The Paraurethral Space: A Newly Described Anatomical Landmark and Its Surgical Applications.

STUDY

OBJECTIVE

This video aims to describe the newly defined paraurethral space, detailing its surgical access, relevant anatomy, and applications in surgery through a laparoscopic robotic-assisted approach.

DESIGN

A detailed dissection of this avascular space and a description of its utility in urethropexy, paravaginal repair, and mesh excision are presented through narrated video footage.

SETTING

Pelvic floor disorders often require surgical intervention after failed conservative therapy [1]. Traditionally, these surgeries are performed through a vaginal approach, which may limit access and visibility of vital anatomy. Accessing the paraurethral space approach offers direct access to the entirety of the arcus tendineus fascia pelvis, obturator internus muscle, and levator ani muscles.

INTERVENTIONS: Transperitoneal robotic laparoscopy was performed through a paraurethral approach on patients with paravaginal and paraurethral defects and mesh erosion. The borders of the paraurethral space are defined as follows: Lateral Border: The medial aspect of the obturator internus and levator ani muscles, including their attachments to the arcus tendineus fascia pelvis [2]. Medial Border: The proximal superior urethra and lateral bladder wall. Anterior Border: The inner (dorsolateral) aspect of pubic bone. Posterior Border: Pubo-cervical fascia All surgeries were performed using three robotic ports with the da Vinci Xi system.

CONCLUSION

The paraurethral space is an avascular anatomical landmark that has not been previously described in the literature. Dissection of this space allows access to lateral vaginal support tissues, which are critical for the repair of paravaginal [3] and paraurethral defects [4]. A transperitoneal approach to the paraurethral space provides optimal visualization of the relevant anatomy and direct access for defect repair and mesh excision that would otherwise be technically challenging via traditional transvaginal or transperitoneal retropubic approaches [5].