- Email: [email protected]
Extraperitoneal Approach to Laparoscopic Burch Colposuspension
Extraperitoneal Laparoscopic Burch Colposuspension Lee et al
Extraperitoneal Approach to Laparoscopic Burch Colposuspension Chyi-Long Lee, M.D., Chih-Feng Yen, M.D., Chin-Jung Wang, M.D., Smita Jain, MBBS, DFFP, and Yung-Kuei Soong, M.D. Abstract Study Objective. To evaluate 3-year outcomes of extraperitoneal laparoscopic colposuspension in treating genuine stress incontinence. Design. Retrospective review (Canadian Task Force classification II-2). Setting. University-based, tertiary-level center for endoscopic surgery. Patients. One hundred sixty women with genuine stress incontinence with bladder neck hypermobility. Intervention. Extraperitoneal space was created with CO2 through a 10-mm midline port 2 cm above the pubic hairline. A pair of sutures was inserted at the level of midurethral and urethrovesical junction, fixing them to Cooper’s ligament on each side with proper tension. Measurements and Main Results. Of 160 women, 10 were lost to follow-up. On follow-up questionnaire sent to 150 patients, 148 (98.7%) were pleased with the results of surgery. Stress incontinence was cured in 136 women (90.7%) after a minimum of 3 years’ follow-up. Conclusion. Cure rates for extraperitoneal colposuspension were similar to those reported for traditional laparoscopic or laparotomy Burch procedures; however, this is a more direct method to expose the space of Retzius, thus eliminating the need to open and close peritoneum. (J Am Assoc Gynecol Laparosc 8(3):374–377, 2001)
expose the space of Retzius, thus eliminating opening and closing peritoneum. For 3 years we followed 160 patients treated by this method. To the best of our knowledge, this is the largest reported series of extraperitoneal Burch colposuspension.
Incontinence is not a life-threatening condition, but materially influences quality of life. Burch colposuspension is considered the gold standard in treating genuine stress incontinence, with good long-term results.1,2 Benefits of laparoscopic surgery over traditional abdominal surgery are well known.3 Laparoscopic Burch colposuspension was first attempted in early 1990s. It can be approached either intraperitoneally or extraperitoneally, with the former performed more commonly. Few articles report experience with extraperitoneoscopic colposusupension, and whether the transperitoneal or the extraperitoneal approach should be preferred is debated. The extraperitoneal procedure is in accordance with the technique originally described by Burch. It is a more direct method to
Materials and Methods Between March 1995 and March 1998, 160 consecutive women (mean age 48.6 yrs, range 34-68 yrs; mean parity 3.8, range 0–7; mean body weight 52.4 kg, range 42–82 kg) with urodynamically proved moderate to severe urinary stress incontinence with bladder neck hypermobility underwent extraperitoneoscopic colposuspension. Preoperative evaluation consisted
From the Department of Obstetrics and Gynecology, Division of Gynecologic Endoscopy, Chang Gung Memorial Hospital, Chang Gung University, Linkou Medical Center, Taipei, Taiwan (all authors). Address reprint requests to Chyi-Long Lee, M.D., Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, 5, Fu-Hsin Street, Kwei-Shan, Tao-Yuan, Taiwan; fax 886 3 3288252. Accepted for publication March 12, 2001. Reprinted from the JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS, August 2001, Vol. 8 No. 3 © 2001 The American Association of Gynecologic Laparoscopists. All rights reserved. This work may not be reproduced in any form or by any means without written permission from the AAGL. This includes but is not limited to, the posting of electronic files on the Internet, transferring electronic files to other persons, distributing printed output, and photocopying. To order multiple reprints of an individual article or request authorization to make photocopies, please contact the AAGL.
