Transvaginal urethrolysis was first described in 1984 by Leach and Raz.12 The goal of this procedure is to release the urethra from the surrounding obstructing fibrous tissue. It is performed through an anterior midline or inverted U-shaped incision, and dissection of the vaginal wall off of the underlying periurethral fascia. The submucosa is infiltrated with lidocaine and Marcaine before the incision to facilitate the dissection. The dissection proceeds bilaterally to the urethra and up to the pelvic fascia. When the endopelvic fascia is reached it is perforated. Dissection is performed until adequate urethral mobility is obtained. If dissection between the urethra and pubic bone is excessively difficult, a suprameatal incision may be made and dissection performed anterior to the urethra. In some cases it may desirable to interpose a free vaginal wall or Martius flap between the urethra and the pubic bone to prevent readherence of these structures.

Retropubic urethrolysis has been described by Webster and Kreder.13 It is performed through a Pfannenstiel or low midline incision. It is less often used than a transvaginal approach because it is associated with higher morbidity and more difficult dissection.

Infrapubic urethrolysis has been described by Petrou et al.14 It involves an inverted U incision made around and 1 cm away from the urethral meatus, between the 3 and 9 o'clock positions. Using sharp dissection, a plane is developed above the urethra to the bone of the symphysis pubis. Sharp and blunt dissection frees the urethra, vesical neck, and bladder from the pubic and pelvic attachments anteriorly and laterally. The retropubic space is reached with the index finger, and further mobilization can be accomplished. With this exposure, the lateral wings of the sling or suspension sutures can be cut. As with a traditional transvaginal urethrolysis, a Martius flap may be harvested and placed between the urethra and pubis. Equivalent success rates have been demonstrated with all of the approaches to urethrolysis.15

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