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Laparoscopic Burch colposuspension for stress urinary incontinence: When, how, and why?

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Female SUI is a common condition without a clear-cut surgical solution. Here, the authors offer step-by-step guidance on a laparoscopic technique to effectively treat this growing problem.


 

References

KEY POINTS
  • Laparoscopic Burch colposuspension provides high long-term success rates, reduced morbidity, and accelerated convalescence.
  • A growing number of studies have shown the laparoscopic Burch to have results similar to traditional laparotomy when conventional surgical techniques and suture materials are used.
  • When we limit the discussion to 2 comparable techniques—a laparoscopic versus open 2-suture procedure—there is moderately strong evidence that the laparoscopic approach maintains efficacy while modestly reducing morbidity.
  • The selection of suture material and the total number and placement of sutures are crucial to the long-term cure rate.

Despite the growing body of medical knowledge on stress urinary incontinence (SUI), controversies over its management remain.

SUI is the most common type of inconti-nence and occurs almost exclusively in females. A recent survey by the National Association for Continence revealed that SUI affects approximately 16.5 million women in the United States.1 Nearly two thirds of these women are under 50 years of age.

Still, there is no surgical procedure of choice for women with this condition. In fact, a recent systematic review of the literature by Black and Downs could not determine the “best procedure” based on scientific clinical evidence.2

Among the large number of surgical options for SUI treatment is bladder-neck suspension via a laparoscopic Burch colposus-pension. When it is properly executed, this procedure offers high long-term success rates, reduced morbidity, and accelerated convalescence. In this article, we describe how to perform the laparoscopic Burch procedure (reviewing both conventional suturing techniques and the Tanagho modification)3 and discuss when to consider a laparoscopic approach. In addition, we explain why the procedure should be part of your surgical options for female SUI.

Retropubic versus transvaginal suspensions

With so many surgeries to choose from, determining which procedure would be best for a woman with genuine stress urinary incontinence is a challenge. In 1997, the American Urological Association published a report designed to offer some guidance.

An 8-member panel reviewed data from 282 articles, all of which followed patients for a minimum of 12 months for short-term cure/dry results, and 48 months for long-term results. The Report on the Surgical Management of Female Stress Urinary Incontinence—based on expert opinion and evidence from the literature (as determined by probability estimates)—stated that retropubic suspensions and slings are the most efficacious procedures for long-term success.

Still, the panel noted that these interventions are associated with slightly higher complication rates—including an increased incidence of voiding dysfunction—and longer convalescence than other SUI procedures. For patients willing to accept these complication rates for the sake of improved long-term success, the panel concluded, retropubic suspension and slings are appropriate. However, for patients valuing a decreased hospital stay, reduced morbidity, and an earlier return to normal activity, transvaginal suspensions—the only minimally invasive option widely offered at that time—were the better option.4

The Burch procedure

In the classic Burch colposuspension, a physician places 2 bilateral nonabsorbable sutures through the pubocervical fascia—1 at the level of the midurethra, the other at the urethrovesical junction (UVJ)—and fixes them to Cooper’s ligament. But since 1991, when Vancaille and Schuessler introduced a laparoscopic approach to a retropubic colposuspension (MMK technique),5 a growing number of studies have shown the laparoscopic Burch to have results similar to traditional laparotomy when conventional surgical techniques and suture materials are used.6-24

A number of reports have also described modifications or alternatives to the classic laparoscopic Burch.25-28 These variations—which use stapling devices, mesh placement, bone anchors, and even fibrin glue—avoid laparoscopic suturing, thereby reducing the surgical complexity and shortening the learning curve. They also may lower the cost per procedure by decreasing time in the operating room.29-32 Still, an experienced laparoscopist who has mastered endoscopic suturing can perform a laparoscopic Burch using “standard” suturing in a time frame comparable to that of one of the modifications.33

Retropubic suspensions and slings are associated with slightly higher complication rates than other SUI procedures.

As far as outcomes go, it is the selection of suture material, the total number of sutures used, and their proper placement that are crucial to an optimal long-term cure rate—regardless of the surgical access to the space of Retzius.34-36 In fact, if a surgeon laparoscopically employs the identical operative technique, “suture for suture,” that he or she would use via laparotomy, there is no biological reason why the continence cure rates would be any different.

When? Burch procedure versus the TVT sling

Several studies have demonstrated that for patients with intrinsic sphincter deficiency (ISD) the Burch colposuspension cure/dry rate is less than that of a standard sling procedure.37 We therefore obtain urodynamic studies on all patients presenting with SUI who we feel are at risk for ISD ( TABLE). For patients with ISD and urethral hypermobility, we recommend the minimally invasive pubovaginal sling tension-free vaginal tape (TVT) procedure. In the absence of urethral hypermobility, we first utilize periurethral bulking agents to correct the ISD. If this is not successful, we proceed with urethrolysis and a traditional sling procedure.

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