Topographic-anatomic considerations in vaginal surgical therapy of stress incontinence

Abstract

The medial pubourethral ligament and the posterior pubourethral ligaments have the important task (for continence) of fixing the neck of the bladder. If the neck of the bladder is placed in relationship to height of the posterior wall of the symphisis, viscerographic examinations show that the neck of the bladder is high in 9% of cases, medium-high in 26%, and low in 65%. When performing reconstructive surgery following detachment of the neck of the bladder as a result of abdominal pressure, these topographic-anatomic features can only be taken into consideration if the primary, original site of the neck of the bladder is known. Intraoperative exposure of the ligament insertion and of the posterior pubourethral ligaments will always permit the primary location of the neck of the bladder to be determined. This is situated 2.3 cm beneath the insertion, and joining the medial ligament to the dorsal urethra will guarantee normal repositioning of the neck of the bladder. If the primary location of the neck of the bladder is unknown in the individual case being treated, the deep tissue pad which develops subsequent to anterior colporraphy corresponds to a nonspecific tissue accumulation with incalculable outcome.