374
August 2001, Vol. 8, No. 3
The Journal of the American Association of Gynecologic Laparoscopists
with 1-0 polypropylene sutures was introduced into the Retzius space. Two sutures were used to raise and pull the anterior vaginal wall forward to Cooper’s ligament. The sutures were inserted at the level of midurethral and urethrovesical junction and at least 2 cm from the urethra. They were tied extracorporeally. The procedure was repeated on the contralateral side. Methylene blue was injected into bladder through the Foley catheter, or through a cystoscope in the case of suspected bladder injury. The retropubic space was irrigated with copious lactated Ringer’s solution. All debris and blood were removed. No suprapubic catheter was used. The 10-mm incisions were closed with 2 polyglycolic acid with mattress sutures and the other puncture site was approximated with sterile adhesive tape. A Foley catheter was in place to drain the bladder and removed 24 to 48 hours later after residual urine was less than 50 ml. Average operating time was 28 ± 14 minutes (range 20–90 min), excluding time for concomitant procedures. Estimated blood loss from colposuspension was minimal (average <50 ml, range 20–200 ml). Three women (1.9%) had intraoperative bladder injury, which was repaired laparoscopically with 3-0 polyglactin sutures. They had an uneventful recovery after continuous urinary bladder drainage for 5 days. No surgical emphysema occurred in any patient. No procedure had to be converted to laparotomy, although three were converted to transperitoneal approach. Other intraoperative complications were lacerations of pubocervical fascia in two women that occurred during extracorporeal knot tying. They may have been caused by too tight suture or atrophic change of pubocervical fascia; they were easily repaired. Women undergoing only laparoscopic Burch procedure had minimal postoperative discomfort that was generally managed with oral analgesics. Postoperative fever in two women subsided with 48 hours of antibiotic treatment. Fifteen patients (10%) had immediate postoperative voiding difficulties that were cured with continuous urinary bladder drainage for 7 days. In 23 patients (15.3%) detrusor instability improved with administration of oxybutynin. In general, intraoperative, immediate, and long-term postoperative complications were few and self-limiting. Mean hospital stay was 3.5 ± 2.4 days (range 2–8 days). The average hospital stay for patients who
of complete history with urinary incontinence questionnaires, physical examination with emphasis on neurologic history and current drug therapy, urinalysis, urine culture, stress test, Q-tip test, and urodynamic study (cystometry, urethral closure pressure, voiding pressure). All patients had demonstrable urinary leakage on the pad test. Exclusion criteria were evidence of abnormalities on preoperative evaluations, history of unsuccessful antiincontinence surgery, detrusor instability, and stress incontinence due to low urethral closure pressure (<20 cm H2O). Fifty-four women (33.8%) had undergone a previous major pelvic operation, but none had had previous antiincontinence surgery. Twenty-two patients underwent only extraperitoneal laparoscopic colposuspension and 138 (86.2%) had concomitant procedures: vaginal total hysterectomy (38), Gullian uterine suspension with or without McCall culdoplasty (10), laparoscopic-assisted vaginal hysterectomy (LAVH, 88), and laparoscopic myomectomy (2). Operative Technique Our standard technique for extraperitoneal Burch colposuspension is described elsewhere.4 The procedure was performed under general endotracheal anesthesia with videolaparoscopy. A 20F Foley catheter with 30-ml balloon tip was inserted into the bladder. A 10-mm puncture site was made at midline 2 cm above the pubic hairline and a cannula was inserted into the space of Retzius. Expansion in the space of Retzius was maintained by insufflating CO2 at 20 mm Hg pressure. Two 5-mm puncture sites were made in the lower abdomen at the paramedian line at the level of the pubic hairline under extraperitoneoscopic guidance. If an intraperitoneal lesion was to be treated, a second 10-mm laparoscope was inserted through the umbilicus. All visible intraperitoneal abnormalities, such as adhesions and endometriosis, were excised laparoscopically after Burch colposuspension. If hysterectomy was indicated, LAVH was performed before Burch colposuspension.5 Vaginal hysterectomy and obliteration of cul-de-sac (McCall culdoplasty) was performed before the Burch procedure. The anterior vaginal wall was lifted with two fingers in the vagina to facilitate proper placement of sutures. After the retropubic space was created, the bladder was mobilized and paravaginal fatty tissue removed. Through the 5-mm port, a needle holder
375
Extraperitoneal Laparoscopic Burch Colposuspension Lee et al
underwent laparoscopic colposuspension alone was 48 hours (range 25–96 hrs). Forty-two patients returned to daily activities within 1 week and 118 in 2 weeks. Postoperatively, patients were seen 1 week, 6 weeks, and 6 months postoperatively, and every 6 months thereafter (mean follow-up 46 mo, range 36–60 mo). They were interviewed regarding remaining stress incontinence, urge symptoms, obstructive bladder problems, complications, and other adverse effects. They were considered cured (no urinary leakage), improved (need for pads), or failed (need for pads) based on subjective reports and results of physical examination. At the last evaluation 10 patients were lost to follow-up. Of the remaining 150, 136 (90.7%) were cured, 144 (96%) were satisfied with the outcome, and 4 (2.7%) were considered failures.
