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Also known as
Cave of Retzius, Retzius' space, prevesical space, cavum Retzii, retropubic space, Retzius space, Retzius cavity
Definition
The retropubic space, also known as the Space of Retzius or Cave of Retzius, is a potential avascular space located between the pubic symphysis and the urinary bladder. It is a preperitoneal space situated behind the transversalis fascia and in front of the peritoneum. This space is named after the Swedish anatomist Anders Retzius (1796-1860). The space serves as a useful landmark in various gynecological and urological surgeries.
Structure:
The space is located in the pelvic region and is bounded by the following structures:
- Anteriorly: Symphysis pubis
- Laterally: Pubic rami and obturator internus muscles
- Posteriorly: Urinary bladder
- Floor: Anterior vagina (in women) and proximal urethra
Function:
The retropubic space is a potential space. Its compartmental pressure is directly affected by changes in intra-abdominal pressure, which in turn influences the physiology of urination and continence. Normal intra-abdominal pressure ranges from 5 to 7 mmHg, but can reach 10 to 15 mmHg chronically in conditions such as pregnancy or obesity. This elevated pressure is relayed to the adjacent retropubic compartment and can affect the structures within.
Clinical Significance:
The retropubic space is a crucial surgical landmark in several gynecological and urological procedures. Access to this space is typically achieved by separating the rectus abdominis muscle at the midline and dissecting tissue towards the symphysis pubis until the peritoneum is reached. Examples of surgeries involving the retropubic space include:
- Sling procedure: A first-line surgical treatment for women with stress incontinence.
- Artificial urinary sphincters: Considered a first-line surgical treatment for certain types of incontinence in men.
- Burch colposuspension: A retropubic procedure used in the treatment of urinary incontinence in women.
Clinical Context
The Space of Retzius is of significant clinical importance due to its proximity to vital structures such as the urinary bladder and, in males, the prostate gland. It is a crucial anatomical landmark in various surgical procedures, particularly in urology and gynecology. Pathologies within this space are more common than previously believed [1].
Relevant Medical Conditions and Procedures:
- Urinary Incontinence: The space is frequently accessed during procedures for stress urinary incontinence, such as sling procedures (first-line treatment for women) and the implantation of artificial urinary sphincters (first-line treatment for certain types of incontinence in men) [1]. The Burch colposuspension, a retropubic procedure, is also used to treat urinary incontinence in women [1].
- Prostate Surgery: The Space of Retzius is utilized in surgical approaches for prostatectomy, including robot-assisted radical prostatectomy. Techniques that preserve the Retzius space have been associated with a lower incidence of postoperative inguinal hernia development [8]. Novel anterior approaches involving the development and closure of the Retzius space following prostatectomy are also being explored [9].
- Pelvic Hematomas: Large hematomas can form in the Retzius space, sometimes requiring surgical intervention, though conservative management may be possible for hemodynamically stable patients [3, 5].
- Penile Implants: The avascular nature of this potential space makes it suitable for the placement of prosthesis reservoirs during penile implant procedures [2].
Patient Selection Criteria:
Patient selection for procedures involving the Space of Retzius depends on the specific condition being treated. For urinary incontinence, criteria may include the type and severity of incontinence, patient’s overall health, and previous treatment history. For prostatectomy, patient age, cancer stage, and comorbidities are considered.
Surgical Procedures:
Access to the Space of Retzius is typically achieved by separating the rectus abdominis muscle at the midline and bluntly dissecting the tissue towards the symphysis pubis until the peritoneum is reached [1]. Surgical techniques are continuously evolving, with new approaches aiming to minimize complications and improve outcomes [9].
Expected Outcomes:
Outcomes vary depending on the procedure. For incontinence surgeries, success rates are generally high, leading to improved quality of life. For prostatectomy, outcomes include cancer control and preservation of urinary and sexual function. Careful surgical technique and patient selection are crucial for optimal results.