Operative Setup and General Entry into the Retropubic Space

The patient is supine, with the legs supported in a slightly abducted position, allowing the surgeon to operate with one hand in the vagina and the other in the retropubic space. The vagina, perineum, and abdomen are sterilely prepped and draped in a sterite manner that permits easy access to the lower abdomen and vagina. A three-way 18-French Foley catheter with a 20-mL balloon is inserted into the bladder and kept in the sterile field. The drainage port of the catheter is left to gravity drainage and the irrigation port is connected to sterile water with or without blue dye. One perioperative intravenous dose of an appropriate antibiotic should be given as prophylaxis against infection.

A Pfannenstiel or Cherney incision is made. During intraperitoneal surgery, the peritoneum is opened, the surgery is completed, and the cul-de-sac is obliterated, if necessary. The retropubic space is then exposed. Staying close to the back of the pubic bone, the surgeon's hand is introduced into the retropubic space and the bladder and urethra are gently moved downward. Sharp dissection is not usually necessary in primary cases. To aide visualization of the bladder, 100 mL of sterile water with methylene blue or indigo carmine dye may be instilled into the bladder after the catheter drainage port is clamped.

If previous retropubic or needle suspension procedures have been performed, dense adhesions from the anterior bladder wall and urethra to the symphysis pubis are frequently present. These adhesions should be dissected sharply from the pubic bone until the anterior bladder wall, urethra, and vagina are free of adhesions and are mobile. If identification of the urethra or lower border of the bladder is difficult, one may perform a cystotomy, which, with a finger inside the bladder, helps to define the bladder's lower limits for easier dissection, mobilization, and elevation.

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