Laparoscopic Burch colposuspension for stress urinary incontinence: When, how, and why?
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.
For women who have concomitant pelvic-support defects such as uterine prolapse, vaginal vault inversion, or lateral cystoceles, we routinely perform laparoscopic reconstructive surgery, including the laparoscopic Burch for correction of the SUI.
Still, the difficult question remains: Which minimally invasive procedure—a laparoscopic Burch or a TVT—is preferable for the patient with genuine SUI without ISD or any additional pelvic-support defects aside from urethral hypermobility? Only a few studies comparing the clinical outcomes of the TVT and laparoscopic Burch procedures have reported preliminary findings. One retrospective study of 74 women followed for at least 1 year demonstrated an overall objective cure rate of 88% for the laparoscopic Burch versus 92% for the TVT procedure.38 There were no significant differences in time to resumption of normal voiding or in irritative symptoms such as frequency, urgency, and urge incontinence. The TVT group, however, was noted to have a shorter operative time and hospital stay.
Another study reported a higher cure or improvement rate (94%) among patients undergoing the laparoscopic Burch than the TVT (82%). Postoperative voiding difficulty was also significantly less in the laparoscopic group (0% versus 18%).39
Although these early studies suggest that laparoscopic Burch and TVT are comparable, we anxiously await the results of welldesigned, prospective, randomized clinical trials currently under way. One recent report (level I evidence) has demonstrated that the open Burch and the TVT procedure have equivalent results.40
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Patients at risk for intrinsic sphincter deficiency
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How? The laparoscopic Burch technique
Preparing the patient. As always, obtain informed consent prior to the procedure. Beyond the usual surgical risks of blood loss, infection, surgical injury, failure rate, and thromboembolic complications, patients also face potential postoperative voiding dysfunction, as mentioned earlier, as well as de novo detrusor instability. Also inform your patients of the possible conversion to laparotomy.
Administer a single intravenous dose of an appropriate broad-spectrum antibiotic no more than 1 hour prior to surgery. For patients undergoing additional laparoscopic reconstructive surgery, we recommend a modified bowel preparation to improve visualization by decompressing the sigmoid colon.
Administer general anesthesia and place the patient in a dorsal lithotomy position with both arms tucked. Support the patient’s lower extremities with Allen Universal Stirrups (Allen Medical Systems, Mayfield, Ohio) and avoid excessive flexion of the knees or hips. Insert a 16F 3-way Foley catheter into the bladder—this allows intermittent bladder filling during the procedure—and inflate the bulb to 10 cc to facilitate identification of the UVJ throughout surgery.
Entering the space of Retzius. We routinely perform operative laparoscopy after Veress needle insertion and insufflation through an umbilical incision. (Use open laparoscopy for patients with prior abdominal surgery and paraumbilical scarring.)
Under direct visualization, place 2 additional accessory 10-mm trocars in the lower quadrants, just lateral to the inferior epigastric arteries. Brief insufflation to greater than 20 mm Hg intra-abdominal pressure facilitates safe entry for these secondary trocars. Although you may opt for smaller trocars, the 10-mm size allows unhindered passage of suture, thus providing more options for maximizing favorable ergonomics with future suture placement.
Although a preperitoneal, or extraperitoneal, approach has been described, we favor a transperitoneal entrance into the space of Retzius. The extraperitoneal approach allows the use of regional anesthesia, avoids intraabdominal adhesions, and eliminates the associated risks of peritoneal entry.31 The disadvantages, however, are significant, including failure to enter the retropubic space secondary to abdominal wall scarring, the inability to perform concomitant vault suspension, and the cost of commercially available dissecting balloons. With experience, a transperitoneal approach will not prolong operative time.
With experience, a transperitoneal approach into the space of Retzius will not prolong operative time.
Approaching the bladder. Distend the bladder in a retrograde fashion with 300 mL to 400 mL of normal saline. This allows identification of the superior margin of the bladder dome and provides mass traction posteriorly. Use the urachus to identify the midline; then, grasp the anterior abdominal wall peritoneum and apply downward traction ( FIGURE 1). Next, create a transverse incision 3 cm to 4 cm above the bladder reflection, using monopolar endoscopic scissors on a 70-watt pure-cut setting ( FIGURE 2). The incision should be within the obliterated umbilical ligaments, but can be extended slightly beyond for patients undergoing a combined laparoscopic Burch-paravaginal repair.41 Using a combination of blunt and electrocautery dissection, you then can easily dissect the loose areolar tissue of the prevesicle space down to the level of the pubic symphysis and ramus ( FIGURE 3).
