The Retropubic Space
The retropubic space (space of Retzius) is the potential preperitoneal compartment behind the pubic symphysis and anterior to the bladder. For the reconstructive urologist and urogynecologist it is the single most operatively important pelvic space: the operative field of retropubic radical prostatectomy, Burch colposuspension, retropubic midurethral slings (TVT), Stoppa-type hernia repair, artificial urinary sphincter pump placement, suprapubic catheter insertion, and laparoscopic pelvic-lymph-node dissection. It is also the compartment that fills with blood after a pelvic fracture (retropubic hematoma) and the space whose bounding structures (pubourethral ligaments, puboprostatic ligaments, dorsal vein complex, Cooper's ligament, corona mortis) govern most of the technique at urogenital-tract reconstructive surgery.
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 — opened in seconds by blunt dissection after incising the transversalis fascia behind the pubis. Its boundaries:
| Boundary | Structure |
|---|---|
| Anterior | Posterior aspect of the pubic bones and symphysis, covered by transversalis fascia |
| Posterior | Anterior surface of the bladder and prostate (M) / bladder and anterior vagina (F) |
| Superior | Peritoneal reflection from anterior abdominal wall → bladder (~2–3 fingerbreadths above pubis when the bladder is empty, higher when full) |
| Inferior | Urogenital diaphragm / puboprostatic ligaments (M); pubovesical ligaments and arcus tendineus fasciae pelvis (F) |
| Lateral | Obturator 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; the anchor for Burch colposuspension and Stoppa / laparoscopic hernia mesh fixation.
- Pubourethral ligaments (F) — anterior, middle, and posterior components from the posterior pubis to the urethra and anterior vaginal wall. Middle pubourethral ligaments support the midurethra in women — preserved during continence-sparing prostatectomy (the male puboprostatic analog).
- Puboprostatic ligaments (M) — from the posterior pubis to the prostatic apex / striated urethra; typically preserved in modern nerve-sparing / continence-sparing prostatectomy.
- 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).
- Arcus tendineus levator ani (ATLA) — origin of levator ani from the obturator fascia.
Vascular
The retropubic space is highly vascular. The dominant structures:
- Dorsal vein complex (DVC / Santorini's plexus) — thick venous network anterior to the urethra / bladder neck, richly communicating with the vesical plexus. Dominant bleeder of apical prostatectomy dissection.
- Deep dorsal vein of the penis / clitoris — the midline contribution to the DVC.
- Inferior vesical vessels (M) / vaginal artery (F) — enter the bladder base / upper vagina from the pelvic sidewall, carrying the cavernous nerves.
- Obturator neurovascular bundle — nerve, artery, vein — at the anterolateral edge of the space, emerging through the obturator canal.
- Corona mortis — aberrant obturator vessel crossing over the superior pubic ramus in 20–30% of patients, communicating between the obturator and external iliac / inferior epigastric system. Must be identified before Cooper's-ligament dissection.
- Accessory internal pudendal arteries — present in ~10–15% of men, running above the pelvic diaphragm in the retropubic space before entering the penis; their inadvertent sacrifice is an unrecognized cause of post-prostatectomy arteriogenic ED.
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 bladder-neck / prostate junction.
Adipose and lymphatic
Loose preperitoneal fat (the "Retzius fat pad"), prevesical lymph nodes, and the obturator lymph node basin along the obturator nerve — the first landing zone of bladder and prostate cancer and the target of pelvic lymphadenectomy.
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
| Plane | Approach |
|---|---|
| Between transversalis fascia and bladder | The plane developed by blunt dissection for retropubic prostatectomy, Burch, TVT, suprapubic catheter, cystotomy. |
| Cave of Retzius (preperitoneal plane) | Same as above — the classical eponymous name. |
| Between bladder neck and prostate | The plane of bladder-neck-sparing radical prostatectomy. |
| Between urethra and pubic symphysis | Plane for division of puboprostatic / pubovesical ligaments in classical prostatectomy; modern techniques preserve these for continence. |
| Around Cooper's ligament | Identify before suture placement; avoid the corona mortis (20–30%). |
Operative Uses of the Retropubic Space
Retropubic radical prostatectomy (RRP)
Classical Walsh technique. Enter the space via a lower-midline incision, develop bluntly, divide the endopelvic fascia lateral to the puboprostatic ligaments, control the dorsal vein complex (suture or stapler), incise the urethra at the apex, dissect the prostate off the rectum (in Denonvilliers' plane), preserve the neurovascular bundles posterolaterally, and reconstruct the urethrovesical anastomosis. Replaced in most centers by robotic approach but the anatomy is identical.
Burch colposuspension
Retropubic access; elevation of the paravaginal fascia at the bladder neck to Cooper's ligament with 2–4 permanent sutures on each side. Historic workhorse for stress urinary incontinence; has been superseded by midurethral slings but retains a role in women undergoing concurrent laparotomy or robotic hysterectomy, and in those who decline mesh.