and none requested additional surgery. The overall complication rate was 10.4%, which is favorable compared with abdominal or laparoscopic retropubic colposuspension. Laparoscopic Burch repair appears to cause some de novo detrusor instability, with frequency after laparotomy Burch suspension ranging from 2% to 20%.12,13 Possible causes include disruption of anatomic innervation of the bladder and urinary obstruction by urethral kinking due to overcorrection of colposuspension. All 23 patients (15.3%) who developed the disorder responded dramatically to administration of oxybutynin and bladder retraining. There are three major differences between the extraperitoneal approach and traditional laparoscopic colposuspension. First, when the laparoscopic operation is performed extraperitoneally, not transperitoneally, it may eliminate opening and closing peritoneum. Second, dissection is mainly achieved bluntly with insufflating CO2 pressure of 20 mm Hg assisted with scissors and grasping forceps. Therefore, capillary lacerations when dissecting the space of Retzius are compressed. Third, extraperitoneal approach can avoid interference by intestine and reduces the chance of injury to intraperitoneal organs. Moreover, it may reduce adhesion formation and discomfort resulting from pneumoperitoneum. This procedure can be performed after LAVH and vaginal hysterectomy, vaginal reparative surgery, or repair of other pelvic support defects. The vaginal defects must be corrected to help ensure long-lasting success of colposuspension.8,14 Although this technique has number of advantages, it is not without limitations. In our series, three procedures were converted to transperitoneal approach. In women who have had previous low abdominal surgery with Pfannenstiel incision, the space of Retzius could be difficult to develop due to destruction of anatomic structures and dense scar formation, and the procedure may have to be shifted to transperitoneal route.
Discussion Traditional open colposuspension, first described by Burch in 1961, has become the procedure of choice for treating genuine stress incontinence because its long-term success rate is superior to those of anterior colporrhaphy and transvaginal needle suspension.6,7 Laparoscopic Burch colposuspension eliminates abdominal incision and, in our experience, produces adequate visualization of the space of Retizus. Tissue dissection is confined to the space of Retizus, thus limiting the likelihood of bleeding and vascular and urinary tract injury. Moreover, because of direct entry into the space, the technique produces adequate visualization and access to pubocervical fascia and Cooper’s ligament. Mean operating time was 28 minutes for isolated extraperitoneal Burch laparoscopic colposuspension, and it decreased after the first 60 cases. Blood loss was minimal possibly because of magnified view and clear recognition of anatomic structures, easy dissection within planes, and precise coagulation of blood vessels. As in other reports,8–10 hospital stay was shorter for women undergoing isolated extraperitoneal colposuspension. It is difficult to define surgical success with the antiincontinence procedure. Patients were considered cured, improved, or failed based on subjective reports and results of physical examination. Cure rates after laparoscopic colposuspension vary between 68.6% and 100%.11 Our cure rate in this series was 90.7%, but 96% of women were satisfied with the outcome
Conclusion We believe extraperitoneoscopic Burch laparoscopic colposuspension is a practicable surgical procedure for managing stress incontinence. Three key points for performing the procedure are carefully
376
August 2001, Vol. 8, No. 3
The Journal of the American Association of Gynecologic Laparoscopists
selected patients, proper suture placement to avoid suspending defective pubocervical fascia, and excellent endoscopic skill.
