Weekly Surgery | Professor Xiao Binmei: Urethral Ligament Plasty (ULP)

Urethral Ligament Plasty (ULP)

Incision and Exposure

A longitudinal incision is made in the paraurethral groove from the external urethral orifice to the bladder neck, with a length of about 3–4 cm, to fully expose the underlying structures such as the pubourethral ligament (PUL), external urethral ligament (EUL), and pubococcygeus muscle (PCM).

Suture Position and Ligament Plication

Sutures need to pass through multiple attachment points of the ligaments, including:

Medially: the urethral and pubic parts of the pubourethral ligament, as well as the external urethral ligament;
Laterally: part of the pubococcygeus muscle.

The purpose is to plicate and tighten the relaxed ligamentous structures, and utilize the inflammatory reaction around the sutures to promote new collagen formation, thereby permanently reinforcing the ligaments.

Knotting and Fixation

Take care not to tie the knots too tightly to avoid postoperative dysuria.

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Case History

Patient Information

Female, 55 years old.

Chief Complaint

Urinary leakage with coughing for 4 years, aggravated for 2 years.

History of Present Illness

The patient reported involuntary urinary leakage during coughing and heavy physical labor without obvious inducement 4 years ago, without frequent or urgent urination. The symptoms worsened 2 years ago, with leakage occurring both when lying flat and standing, requiring daily use of adult diapers. Due to severe impact on quality of life, she was admitted for treatment.

Past History

Bilateral tubal ligation 24 years ago; history of hypertension, currently taking amlodipine besylate with well-controlled blood pressure.

Obstetric and Gynecologic History

Married at 20, G3P3, 3 full-term deliveries; husband and children are healthy.

Menstrual History

Menopause at 52, no abnormal vaginal bleeding or discharge after menopause.

Gynecological Examination

Vulva: normal development.
Vagina: unobstructed, small amount of white, odorless discharge.
Cervix: smooth, atrophic, medium consistency, no tenderness on motion or swinging.
Uterus: anteverted, atrophic, medium consistency, mobile, non-tender.
Bilateral adnexa: no masses palpable, non-tender.
Cough test: positive.
Marshall test (digital pressure test): positive.

Auxiliary Examinations

1.Pelvic floor ultrasound:

Anterior compartment: increased bladder neck mobility, moderate cystocele (Green type II), open posterior urethral angle, stress urinary incontinence.
Middle compartment: uterine prolapse.
Posterior compartment: perineal body descent.
No obvious rupture of levator ani or anal sphincter; mild expansion of levator ani hiatus area.

2.Gynecological color Doppler ultrasound: small myoma in the anterior uterine wall, uterine atrophy.

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Admission Diagnosis

Stress urinary incontinence
Hypertension
Uterine myoma

Surgical Procedure

Transvaginal Urethral Ligament Plasty (ULP) is planned.

Postoperative Condition

The urinary catheter was removed on the 2nd postoperative day.

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Postvoid Residual Urine Examination

After urination, no anechoic area remained in the bladder, indicating no significant residual urine.

After catheter removal, the patient was instructed to hold urine. No leakage occurred when standing, moving, or coughing with a full bladder.

About the Surgeon

Xiao Binmei

Chief Physician, Department of Gynecology, Xiangya Hospital, Central South University

Visiting Scholar, Red Cross Hospital Chemnitz, Germany; and University of California Davis Medical Center, USA
Vice Chairman, Youth Committee of the 1st Committee of Gynecology Branch, Chinese Geriatrics Society
Expert Member, Professional Group of Minimally Invasive Treatment for Female Genital Reconstruction, Chinese Association of Plastics and Aesthetics
Vice Chairman, Pelvic Floor Professional Group, Hunan Female Physicians Association
Vice Chairman, Pelvic Floor Professional Committee, Hunan Rehabilitation Medicine Association
Vice Chairman, Hunan Professional Committee for Prevention and Treatment of Female Pelvic Floor Dysfunction

Major in gynecologic urology, specialized in surgical treatment and individualized rehabilitation for difficult and recurrent pelvic floor diseases such as uterine prolapse, urinary incontinence, and genital fistula.

About the Supervising Expert

Professor Peter Petros

Doctor of Science (University of Western Australia)
Doctor of Surgery (University of Western Australia)
Doctor of Medical Sciences (Uppsala University)
Bachelor of Medicine/Bachelor of Surgery (University of Sydney)
Doctor of Medicine (University of Sydney)
Fellow, Royal College of Obstetricians and Gynaecologists (London)
Fellow, Royal Australian and New Zealand College of Obstetricians and Gynaecologists
Pelvic floor surgeon, gynecologist and urogynecologist

Former Associate Professor of Obstetrics and Gynecology, Uppsala University (Sweden); Adjunct Professor, School of Engineering and Mathematical Sciences, University of Western Australia; Honorary Professor, St Vincent’s Hospital, University of New South Wales; Visiting Professor of Urology, Case Western Reserve University (USA).

In 1990, together with the late Professor Ulmsten of Uppsala University, he co-proposed the Integral Theory, a major breakthrough from the previous view that urinary incontinence originated from the bladder itself. The theory holds that stress urinary incontinence and urge urinary incontinence are mainly caused by relaxation of the vagina or its supporting ligaments. Based on this theory, he pioneered various anti-incontinence surgeries such as TVT-O and UPL (Urethral Pubic Ligament Plication), and published more than 360 pelvic floor-related papers and studies.

Editor: Qing Huan

Reviewer: Ma Ye