Retropubic midurethral sling (TVT)
Two trocars passed blindly from a small vaginal incision along the back of the pubic symphysis, through the retropubic space, exiting at two suprapubic punctures. Risks: bladder perforation (most common; confirmed by cystoscopy), bowel / iliac injury if trocar deflects laterally, obturator / femoral nerve injury if too lateral, and retropubic hematoma from dorsal vein complex or corona mortis.
Stoppa / laparoscopic pre-peritoneal hernia repair
The retropubic space is entered extraperitoneally. Mesh placed over the myopectineal orifice, anchored to Cooper's ligament. The corona mortis must be identified.
Artificial urinary sphincter (AUS)
Pump placed in the scrotum (M) / labium majus (F); the pressure-regulating balloon is placed in the retropubic space through the same or a separate incision; the cuff is placed around the bulbar urethra (M) or bladder neck (F).
Male sling (urethral sling)
Retropubic, transobturator, or quadratic trajectories all traverse or abut the retropubic space. The retropubic approach places the sling anchors behind the pubis for bladder-neck or bulbar urethral compression.
Suprapubic catheter / cystostomy
Percutaneous or open access through the retropubic space into the bladder dome. Safer when bladder is distended (pushes peritoneum cephalad).
Cystotomy
Any trans-retropubic access to the bladder — VVF repair, bladder diverticulectomy, partial cystectomy — follows the same anatomy.
Pelvic lymphadenectomy (bladder, prostate, gynecologic)
The obturator nodes are the first landing zone for bladder and prostate cancer; the external iliac and internal iliac nodes complete the standard template. The retropubic dissection extends laterally to the obturator nerve, which must be identified and preserved.
Sex-Specific Features
Female
- Puboprostatic analog = pubovesical / pubourethral ligaments.
- Arcus tendineus fasciae pelvis (ATFP) is the lateral attachment of the anterior vaginal wall; detachment = paravaginal defect.
- 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 drains the penile dorsal system; Santorini's plexus dominates the bleeding.
- Accessory internal pudendal arteries (10–15%) may run in the retropubic space; their preservation matters for erectile function.
- The retropubic space sits anterior to the urethra, bladder, prostate, and seminal vesicles.
Clinical Correlations for the Reconstructive Surgeon
- DVC control is the rate-limiting step of apical prostatectomy dissection. Techniques: suture ligation, athermal division, stapler. Over-aggressive DVC suture can shorten membranous urethra and worsen continence; under-controlled DVC bleeds into the retropubic space.
- Corona mortis must be actively sought during any dissection along the superior pubic ramus (Burch, Stoppa, pelvic-fracture packing, Cooper's-ligament repair). Clip and divide rather than allowing avulsion.
- Retropubic hematoma after TVT — the commonest mechanism of life-threatening bleeding after a midurethral sling. Bladder perforation is the commonest complication overall (confirmed on intraoperative cystoscopy).
- Pubic osteomyelitis / osteitis pubis can follow retropubic surgery (especially with mesh) and produces severe pelvic pain; MRI-confirmed and usually managed with long-course antibiotics ± mesh removal.
- Fournier's gangrene extension into the retropubic space via Scarpa's fascia is possible; this is the reason Fournier-specific debridement must carefully examine the retropubic compartment.
- Preperitoneal pelvic packing (PPPP) for pelvic-fracture hemorrhage uses the retropubic space; packs are placed around the bladder and paravesically, then the rectus closed loosely. Angioembolization often follows.
- Urachal pathology. Remnants, cysts, and adenocarcinoma arise along the midline urachal ligament in the retropubic space; partial cystectomy with en-bloc urachus and umbilicus removal is the treatment of urachal adenocarcinoma.
- Anatomy preservation for post-prostatectomy continence. Three modifiable factors: membranous urethral length, puboprostatic-ligament preservation (Retzius-sparing when robotically feasible), and nerve-sparing apical dissection. All three live in the retropubic space.
- Retropubic access in the radiated / reoperative pelvis. Adhesions obscure planes; sharp dissection on the underside of the pubis, careful identification of the DVC, and liberal ureteric stenting are the rules.
- Robotic Retzius-sparing radical prostatectomy. Newer approach that enters the prostate via the pouch of Douglas, preserving the retropubic attachments and DVC anteriorly. Potentially better early continence but steeper learning curve and concerns about positive margins at the anterior prostate.
References
- 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.
- 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.
- Mandel A, Parekh S, Choudhary M, et al. "Analysis of the Current Surgical Anatomical Knowledge of Radical Prostatectomy: An Updated Review." Eur Urol. 2025. doi:10.1016/j.eururo.2025.06.002
- 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
- Hamner JJ, Carrick KS, Ramirez DMO, Corton MM. "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
- Kanjanasilp P, Ng JL, Kajohnwongsatit K, et al. "Anatomical Variations of Iliac Vein Tributaries and Their Clinical Implications During Complex Pelvic Surgeries." Dis Colon Rectum. 2019;62(7):809–814. doi:10.1097/DCR.0000000000001335
- Galán JJ, Lledó S. "Anatomy of the Corona Mortis: Review." Surg Radiol Anat. variable.