7. Bhatia NN, Bergman A: Modified Burch versus Pereyra retropubic urethropexy for stress incontinence. Obstet Gynecol 66(2)255–261, 1985
References
8. Wiskind AK, Stanton SL: The Burch colposuspension for genuine stress incontinence. Te Linde’s Operative Gynecology Update 1:1–13, 1993
1. Bergman A, Ballard CA, Koonings PP: Comparison of three different surgical procedures for genuine stress incontinence: Prospective randomized study. Obstet Gynecol 160:1102–1106, 1989
9. Vancaillie TG, Schuessler WW: Laparoscopic bladder neck suspension. J Laparoendosc Surg 1:169–173, 1991
2. Bergman A, Giovanni E: Three surgical procedures for genuine stress incontinence: Five year follow up of a prospective randomized study. Am J Obstet Gynecol 173:66–71, 1995
10. Alabala DM, Schuessler WW, Vancaillie TG: Laparoscopic bladder neck suspension. J Endocrinol Urol 6(2):137–141, 1992
3. Lee CL, Lai YM, Soong YK: Laparoscopic ovariopexy Hum Reprod 10:372–374, 1995
11. Lose G: Laparoscopic Burch suspension. Acta Obstet Gynecol Suppl 168(77):29–33, 1998
4. Lee CL, Yen CF, Wang CJ, et al: Extraperitoneoscopic colposuspension using CO2 distension method. Int Surg 83:262–264, 1998
12. Cardoso L, Stanton LS, Williams JE: Detrusor instability following surgery for genuine stress incontinence. Br J Urol 51:204–207, 1979
5. Lee CL, Huang KG, Wang CL, et al: Radical laparoscopic surgery for carcinoma of the cervical stump. J Am Assoc Gynecol Laparosc 7(2):241–244, 2000
13. Sand PK, Hill RC, Osteogard DR: The effect of retropubic urethropexy on detrusor instability. Obstet Gynecol 71:818–822, 1988
6. Stanton LS, Cardozo LD: A comparison of vaginal and suprapubic surgery in the correction of incontinence due to urethral sphincter incontinence. Br J Urol 51:497–499, 1979
14. Wiskind AK, Crighton MD, Stanton SL: The incidence of genital prolapse after the Burch colposuspension . Am J Obstet Gynecol 167:399–405, 1992
377
Extraperitoneal Approach to Laparoscopic Burch Colposuspension Chyi-Long Lee, M.D., Chih-Feng Yen, M.D., Chin-Jung Wang, M.D., Smita Jain, MBBS, DFFP, and Yung-Kuei Soong, M.D. Abstract Study Objective. To evaluate 3-year outcomes of extraperitoneal laparoscopic colposuspension in treating genuine stress incontinence. Design. Retrospective review (Canadian Task Force classification II-2). Setting. University-based, tertiary-level center for endoscopic surgery. Patients. One hundred sixty women with genuine stress incontinence with bladder neck hypermobility. Intervention. Extraperitoneal space was created with CO2 through a 10-mm midline port 2 cm above the pubic hairline. A pair of sutures was inserted at the level of midurethral and urethrovesical junction, fixing them to Cooper’s ligament on each side with proper tension. Measurements and Main Results. Of 160 women, 10 were lost to follow-up. On follow-up questionnaire sent to 150 patients, 148 (98.7%) were pleased with the results of surgery. Stress incontinence was cured in 136 women (90.7%) after a minimum of 3 years’ follow-up. Conclusion. Cure rates for extraperitoneal colposuspension were similar to those reported for traditional laparoscopic or laparotomy Burch procedures; however, this is a more direct method to expose the space of Retzius, thus eliminating the need to open and close peritoneum. (J Am Assoc Gynecol Laparosc 8(3):374–377, 2001)
expose the space of Retzius, thus eliminating opening and closing peritoneum. For 3 years we followed 160 patients treated by this method. To the best of our knowledge, this is the largest reported series of extraperitoneal Burch colposuspension.
