There is currently a mesh suspension throughout the United Kingdom and other countires. This means that the previous widely practiced Mid-Urethral tape cannot be offered as an option for management of Stress Urinary Incontinence (SUI). There is, therefore, an increase in non-mesh continence surgery being offered currently as well as a potential increased demand for it in the future even if the mesh is reintroduced as women are increasingly requesting non-mesh continence surgery

Knowledge of different techniques is important for the pelvic surgeon to possess, as different entry techniques can suit women of different body habitus and history of pelvic surgeries. In case of difficultly in gaining intrabdominal access with one technique, possessing knowledge and skill of using a different technique allows the surgeon to complete the procedure laparoscopically. This avoids conversion to an open procedure and the consequent disadvantages that may arise with an open procedure including an increased length of hospital stay, poorer health-related quality of life postoperatively and a longer recovery1.

This video describes two techniques of entering the retropubic space to perform a laparoscopic colposuspension. This includes the transperitoneal and the extraperitoneal entry techniques. 

The Transperitoneal Entry Technique: Laparoscopic entry into the abdomen is made as for routine laparoscopic procedures. The bladder is filled and the peritoneal reflection between the bladder and the anterior abdominal wall is opened to enter the retropubic space. Fascia is further dissected, and the anatomy is delineated using blunt dissection. Anteriorly, the pubic bone, laterally, the superior pubic ramus and the iliopectineal ligament and inferiorly, the bladder is visualised. Lateral ports are then inserted as routine.

The Extraperitoneal Entry Technique: The Veress needle is inserted supra-pubically to insufflate the suprapubic space. The primary optical port enters at the umbilicus and is then tunnelled into the retropubic space. The trocar is initially directed subcuticularly, parallel to the rectus sheath, the direction then changes to pierce the sheath in enter the retropubic space. Both Veress needle and the primary port are in the same distended pre-vesical space. The retropubic space is further dissected bluntly using the tip of the laparoscope to delineate the anatomy. Anteriorly, the pubic bone, laterally, the iliopectineal ligament and inferiorly, the bladder are visualised. Lateral 5 mm ports are placed under vision, 4-5cms lateral to the Veress needle and superior to the pubic symphysis.

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This video reviews two entry techniques for gaining access to the retropubic space to perform a laparoscopic colposuspension. Familiarity of the pelvic surgeon with both these techniques is advised so that the optimal entry technique is chosen and to possess a backup in case of failure of gaining access to the retropubic space with one laparoscopic technique.

Lapitan M, Cody D, Grant A. Open retropubic colposuspension for urinary incontinence in women. Cochrane Database of Systematic Reviews. 2009;1:CD002912.