Skip to main content

The Retropubic Space

The retropubic space (space of Retzius) is the potential preperitoneal compartment behind the pubic symphysis and anterior to the bladder.[1] It is an important operative field for retropubic radical prostatectomy, Burch colposuspension, retropubic midurethral slings, preperitoneal hernia repair, selected artificial urinary sphincter reservoir placement, and suprapubic bladder access. Hemorrhage from pelvic fracture or surgery may collect here.

See also Bony Pelvic Anatomy for Cooper's ligament / pubic anatomy; Pelvic Vascular Anatomy for the corona mortis; The Bladder and The Prostate for organ pedicles; The Penis for dorsal vein complex anatomy.

Boundaries​

The retropubic space is a potential space developed through a preperitoneal approach; the precise entry plane varies with the operation and prior surgery. Its boundaries:[1]

BoundaryStructure
AnteriorPosterior aspect of the pubic bones and symphysis, covered by transversalis fascia
PosteriorAnterior surface of the bladder and prostate (M) / bladder and anterior vagina (F)
SuperiorPeritoneal reflection from anterior abdominal wall onto the bladder; its position changes with bladder filling and prior surgery, so a fixed fingerbreadth rule is unsafe
InferiorPuboprostatic attachments and bladder neck (M); pubovesical / pubourethral attachments (F), with the perineal membrane farther caudal
LateralObturator internus fascia; arcus tendineus fasciae pelvis (ATFP) continuing back to the ischial spine; obturator neurovascular bundle anterolaterally

The retropubic space communicates laterally with the paravesical space on each side of the bladder, and superolaterally with the preperitoneal space of the anterior abdominal wall, which is why pelvic-fracture hematomas can extend both upward and laterally.

Structural Contents​

Periosteal and ligamentous​

  • Pubic symphysis and posterior pubic body. The anterior wall.
  • Cooper's (pectineal) ligament. Thick fibrous band along the pectineal line of the superior pubic ramus; a fixation landmark for Burch colposuspension and some preperitoneal hernia repairs.
  • Paraurethral attachments (F). Retropubic fibromuscular tissue supports the urethra and anterior vaginal wall in the region between the posterior pubis and pelvic sidewall.[2] Hamner and colleagues found no histologically discrete pubourethral ligament in four specimens.[2]
  • Puboprostatic ligaments (M). From the posterior pubis toward the prostatic apex and urethral sphincter region.[3] Some continence-sparing techniques preserve these attachments when oncologically and technically feasible.
  • Arcus tendineus fasciae pelvis (ATFP, "white line"). Fibrous band from the posterior pubis to the ischial spine along the obturator fascia; the lateral attachment of the anterior vaginal wall (Level-II support).[4]
  • Arcus tendineus levator ani (ATLA). Origin of levator ani from the obturator fascia.

Vascular​

The central preperitoneal plane is relatively avascular, but vascular structures encountered during retropubic dissection can bleed substantially.[15] Relevant structures include:

  • Dorsal vein complex (DVC / Santorini's plexus). Male venous network anterior to the prostatic apex and urethra that can bleed substantially during prostatectomy.[3]
  • Deep dorsal vein of the penis. Contributes to the male prostatic venous plexus. The deep dorsal vein of the clitoris drains toward the female vesical venous plexus, not a prostatic plexus (see The Perineum).
  • Inferior vesical vessels (M) or vaginal branches (F). Approach the bladder base or upper vagina from the pelvic sidewall; nearby autonomic nerves travel in their own variable fascial pathways rather than inside a fixed vascular bundle.
  • Obturator neurovascular bundle. Nerve, artery and vein at the anterolateral edge of the space, emerging through the obturator canal.
  • Corona mortis. Variable arterial and/or venous connection between obturator and external iliac or inferior epigastric systems across the superior pubic ramus.[5] The adjacent vascular-anatomy review documents a pooled estimate near 46% across 1,455 hemipelves with marked heterogeneity, not a universal 20–30% rate or safe distance.[5] Anticipate and identify crossing vessels during Cooper's-ligament dissection.
  • Accessory pudendal arteries. Variable supralevator arterial routes near the prostate or apex. A 23-study meta-analysis estimated presence in 28.5% of patients, whereas surgical detection and definitions differ.[6] Preservation is desirable when feasible, but transection is not established as an independent cause of postoperative erectile dysfunction; one 880-patient cohort found no significant association after adjustment.[6][7] (Meta-analysis; cohort)

Neural​

  • Obturator nerve. Exits the obturator canal anterolaterally; supplies medial-thigh sensation and the adductor compartment. At risk during TOT sling passage, obturator lymphadenectomy, and retropubic dissection extending laterally.
  • Pelvic plexus branches to the bladder and prostate. Enter the bladder base posterolaterally; not typically encountered in pure anterior retropubic dissection but at risk at the junction of the bladder neck and prostate.

