The surgical anatomy of needle bladder neck suspension

Objective: To define the surgical anatomy of needle bladder neck suspension in order to explain this operation's effect on urethral support and gain information useful in minimizing intraoperative complications. Methods: Needle bladder neck suspension was carried out on two unembalmed, multiparous cadavers. After fixing the suspensory sutures in place, the pelvis of one cadaver was completely dissected. The second cadaver was serially sectioned at 1-cm intervals, and the sections were subjected to both anatomic and histologic examination. These findings were correlated with the findings noted during an autopsy dissection of a woman who previously had undergone needle bladder neck suspension at our institution and with our surgical experience with this operation. Results: The plane of dissection used to enter the space of Retzius lay between the vaginal mucous membrane and the visceral endopelvic fascia. The point of entry into the retropubic space lay between the levator ani muscles and its superior fascia, lateral to the arcus tendineus fasciae pelvis, the paraurethral vascular plexus, and bladder neck. It was cephalad to the perineal membrane (urogenital diaphragm). The paraurethral supporting tissues incorporated in the suspensory suture included the portion of the endopelvic fascia that lies between the vagina and urethra and, usually, the arcus tendineus fasciae pelvis. Attaching the suspensory sutures in needle bladder neck suspension seems to stabilize the bladder neck by providing a new point of lateral fixation for its supporting endopelvic fascia. Conclusion: Needle bladder neck suspension stabilized the supportive fascia of the urethra, and vascular injury may be minimized by detailed knowledge of paraurethral anatomy.