Incontinence is not a life-threatening condition, but materially influences quality of life. Burch colposuspension is considered the gold standard in treating genuine stress incontinence, with good long-term results.1,2 Benefits of laparoscopic surgery over traditional abdominal surgery are well known.3 Laparoscopic Burch colposuspension was first attempted in early 1990s. It can be approached either intraperitoneally or extraperitoneally, with the former performed more commonly. Few articles report experience with extraperitoneoscopic colposusupension, and whether the transperitoneal or the extraperitoneal approach should be preferred is debated. The extraperitoneal procedure is in accordance with the technique originally described by Burch. It is a more direct method to
Materials and Methods Between March 1995 and March 1998, 160 consecutive women (mean age 48.6 yrs, range 34-68 yrs; mean parity 3.8, range 0–7; mean body weight 52.4 kg, range 42–82 kg) with urodynamically proved moderate to severe urinary stress incontinence with bladder neck hypermobility underwent extraperitoneoscopic colposuspension. Preoperative evaluation consisted
From the Department of Obstetrics and Gynecology, Division of Gynecologic Endoscopy, Chang Gung Memorial Hospital, Chang Gung University, Linkou Medical Center, Taipei, Taiwan (all authors). Address reprint requests to Chyi-Long Lee, M.D., Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, 5, Fu-Hsin Street, Kwei-Shan, Tao-Yuan, Taiwan; fax 886 3 3288252. Accepted for publication March 12, 2001. Reprinted from the JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS, August 2001, Vol. 8 No. 3 © 2001 The American Association of Gynecologic Laparoscopists. All rights reserved. This work may not be reproduced in any form or by any means without written permission from the AAGL. This includes but is not limited to, the posting of electronic files on the Internet, transferring electronic files to other persons, distributing printed output, and photocopying. To order multiple reprints of an individual article or request authorization to make photocopies, please contact the AAGL.
374
August 2001, Vol. 8, No. 3
The Journal of the American Association of Gynecologic Laparoscopists
with 1-0 polypropylene sutures was introduced into the Retzius space. Two sutures were used to raise and pull the anterior vaginal wall forward to Cooper’s ligament. The sutures were inserted at the level of midurethral and urethrovesical junction and at least 2 cm from the urethra. They were tied extracorporeally. The procedure was repeated on the contralateral side. Methylene blue was injected into bladder through the Foley catheter, or through a cystoscope in the case of suspected bladder injury. The retropubic space was irrigated with copious lactated Ringer’s solution. All debris and blood were removed. No suprapubic catheter was used. The 10-mm incisions were closed with 2 polyglycolic acid with mattress sutures and the other puncture site was approximated with sterile adhesive tape. A Foley catheter was in place to drain the bladder and removed 24 to 48 hours later after residual urine was less than 50 ml. Average operating time was 28 ± 14 minutes (range 20–90 min), excluding time for concomitant procedures. Estimated blood loss from colposuspension was minimal (average <50 ml, range 20–200 ml). Three women (1.9%) had intraoperative bladder injury, which was repaired laparoscopically with 3-0 polyglactin sutures. They had an uneventful recovery after continuous urinary bladder drainage for 5 days. No surgical emphysema occurred in any patient. No procedure had to be converted to laparotomy, although three were converted to transperitoneal approach. Other intraoperative complications were lacerations of pubocervical fascia in two women that occurred during extracorporeal knot tying. They may have been caused by too tight suture or atrophic change of pubocervical fascia; they were easily repaired. Women undergoing only laparoscopic Burch procedure had minimal postoperative discomfort that was generally managed with oral analgesics. Postoperative fever in two women subsided with 48 hours of antibiotic treatment. Fifteen patients (10%) had immediate postoperative voiding difficulties that were cured with continuous urinary bladder drainage for 7 days. In 23 patients (15.3%) detrusor instability improved with administration of oxybutynin. In general, intraoperative, immediate, and long-term postoperative complications were few and self-limiting. Mean hospital stay was 3.5 ± 2.4 days (range 2–8 days). The average hospital stay for patients who