Adipose and lymphatic​

Loose preperitoneal fat (the "Retzius fat pad") and prevesical lymphatics lie here; the obturator lymph-node basin is lateral and is one of several pelvic drainage basins relevant to bladder and prostate cancer. Pelvic lymphadenectomy templates are disease- and guideline-specific.

Urachus​

The median umbilical ligament (urachus remnant) runs from the bladder dome to the umbilicus in the midline across the retropubic space anteriorly. Urachal cysts, sinuses, and adenocarcinomas arise along this ligament.

Key Fascial Planes​

PlaneApproach
Between abdominal-wall fascia and bladderPrevesical plane developed for selected retropubic operations; the method and safety assessment differ across prostatectomy, Burch, sling and bladder access.
Cave of Retzius (preperitoneal plane)Same as above — the classical eponymous name.
Between bladder neck and prostateThe plane of bladder-neck-sparing radical prostatectomy.
Between urethra and pubic symphysisPlane around anterior urethral / prostatic attachments; division or preservation depends on the approach, anatomy and oncologic constraints.
Around Cooper's ligamentIdentify variable arterial and venous corona-mortis connections before fixation or dissection; no single prevalence or fixed safe zone applies.[5]

Operative Uses of the Retropubic Space​

Retropubic radical prostatectomy (RRP)​

In the classical open approach, retropubic exposure gives access to the anterior prostate, endopelvic fascia, puboprostatic attachments, dorsal vein complex, apex and urethra. Posterior dissection then follows the prostate–rectum fascial relationship, with nerve-sparing and reconstruction adapted to tumor location and anatomy.[8][9] Robotic approaches use related landmarks but different access, visualization and preservation maneuvers.[9]

Burch colposuspension​

Retropubic access permits suspension of periurethral or paravaginal tissue near the bladder neck to Cooper's ligament. Suture number, material and operative approach vary.[10] It remains a mesh-free surgical option for selected stress urinary incontinence patients, including some undergoing concurrent abdominal surgery.[10]

Retropubic midurethral sling (TVT)​

Passage behind the pubis places a midurethral sling through the retropubic space; route and device instructions vary. Bladder or urethral perforation and bleeding are important hazards, and rare bowel or major-vessel injuries have been reported.[10] The 2023 AUA/SUFU female SUI guideline states in the supporting text for Statement 4 that intraoperative cystoscopy should be performed with midurethral sling surgery to assess lower-tract integrity.[10]

Stoppa / laparoscopic pre-peritoneal hernia repair​

Preperitoneal access includes the medial retropubic region and the myopectineal orifice. Mesh coverage and fixation technique depend on the repair; Cooper's ligament is a landmark. Identify variant corona-mortis vessels when dissecting nearby.

Artificial urinary sphincter (AUS)​

The pressure-regulating balloon may occupy a retropubic or prevesical position or a selected ectopic position depending on prior pelvic surgery, radiation and device-specific planning. Pump and cuff positions vary with anatomy and indication.

Male sling (urethral sling)​

Some male slings use retropubic anchoring, but transobturator and other designs do not all traverse the retropubic space. The relevant risks and fixation points depend on the device and route.

Suprapubic catheter / cystostomy​

Percutaneous or open access reaches the bladder through the lower anterior abdominal or prevesical region. Adequate bladder filling can separate bowel from the intended route, but distension alone does not establish a safe trajectory, especially after lower abdominal surgery or when filling is inadequate. Ultrasound or cystoscopic guidance or an open approach may be appropriate to the patient and setting; bowel injury remains possible.[11][12] (BAUS practice-guideline notice; UK audit)

Cystotomy​

Selected abdominal approaches to bladder surgery may develop this anterior space for access. Vesicovaginal fistula repair, diverticulectomy and partial cystectomy have different routes and exposure requirements.

Pelvic lymphadenectomy (bladder, prostate, gynecologic)​

The obturator, external iliac and internal iliac regions are common components of pelvic node dissection, with boundaries and extent determined by disease and the applicable guideline. Node work lies largely lateral to the central Retzius space. The obturator nerve is an important landmark to identify and protect.

