginal wall. We apply two sutures of graded polyester on an SH needle (Ethibond by Ethicon, Inc., Somerville, NJ) bilaterally, using double bites for each suture. These sutures are double-armed so that each end of the suture can subsequently be brought up through Cooper’s ligament (see Figs. 33–4, 33–6, and 33–7). Proper placement of these sutures is important to provide adequate support and to avoid undue urethral kinking or elevation leading to postoperative voiding dysfunction or retention. We prefer to place the sutures in the lateral portion of the vagina just lateral to the tip of the vaginal finger, which should be elevating the most mobile and pliable portion of the vagina lateral to the bladder neck (see Figs. 33–1 through 33–8). The distal suture is placed 2 cm lateral to the proximal third of the urethra, and the proximal suture is placed approximately 2 cm lateral to the bladder wall or slightly proximal to the level of the urethrovesical junction (see Figs. 33–4 and 33–7
Retropubic Urethropexy for Stress Incontinence
Modified Burch Colposuspension
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