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Laparoscopic bladder neck suspension
February ] 997, Vol. 4, No. 2
TheJournal of the American Association of Gynecologic Laparoscopists
Laparoscopic Bladder Neck Suspension Cristo Papasakelariou, M.D., and Beth Papasakelariou, R.N., B.S.N.
Abstract
Study Objective.
To determine the results of transperitoneal laparoscopic bladder neck suspension. Design. Prospective observational study. Setting. A university-affiliated hospital. Patients. Thirty-two consecutive women with the diagnosis of genuine stress incontinence and hypermobile proximal urethra and bladder neck. Interventions. Laparoscopic transperitoneal bladder neck suspension (Burch procedure) in combination with laparoscopic-assisted vaginal hysterectomy or other procedures. Measurements and Main Results. Success was defined as lack of leakage of urine, negative Q-Tip test, and good voiding control without need for drugs 6 weeks postoperatively. Over a minimum follow-up of 24 months, the procedure yielded satisfactory urethrovesical support in all patients and an overall success rate of 90.6%. Conclusions. Laparoscopic transperitoneal bladder neck suspension (Burch procedure) is an excellent endoscopic technique for the surgical treatment of genuine stress incontinence, although it awaits the test of time.
Urinary stress incontinence has a tremendous impact on the well-being of the affected individual. Its exact frequency is hard to estimate since a significant portion of patients suffer in silence. 1-4 They consider incontinence a normal event of aging or have poor expectations for the outcome of therapy. 5 However, stress incontinence is a significant health problem with an estimated annual cost of $10.3 billion. 1 In nursing homes, the cost is estimated at $2 billion annu-
ally, or about 10% of total nursing home care costs. 6 Despite advances in pharmacologic and behavioral therapies, surgery is effective, with potential longterm f'mancial advantages in the total cost of health care. Laparoscopic bladder neck suspension is one of the most recent surgical options in the management of genuine urinary stress incontinence (GUSI). 7' 8 The present study was undertaken to determine the effectiveness of the procedure in a prospective manner.
From the Department of Obstetrics, Gynecology and Reproductive Sciences, St. Joseph Hospital, Houston, Texas (both authors), and Department of Obstetrics and Gynecology, University of Texas Medical School, Houston, Galveston, Texas (Dr. Papasakelariou). Address reprint requests to Cristo Papasakelariou, M.D., 1315 Calhoun, Suite 1300, Houston, TX 77002; fax 713 756 5510. Presented at the 24th annual meeting of the American Association of Gynecologic Laparoscopists, Orlando, Florida, November 8-12, 1995.
185
Laparoscopic Bladder Neck Suspension Papasakelariouand Papasakelariou
Materials and Methods
From January 1992 to March 1993, 34 women (average age 50 yrs, range 34-68 yrs) with GUSI and a hypermobile proximal urethra and bladder neck were treated with transperitoneal modified Burch procedures. Two patients were lost to follow-up, leaving a study group of 32 subjects. Inclusion criteria were a diagnosis of GUSI and follow-up of at least 2 years. Women with a previous surgical procedure to correct stress incontinence, detrusor instability, and type III stress incontinence (nonmobile urethra and maximum urethral closure pressure <20 cm H20) were excluded. Preoperatively all patients underwent a detailed history and physical examination, Q-Tip test, stress test, voiding diary, urinalysis and culture, and postvoid residual and urodynamic testing in both supine and standing positions. Urodynamic studies helped identify four women, three with detrusor instability and one with type III stress incontinence, who were excluded from the study. The subjects were divided into two groups. Those in group A underwent laparoscopic-assisted vaginal hysterectomy (LAVH) plus laparoscopic bladder neck suspension (LBNS). Indications for hysterectomy were pelvic endometriosis (6 patients), menorrhagia (4), and symptomatic uterine myomas (2). Patients in group B underwent LBNS plus another procedure: salpingo-oophorectomy (6 patients), endometrial ablation (5), lysis of adhesions (4), enterocele repair (Halban procedure; 3), and liposuction (2). The women were followed at office visits every 6 months. A questionnaire was given by the office nurse followed by a pelvic examination, Q-Tip test, stress test, and postvoid residual test. A positive Q-Tip test was defined as a straining angle of over 30 degrees. Cure was defined as complete subjective relief of urinary incontinence and absence of loss of urine on physical examination. We did not include an "improved" group in this study. Patients who continued to complain of stress incontinence were defined as failures and were evaluated by videourodynamic testing. The data were stored on 4D First software on a Macintosh computer.