Sex-Specific Features​

Female​

  • Puboprostatic analog. The corresponding female region contains pubovesical and paraurethral attachments; a discrete pubourethral ligament was not found in the cited histologic specimens.[2]
  • Arcus tendineus fasciae pelvis (ATFP) is the lateral attachment of the anterior vaginal wall; detachment produces a paravaginal defect.[4]
  • Cooper's ligament suture fixation is the Burch principle.
  • The retropubic space sits anterior to the urethra, bladder, and anterior vaginal wall.

Male​

  • Puboprostatic ligaments anchor the prostatic apex to the pubis.
  • DVC receives the penile dorsal system and can be a major source of bleeding in apical dissection.
  • Accessory pudendal arteries may pass near the apex; detection rates vary by imaging, dissection and definition. Preserve a functional vessel where feasible without claiming that division inevitably causes erectile dysfunction.[6][7]
  • The retropubic space lies anterior to the bladder and prostate; the seminal vesicles are farther posterior.

Clinical Correlations for the Reconstructive Surgeon​

  • DVC control in prostatectomy. Venous bleeding can obscure apical planes; suture, stapling and athermal strategies have different tradeoffs. No single DVC maneuver guarantees preserved membranous urethral length or continence.
  • Corona mortis. Anticipate a crossing artery and/or vein during superior-pubic-ramus dissection. Preserve it when possible or obtain controlled hemostasis if division is required; do not use a fixed coordinate or automatic clip-and-divide rule. Injury to an arterial or venous corona mortis can cause severe bleeding that is difficult to control; identify crossing vessels before dissecting near Cooper's ligament.[5]
  • Retropubic sling complications. Bladder perforation and retropubic hematoma are recognized risks; rare severe vascular or bowel injuries require prompt recognition.
  • Pubic osteomyelitis / osteitis pubis. Persistent pubic pain after retropubic surgery has a broad differential; infection or inflammatory change may require imaging and specialist evaluation. Antibiotics, drainage or implant removal depend on the established diagnosis and source control.
  • Infection spread. Severe perineal infection can extend along contiguous fascial planes; surgical exploration follows the observed disease extent.
  • Preperitoneal pelvic packing. In selected pelvic-fracture hemorrhage, packs can be placed in the preperitoneal or paravesical region as part of a trauma-control pathway; sequencing with other hemorrhage control depends on physiology and local protocol.
  • Urachal pathology. Remnants and rare tumors can arise along the median umbilical ligament. Management of a suspected urachal carcinoma requires staging and multidisciplinary planning; en-bloc urachus and umbilicus resection with an appropriate bladder margin is a common surgical approach.
  • Anatomy preservation for post-prostatectomy continence. Membranous urethral length, apical dissection and anterior attachments are relevant, but individual preservation maneuvers have different evidence strength and must not compromise cancer control. A 2023 RCT review found the clearest early-continence signal for Retzius-sparing surgery, with lower-certainty support for some other maneuvers.[13] (RCT review)
  • Retropubic access in the radiated / reoperative pelvis. Scarred planes and altered vascular anatomy call for case-specific planning. For open exposure, staying close to the posterior pubic bone at midline while displacing the bladder and urethra caudally, with blunt development aided by a filled Foley balloon, has been described; when prior retropubic surgery or dense adhesions are present, sharp entry to free the anterior bladder, urethra and vagina from the pubic bone is used instead. When the urethra or lower bladder border cannot be identified, a high cystotomy with a finger inside the bladder to define its lower limit can help guide mobilization.[1]
  • Robotic Retzius-sparing radical prostatectomy. Posterior access preserves more anterior retropubic attachments and is associated with faster early continence recovery in pooled studies. In Gong and colleagues' 2025 meta-analysis of mixed study designs, positive margins were more frequent with Retzius-sparing than standard robotic prostatectomy overall (170/774 [22.0%] versus 115/710 [16.2%]; OR 1.51, 95% CI 1.15–1.98) and in the ≥pT3 subgroup (OR 1.81, 95% CI 1.18–2.77).[14] Only three studies in Gong and colleagues' synthesis reported biochemical recurrence at one year; operative selection must weigh this margin signal against early functional outcomes.[14] Barayan and colleagues followed a previously randomized cohort by treatment received (57 Retzius-sparing, 63 standard; median follow-up 71.24 months): biochemical recurrence occurred in 10/57 versus 6/63, and five-year biochemical recurrence-free survival was 85% versus 91% (p = 0.21).[16] (2025 synthesis)

References​

1. Karram MM, Baggish MS. Anatomy and Surgical Exposure of the Retropubic Space. In: Baggish MS, Karram MM, eds. Atlas of Pelvic Anatomy and Gynecologic Surgery. 5th ed. Elsevier; 2021:401–418.