of complete history with urinary incontinence questionnaires, physical examination with emphasis on neurologic history and current drug therapy, urinalysis, urine culture, stress test, Q-tip test, and urodynamic study (cystometry, urethral closure pressure, voiding pressure). All patients had demonstrable urinary leakage on the pad test. Exclusion criteria were evidence of abnormalities on preoperative evaluations, history of unsuccessful antiincontinence surgery, detrusor instability, and stress incontinence due to low urethral closure pressure (<20 cm H2O). Fifty-four women (33.8%) had undergone a previous major pelvic operation, but none had had previous antiincontinence surgery. Twenty-two patients underwent only extraperitoneal laparoscopic colposuspension and 138 (86.2%) had concomitant procedures: vaginal total hysterectomy (38), Gullian uterine suspension with or without McCall culdoplasty (10), laparoscopic-assisted vaginal hysterectomy (LAVH, 88), and laparoscopic myomectomy (2). Operative Technique Our standard technique for extraperitoneal Burch colposuspension is described elsewhere.4 The procedure was performed under general endotracheal anesthesia with videolaparoscopy. A 20F Foley catheter with 30-ml balloon tip was inserted into the bladder. A 10-mm puncture site was made at midline 2 cm above the pubic hairline and a cannula was inserted into the space of Retzius. Expansion in the space of Retzius was maintained by insufflating CO2 at 20 mm Hg pressure. Two 5-mm puncture sites were made in the lower abdomen at the paramedian line at the level of the pubic hairline under extraperitoneoscopic guidance. If an intraperitoneal lesion was to be treated, a second 10-mm laparoscope was inserted through the umbilicus. All visible intraperitoneal abnormalities, such as adhesions and endometriosis, were excised laparoscopically after Burch colposuspension. If hysterectomy was indicated, LAVH was performed before Burch colposuspension.5 Vaginal hysterectomy and obliteration of cul-de-sac (McCall culdoplasty) was performed before the Burch procedure. The anterior vaginal wall was lifted with two fingers in the vagina to facilitate proper placement of sutures. After the retropubic space was created, the bladder was mobilized and paravaginal fatty tissue removed. Through the 5-mm port, a needle holder
375
Extraperitoneal Laparoscopic Burch Colposuspension Lee et al
underwent laparoscopic colposuspension alone was 48 hours (range 25–96 hrs). Forty-two patients returned to daily activities within 1 week and 118 in 2 weeks. Postoperatively, patients were seen 1 week, 6 weeks, and 6 months postoperatively, and every 6 months thereafter (mean follow-up 46 mo, range 36–60 mo). They were interviewed regarding remaining stress incontinence, urge symptoms, obstructive bladder problems, complications, and other adverse effects. They were considered cured (no urinary leakage), improved (need for pads), or failed (need for pads) based on subjective reports and results of physical examination. At the last evaluation 10 patients were lost to follow-up. Of the remaining 150, 136 (90.7%) were cured, 144 (96%) were satisfied with the outcome, and 4 (2.7%) were considered failures.
and none requested additional surgery. The overall complication rate was 10.4%, which is favorable compared with abdominal or laparoscopic retropubic colposuspension. Laparoscopic Burch repair appears to cause some de novo detrusor instability, with frequency after laparotomy Burch suspension ranging from 2% to 20%.12,13 Possible causes include disruption of anatomic innervation of the bladder and urinary obstruction by urethral kinking due to overcorrection of colposuspension. All 23 patients (15.3%) who developed the disorder responded dramatically to administration of oxybutynin and bladder retraining. There are three major differences between the extraperitoneal approach and traditional laparoscopic colposuspension. First, when the laparoscopic operation is performed extraperitoneally, not transperitoneally, it may eliminate opening and closing peritoneum. Second, dissection is mainly achieved bluntly with insufflating CO2 pressure of 20 mm Hg assisted with scissors and grasping forceps. Therefore, capillary lacerations when dissecting the space of Retzius are compressed. Third, extraperitoneal approach can avoid interference by intestine and reduces the chance of injury to intraperitoneal organs. Moreover, it may reduce adhesion formation and discomfort resulting from pneumoperitoneum. This procedure can be performed after LAVH and vaginal hysterectomy, vaginal reparative surgery, or repair of other pelvic support defects. The vaginal defects must be corrected to help ensure long-lasting success of colposuspension.8,14 Although this technique has number of advantages, it is not without limitations. In our series, three procedures were converted to transperitoneal approach. In women who have had previous low abdominal surgery with Pfannenstiel incision, the space of Retzius could be difficult to develop due to destruction of anatomic structures and dense scar formation, and the procedure may have to be shifted to transperitoneal route.
