Recent publication showed a restoration of urinary continence in over 40% of patients (with mixed and urgency urinary incontinence) after apical fixation (cervicosacropexy and vaginosacropexy). An even higher continence rate was obtained after an additional transobturator tape (TOT). 
So far, the length of the urethra was not considered by placing “midurethal tapes”. 
This study focused on the continence rates after apical fixation with or without transobturator tape in regard to the length of the urethra.

Apical fixation was done by replacing the uterosacral ligaments (USL) on both sides of the small pelvis. Thereby, polyvinylidene-fluoride (PVDF) tapes of identical lengths were placed into the peritoneal folds of both USL and were fixed between the cervix or vaginal vault and the sacral vertebra at level of S1. A transobturator tape was placed according the technique of Delorme et al..   
Measurement of the urethral length was performed under anesthesia before every surgery.
Urinary incontinence symptoms were assessed according to validated urinary incontinence questionnaires like the ICIQ-SF. Urinary continence was defined as no involuntary loss of urine with a micturition frequency below 8 voids within daytime.

These results are based on 290 measurements of patients. The lengths of urethras differed between 2.0 and 4.9 cm. 
Continence rates after apical fixation only were significantly different between patients with short urethras (less than 4.0 cm) compared to those with larger urethras (more than 4.0 cm) (48 – 51% compared to 14%, respectively). There was no significant difference in continence rates among patients with different lengths of urethras after an additional TOT.

Significant differences in urinary continence rates were observed according to different lengths of the urethra.
A urethral length of between 4 – 4.9cm showed a continence rate of only 14% after apical fixation alone. In contrast, urethral lengths less than 4cm (2.0 – 3.9cm) after apical fixation only showed continence rates of 48% and 51%, respectively. Same results were obtained for an additional TOT (but greater number of patients are needed, especially in case of urethral lengths greater than 4cm).

So far, we have no definitely explanation for this observation. One possible explanation for that observation could be the impact of apical fixation on the anterior vaginal wall: smaller urethras benefit more than larger ones from the “stretching” and supportive effect of this standardized apical fixation.