Burch Colposuspension – Dr Neha

DEFINITIONS

Urinary incontinence is defined as involuntary leakage of urine. In addition to the urethra, urine can also leak from an extraurethral source, such as fistulas or congenital malformations of the lower urinary tract. International Continence Society guidelines, urinary incontinence is a symptom, sign, as well as a condition. stress urinary incontinence (SUI), a patient may complain of involuntary urine leakage on exertion or with sneezing or coughing. Concurrently with these events, involuntary leakage from the urethra synchronous with these events

may be a documented sign noted by a provider. And as a condition, incontinence is objectively demonstrated during urodynamic evaluation if involuntary leakage of urine is seen with increased abdominal pressure and absence of detrusor contraction. Under these circumstances, when the symptom or sign of stress urinary incontinence is confirmed with objective testing, the term urodynamic stress incontinence (USI), formerly known as genuine stress incontinence is used.

Risk Factors for Urinary Incontinence

  • Age
  • Pregnancy
  • Childbirth
  • Menopause
  • Hysterectomy
  • Obesity
  • Urinary symptoms
  • Functional impairment
  • Cognitive impairment
  • Chronically increased abdominal pressure
  • Chronic cough
  • Constipation
  • Occupational risk
  • Smoking

Principles of surgery

In Abdominal-approach anti-incontinence procedures attempt to correct stress urinary incontinence (SUI) by stabilizing the anterior vaginal wall and urethrovesical junction in a retropubic location.

Specifically, the Burch procedure, also known as retropubic urethropexy, uses the strength of the iliopectineal ligament (Cooper ligament) to stabilize the anterior vaginal wall and anchor it to

the musculoskeletal framework of the pelvis.

The Burch colposuspension usually is performed through a Pfannenstiel or Cherney incision.

Incision). More recently, however, some surgeons have introduced laparoscopic approaches that use suture or mesh to affix the paravaginal tissues to Cooper ligament. However, compared with open Burch colposuspension, laparoscopic approaches have proved less effective.

Preoperative

PATIENT EVALUATION

Prior to surgery, patients undergo complete urogynecologic evaluation. Urodynamic testing is recommended to differentiate stress and urge incontinence as well as to assess bladder capacity and voiding patterns.

Many women with SUI also may have associated pelvic organ prolapse. For this reason, other indicated pelvic reconstructive surgeries commonly accompany Burch colposuspension.

In women requiring hysterectomy, hysterectomy does not appear to improve or worsen success rates of Burch colposuspension. Hysterectomy in this setting may be performed either vaginally or abdominally without significant differences in perioperative complications.

CONSENT

For most women with SUI, Burch colposuspension offers a safe, effective long-term treatment for incontinence. Success rates vary based on how success is defined, but it is generally believed that this operation provides symptomatic cure in approximately 85 percent of patients. Surgical risks compare similarly with other surgeries for SUI. Intraoperative complications are rare and may include ureteral injury, bladder perforation, and hemorrhage.

Complications, however, are not uncommon postoperatively and may include urinary tract or wound infection, voiding dysfunction, de novo urinary urgency, and pelvic organ prolapse, primarily enterocele formation. Overcorrection of the urethrovesical angle has been suggested as a cause of these long-term urinary and prolapse.

Antibiotic Prophylaxis

Prior to Burch colposuspension, administration of antibiotics preoperatively is warranted.

Intraoperative

Surgical Steps

Anesthesia and Patient Positioning. The patient is placed supine with legs in Allen stirrups,in low lithotomy position. The abdomen and vagina are surgically prepared, and a Foley catheter is placed.

Abdominal Incision. A low Pfannenstiel or Cherney incision is performed Surgery in the space of Retzius is easier to accomplish if the transverse incision is placed low on the abdomen, approximately 1 cm.above the upper border of the pubic symphysis. If hysterectomy, culdoplasty, or other intraperitoneal procedure is planned,the peritoneum is entered and concurrent surgery completed prior to beginning colposuspension.

