Operative Setup and Entry Into the Retropubic Space
Operations involving the retropubic space are best done with the patient in the supine position and the patient’s legs in a frogleg position or, preferably, in low Allen stirrups. Many of these operations are best performed with a hand in the vagina, which allows easy access to the vaginal area. The vagina, perineum, and abdomen are all sterilely prepped and draped in a fashion that permits easy access to the lower abdomen and the vagina. We prefer to use a three-way Foley catheter with a 30-mL balloon that is inserted sterilely into the bladder and kept in the sterile field. This allows easy palpation of the bladder neck, and in situations where the edges of the bladder are not clearly delineated, one can easily fill the bladder in a retrograde fashion to help in dissection or to help diagnose a small cystotomy or inadvertent suture placement in the bladder. The drainage port of the catheter is left to gravity drainage, and the irrigation port is connected to sterile water that is placed on an IV pole. One perioperative IV dose of an appropriate prophylactic antibiotic is given for retropubic operations.
A Pfannenstiel or Cherney incision (Figs. 32–1 and 32–2) (also see Chapter 8) is used to gain entry to the retropubic space. If intraperitoneal surgery is also being performed, the peritoneum is left open until the retropubic repair is completed. Routine assessment and, if appropriate, obliteration of the cul-de-sac are performed in these situations (see Chapter 41). The retropubic space is exposed by staying close to the back of the pubic bone (Fig. 32–3
