The pubourethral ligaments--an anatomical and histological study in the live patient

The aim of the study was to analyze the structure, relations and insertions of the pubourethral ligament in the living female. Thirty-five women, mean age 44 years, were studied. The intravaginal slingplasty (IVS) procedure, as performed via two paraurethral incisions, allowed immediate access to the structures in this area, the urethra, vaginal hammock, pubourethral ligaments and anterior portion of the pubococcygeus muscle. Histological biopsies were performed from the structures identified as ligaments. The pubourethral ligament descends like a fan from the lower part of the pubic bone. It consists of vaginal and urethral parts, joined together by thin fibrous threads, giving the appearance of a continuous sheet of amorphous connective tissue. Each part generally varies between 5 and 7 mm in width and 3-4 mm in thickness. The urethral part is approximately 2 cm long and inserts into the midpart of the urethra. The vaginal part is approximately 3-4 cm long. It inserts into the vaginal hammock posterolaterally, approximately 1 cm short of the bladder neck. Histologically the ligaments consist of smooth muscle, elastin, collagen, nerves and, blood vessels. The dissections confirm that the pubourethral ligaments are strong finite structures. Allowing for differences between cadavers and live patients, relationships and insertions are much as described by Robert Zacharin.