Discussion Traditional open colposuspension, first described by Burch in 1961, has become the procedure of choice for treating genuine stress incontinence because its long-term success rate is superior to those of anterior colporrhaphy and transvaginal needle suspension.6,7 Laparoscopic Burch colposuspension eliminates abdominal incision and, in our experience, produces adequate visualization of the space of Retizus. Tissue dissection is confined to the space of Retizus, thus limiting the likelihood of bleeding and vascular and urinary tract injury. Moreover, because of direct entry into the space, the technique produces adequate visualization and access to pubocervical fascia and Cooper’s ligament. Mean operating time was 28 minutes for isolated extraperitoneal Burch laparoscopic colposuspension, and it decreased after the first 60 cases. Blood loss was minimal possibly because of magnified view and clear recognition of anatomic structures, easy dissection within planes, and precise coagulation of blood vessels. As in other reports,8–10 hospital stay was shorter for women undergoing isolated extraperitoneal colposuspension. It is difficult to define surgical success with the antiincontinence procedure. Patients were considered cured, improved, or failed based on subjective reports and results of physical examination. Cure rates after laparoscopic colposuspension vary between 68.6% and 100%.11 Our cure rate in this series was 90.7%, but 96% of women were satisfied with the outcome
Conclusion We believe extraperitoneoscopic Burch laparoscopic colposuspension is a practicable surgical procedure for managing stress incontinence. Three key points for performing the procedure are carefully
376
August 2001, Vol. 8, No. 3
The Journal of the American Association of Gynecologic Laparoscopists
selected patients, proper suture placement to avoid suspending defective pubocervical fascia, and excellent endoscopic skill.
7. Bhatia NN, Bergman A: Modified Burch versus Pereyra retropubic urethropexy for stress incontinence. Obstet Gynecol 66(2)255–261, 1985
References
8. Wiskind AK, Stanton SL: The Burch colposuspension for genuine stress incontinence. Te Linde’s Operative Gynecology Update 1:1–13, 1993
1. Bergman A, Ballard CA, Koonings PP: Comparison of three different surgical procedures for genuine stress incontinence: Prospective randomized study. Obstet Gynecol 160:1102–1106, 1989
9. Vancaillie TG, Schuessler WW: Laparoscopic bladder neck suspension. J Laparoendosc Surg 1:169–173, 1991
2. Bergman A, Giovanni E: Three surgical procedures for genuine stress incontinence: Five year follow up of a prospective randomized study. Am J Obstet Gynecol 173:66–71, 1995
10. Alabala DM, Schuessler WW, Vancaillie TG: Laparoscopic bladder neck suspension. J Endocrinol Urol 6(2):137–141, 1992
3. Lee CL, Lai YM, Soong YK: Laparoscopic ovariopexy Hum Reprod 10:372–374, 1995
11. Lose G: Laparoscopic Burch suspension. Acta Obstet Gynecol Suppl 168(77):29–33, 1998
4. Lee CL, Yen CF, Wang CJ, et al: Extraperitoneoscopic colposuspension using CO2 distension method. Int Surg 83:262–264, 1998
12. Cardoso L, Stanton LS, Williams JE: Detrusor instability following surgery for genuine stress incontinence. Br J Urol 51:204–207, 1979
5. Lee CL, Huang KG, Wang CL, et al: Radical laparoscopic surgery for carcinoma of the cervical stump. J Am Assoc Gynecol Laparosc 7(2):241–244, 2000
13. Sand PK, Hill RC, Osteogard DR: The effect of retropubic urethropexy on detrusor instability. Obstet Gynecol 71:818–822, 1988
6. Stanton LS, Cardozo LD: A comparison of vaginal and suprapubic surgery in the correction of incontinence due to urethral sphincter incontinence. Br J Urol 51:497–499, 1979
14. Wiskind AK, Crighton MD, Stanton SL: The incidence of genital prolapse after the Burch colposuspension . Am J Obstet Gynecol 167:399–405, 1992
377