2.3. Anatomy of the retropubic space

Knowledge of the anatomy is a prerequisite for an adequate performance, functional success, and avoidance of complications. This accounts for many of the procedures described above in general and Burch colposuspension in particular. The surgeon needs to master the structures of the retropubic space, also known as the “Cave of Retzius” or “Retzius’ space,” named after the Swedish anatomist Anders Retzius (1796‐1860). It constitutes a virtual avascular preperitoneal space between the pubic symphysis and the urinary bladder, behind the transversalis fascia and in front of the peritoneum. Its lateral margins are delimited by the pubic bone and obturator internus muscle and it has yet to be dissected (Figure ​(Figure4).4). Open surgical access to this area is obtained by dividing the rectus abdominis muscle along the midline raphe, separating the muscle strings laterally and entering between the rectus muscle and the peritoneum in the direction of the pubic symphysis. Then, the fatty connective tissue normally filling this space is bluntly dissected. Laparoscopically, this will be performed after opening the peritoneum. The space is dissected by repelling the connective and fatty tissue fibers behind the posterior pubic branch cranially to caudally and medially from the obturator internus muscle. The floor of the Retzius space is formed by the anterior vagina and its endopelvic and pubocervical fascia, stretching along the posterior symphysis and inserting at the level of the arcus tendinous fasciae pelvis (“white line”). The proximal urethra lies in a midline on top of the endopelvic fascia beneath the symphysis. The pubourethral ligaments form the lateral part of the urethra and reach the urethrovesical junction as well as the extraperitoneal bladder portion proximally. An indwelling Foley catheter can be inserted in order to better delineate the bladder boundaries. The “white line,” a tendinous arch originating at the posterior pubic symphysis, stretches along the internal side of the obturator internus muscle and inserts at the ischial spine. The endopelvic fascia is attached to the white line in order to ensure the anterolateral support of the vagina. Detachment at this level is at the origin of paravaginal defects. Lateral to the pubic tubercles, beneath the superior margin of the pubic ramus, is the iliopectineal line and Cooper's ligament. Laterally the following structures can be encountered: first the external iliac artery and vein and second the obturator neurovascular bundle, the latter exiting the pelvis through the obturator foramen. At this level, the so called “Corona mortis,” an anastomosis between the inferior epigastric artery and the obturator arteries, represents a potential source of bleeding in case of an unforeseen lesion (Figure ​(Figure55).

Complete deep dissection of the Retzius space (laparoscopic view). 1, Bladder (half full); 2, Arcus tendinous fascia pelvis; 3, Obturator muscle; and 4, Cooper ligament

Pre‐ & paravesical space (laparoscopic view). 1, Arcus tendinous fascia pelvis; 2, Obturator pedicle; 3, Pubic bone; and 4, Corona mortis crossing the ligament, (anastomosis between obturator vessels and inferior epigastric vessels). Risk of dramatic hemorrhage if injury