2. Hamner JJ, Carrick KS, Ramirez DMO, et al. "Gross and Histologic Relationships of the Retropubic Urethra to Lateral Pelvic Sidewall and Anterior Vaginal Wall in Female Cadavers: Clinical Applications to Retropubic Surgery." Am J Obstet Gynecol. 2018;219(6):597.e1–597.e8. doi:10.1016/j.ajog.2018.09.037

3. Myers RP, Goellner JR, Cahill DR. "Prostate Shape, External Striated Urethral Sphincter and Radical Prostatectomy: The Apical Dissection." J Urol. 1987;138(3):543–550. doi:10.1016/s0022-5347(17)43253-8

4. Ashton-Miller JA, DeLancey JO. "Functional Anatomy of the Female Pelvic Floor." Ann N Y Acad Sci. 2007;1101:266–296. doi:10.1196/annals.1389.034

5. Noussios G, Galanis N, Chatzis I, et al. "The Anatomical Characteristics of Corona Mortis: A Systematic Review of the Literature and Its Clinical Importance in Hernia Repair." J Clin Med Res. 2020;12(2):108–114. doi:10.14740/jocmr4062.

6. Henry BM, Pękala PA, Vikse J, et al. "Variations in the Arterial Blood Supply to the Penis and the Accessory Pudendal Artery: A Meta-Analysis and Review of Implications in Radical Prostatectomy." J Urol. 2017;198(2):345–353. doi:10.1016/j.juro.2017.01.080

7. Williams SB, Morales BE, Huynh LM, et al. "Analysis of Accessory Pudendal Artery Transection on Erections During Robot-Assisted Radical Prostatectomy." J Endourol. 2017;31(11):1170–1175. doi:10.1089/end.2017.0542.

8. Walsh PC, Partin AW, Epstein JI. "Cancer Control and Quality of Life Following Anatomical Radical Retropubic Prostatectomy." J Urol. 1994;152(5 Pt 2):1831–1836. doi:10.1016/s0022-5347(17)32396-0

9. Mandel A, Parekh S, Choudhary M, et al. "Analysis of the Current Surgical Anatomical Knowledge of Radical Prostatectomy: An Updated Review." Eur Urol. 2026;89(2):128–139. doi:10.1016/j.eururo.2025.06.002

10. American Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. "Surgical Treatment of Female Stress Urinary Incontinence." 2023 amendment. Guideline PDF.

11. British Association of Urological Surgeons. "Suprapubic Catheter Practice Guidelines — Revised." 2020. BAUS notice.

12. Hall S, Ahmed S, Reid S, et al. "A National UK Audit of Suprapubic Catheter Insertion Practice and Rate of Bowel Injury With Comparison to a Systematic Review and Meta-analysis of Available Research." Neurourol Urodyn. 2019;38(8):2194–2199. doi:10.1002/nau.24114.

13. Ippoliti S, Colalillo G, Egbury G, et al. "Continence-Sparing Techniques in Radical Prostatectomy: A Systematic Review of Randomized Controlled Trials." J Endourol. 2023;37(10):1088–1104. doi:10.1089/end.2023.0188.

14. Gong W, Yan J, Cui Y, Zhang D, Ma Y. "Comparison of Efficacy of Retzius-sparing Radical Prostatectomy Versus Standard Radical Prostatectomy in the Treatment of Prostate Cancer: A Systematic Review and Meta-analysis." Front Oncol. 2025;15:1547687. doi:10.3389/fonc.2025.1547687.

15. Veit-Rubin N, Dubuisson J, Ford A, Dubuisson J-B, Mourad S, Digesu A. "Burch colposuspension." Neurourol Urodyn. 2019;38(2):553–562. doi:10.1002/nau.23905

16. Barayan GA, Majdalany SE, Butaney M, et al. "Intermediate-Term Oncologic Outcome Assessment for Robot-Assisted Radical Prostatectomy: Comparing Retzius-Sparing with Standard Approach in a Randomized Control Cohort." J Endourol. 2024;38(6):559–563. doi:10.1089/end.2023.0514