Entry into the Space of Retzius. On closure of the peritoneum, the avascular plane between the pubic bone and loose

areolar tissue, that is, the space of Retzius, must be exposed. To enter this space, the fingers of one hand gently dissect along the cephalad surface of the pubic bone. Alternatively, gentle sponge dissection can be used to open this space.The loose areolar tissue found behind the symphysis will separate easily from the bone. However, if the wrong plane is entered, bleeding can occur. Direct exposure of the back of the pubic bone ensures that the correct space has been entered.

The bladder and urethra gently pull downward and away from the pubic bone, and the space of Retzius opens.

In those with prior surgery, sharp dissection may be required. Dissection begins with the curved tips of the Metzenbaum scissors directly on the pubic bone and progresses dorsally until the space is exposed. Clips and sutures can be used to control bleeding vessels.

During space of Retzius dissection, the obturator canal should be identified early to avoid neurovascular injury to the obturator vessels and nerves. The iliopectineal ligament (Cooper ligament) is identified as the space is opened.

Exposing the Anterior Vaginal Wall. Following creation of this space, the index and middle fingers of the surgeon’s nondominant hand are place in the vagina. With one on each side, the finger pads straddle the urethra and push the vagina ventrally. This maneuver alone will clear much of the fat off the anterior vaginal wall.

If necessary, the surgeon can use a Kitner (peanut) sponge or gauze sponge stick on either side of the urethra to wipe the fatty connective tissue laterally. Upward pressure by the vaginal fingers and downward, lateral pressure during this blunt separation reveal the white glistening anterior vaginal wall. Importantly, to protect the delicate urethral musculature, thisdissection should remain lateral to the urethra. Dissection may bring laceration of vessels within the Santorini plexus of paravaginal veins and a risk for significant bleeding. This is controlled easily with upward pressure from the vaginal fingers. Identified vessels can be sealed with electrosurgicalcoagulation, ligation, or placement of vascular clips.

Identifying the Urethrovesical Junction. The urethrovesical junction is identified to aid correct suture placement. This site can be found by using the surgeon’s vaginal hand to position the Foley catheter balloon at the bladder neck. This should be done without pulling the Foley catheter. Tension may drag the bladder into the operative field and increase the risk of suture entry into the bladder.

Suture Placement. A double-armed 2-0 suture of permanent material is placed laterally on each side of the urethra. The surgeon’s vaginal finger is pressed upward to expose the appropriate area, and the needle point is directed toward that finger. A thimble may be used to avoid needlestick injury. A first suture is placed 2 cm lateral to the urethrovesical junction,and a second suture is placed 2 cm lateral to the proximal third of the urethra. With these stitches, a figure-of-eight suture is used to incorporate a wedge of tissue for support. Stitches should incorporate the vaginal muscularis but not the epithelium. Identical sutures are then placed on the opposite side of the urethra.

Both ends of each suture next are placed through the nearest point of the ipsilateral iliopectineal ligament. Slack is removed from each suture, and knots are tied above the ligament. With knot securing, a surgeon invariably creates suture bridges. These should stabilize but not elevate the anterior vaginal wall and urethrovesical junction.

Cystoscopy. Following suture ligation, 1 ampule of indigo carmine is given intravenously. and cystoscopy is performed. This allows identification and removal of any errant sutures that may traverse the bladder mucosa. Moreover, it enables the surgeon to inspect ureteral orifices and document flow as a means to exclude intraoperative ureteral injury.

Catheterization. At completion of colposuspension, the Foley catheter may remain and drain the bladder.

Incision Closure. The abdominal wall fascia is closed in a running fashion with 0-gauge delayed-absorbable suture. The skin is closed using a running subcuticular suture with 4-0 delayed-absorbable material or other suitable skin closure method.

POSTOPERATIVE

In general, recovery follows that associated with laparotomy and varies depending on concurrent surgeries and incision size.Voiding Trials is performed prior to hospital discharge.

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