In the operative report, the surgeon described "placement of mesh into the vagina, dissection through the rectal spaces, and anchoring of the mesh into the levator/pelvic muscles, the cervix, and lastiy to the paraurethral ligaments," and "passage of trocars through the cave of Retzius at the level of the midurethra" (FIGURE 2).
Whereas the anterior wall of the vagina is the site where paraurethral leiomyomas develop, the anterior wall of the proximal urethra is where urethral leiomyomas most frequently do (12).
In addition to these conditions, the differential diagnosis of a urethral caruncle should include the elimination of other diseases that cause paraurethral masses, such as senile urethritis, skeletal abscess, infected urethral diverticulum, ectopic ureterocele, Gartner's duct cyst, residual Mullerian cyst, vaginal wall cyst, and urethral-vaginal neoplasms.
Soft tissue damage during childbirth might weaken post-delivery bladder neck support and as a consequence can produce some sort of weakness of paraurethral connective tissue and fascial structures, altogether resulting in stress urinary incontinence(25-27).
To safely and efficiently develop a paraurethral passage, I perform a hydrodissection and hemostatic injection at the level of the midurethra using a control top 10-cc syringe with a 22-gauge needle.