Surgical Technique Patients were administered general and endotracheal anesthesia and an orogastric tube was inserted. They were placed in dorsolithotomy position using
Mendtec stirrups (Mend Technologies Inc., Dallas, TX). The arms were positioned at the sides and properly padded. Prophylactic cefazolin sodium 2 g was administered intravenously just before the procedure. An 18F Foley catheter with 30-ml balloon was inserted into the bladder. In cases in which LAVH was performed, a Valtchev uterine mobilizer or the Pelosi uterine manipulator was placed into the uterus. A Veress needle was inserted through an intraumbilical incision, creating adequate pneumoperitoneum, followed by insertion of an 11-mm cannula and the laparoscope. The abdominal cavity was inspected and the patient placed in steep Trendelenburg position. Two accessory cannulas were placed in the lower abdomen on the left and right sides at the level of the anterior and superior iliac spine and lateral to the inferior epigastric vessels. The diameter of accessory ports ranged from 5 to 12 mm depending on the instrumentation required during the procedure. In rare instances a 12-mm cannula was placed in the suprapubic region. On completion of other scheduled procedures, we proceeded with bladder neck suspension. The bladder was filled with 200 to 300 ml sterile water to delineate its lateral and superior borders. The urachus was grasped by the assistant at a point that usually corresponded to a distance 3 to 4 cm from the symphysis pubis, and pulled in the direction of the sacral promontory. Using bipolar forceps that were introduced through the left lower port, superficial peritoneal vessels were coagulated and the peritoneum transected in a transverse manner using the carbon dioxide laser at 15 W of power. The laser was introduced through the umbilical port; it is an excellent cutting instrument, and decreases the number of instrument exchanges. With blunt and sharp dissection and the aid of the pneumoperitoneum, the space of Retzius was identified. Two essential aspects of this operation consisted of meticulous hemostasis and patience. Blood can stain the tissue and to a great extent alter anatomic landmarks. On identifying left and fight Cooper's ligaments, the bladder was drained and dissection was continued in the paraurethral and paravesical spaces. The fatty pads were mobilized, exposing the glistening paravaginal fascia. Dissection was limited around the paraurethral space to avoid potential denervation and devascularization. When the dissection was completed, the Pelosi illuminator (Apple Medical, Bolton, MA) was introduced through the vagina and manipulated
186
February 1997, Vol. 4, No. 2
TheJournal of the American Association of GynecoLogic Laparoscopists
by the surgeon or assistant. This provides excellent delineation of the anatomy (Figure 1), and is a good backstop for suture placement. Needles were introduced through a 5-mm cannula as described elsewhere. 9 We used 2-0 monofilament polypropylene suture for the first five cases, and switched to CV-0 THX-36 Gore-Tex suture (W. L. Gore, FlagStaff, AZ) due to its specific characteristics and biocompatibility. 1~Two sutures were placed on each side, the distal suture approximately 2 cm lateral to the midurethra and the proximal suture just lateral to the urethrovesical angle. When suture placement was complete (Figure 2) the surgical site was inspected for potential bleeding and the parietal peritoneum was closed with a purse-string suture (Figure 3). A
diagnostic cystoscopy was performed if there was any question with regard to correct suture placement. The Foley catheter was removed 30 to 36 hours postoperatively and voiding trials were begun. If the residual urine was over 150 ml the patient was discharged from the hospital with a Foley catheter in place for 1 week. In essence the surgical technique was a Burch colposuspension with the Tanagho modification.U The procedure consists of minimal dissection within 2 cm of the urethrovesical junction and urethra; placement of sutures through full thickness of shiny white paravaginal fascia; placement of two sutures on each side, one opposite to the urethrovesical junction and another at the level of the midurethra; removal of adipose tissue lateral to the site of suture placement to facilitate fibrosis; and attaching sutures to Cooper's ligament with tying facilitated by elevating the anterior vaginal wall. Results
None of the patients in this study required laparotomy to complete the procedure, and none suffered a cystotomy. There was one instance of inadvertent placement of suture through the bladder, which was recognized intraoperatively by diagnostic cystoscopy, and the suture was removed. We have not encountered a similar event since we incorporated transillumination into the surgical technique. The operating time for group A was 195 minutes (range 145-260 min) and for group B 204 minutes (range 140-330 min). Blood loss for group A was 290 ml (range 50-800 ml) and for group B was 153 ml (range 50-700 ml). Four women required bladder drainage for only 1 week and none required self-catheterization. Five developed urinary tract infections that were treated successfully with oral antibiotics. All subjects had a negative Q-Tip test. Three women, two from group A and one from group B, complained of leakage of urine. They were defined as failures, and underwent follow-up urodynamic studies (Table 1). All the failures occurred 12 months after colposuspension. The first patient was treated with oral oxybutynin chloride 5 mg 3 times/day on alternate days to minimize the anticholinergic side effects, mainly dry mouth; she is currently asymptomatic. The second underwent a sling procedure, but developed detrusor instability that was partially controlled with oxybutynin
FIGURE 1. Transvaginal illumination of the paraurethral and paravesical spaces.
FIGURE 2. Inspection of the surgical site.
187
Laparoscopic Bladder Neck Suspension Papasakelariouand Papasakelariou
TABLE 1. Profiles of Women with Negative Results
Patient Age (yrs), Gravidity, Parity
Time of Failure (mo)
34, 2, 2002 62, 3, 2012 54, 2, 1011
12 16 18
chloride and imipramine hydrochloride. The third was diagnosed with breast cancer approximately 12 months after her colposuspension and elected not to receive any further treatment for GUSI. Discussion Despite advances in behavioral and pharmacologic therapies, surgical correction is the cornerstone treatment of GUSI. In fact some evidence suggests that initial surgical correction may be even more cost effective than the other modalities.12 The literature is abundant with descriptions of surgical procedures for correcting the disorder, but Burch colposuspension seems to be associated with the best results. 13 It and its variations are preferred by many gynecologists and a growing number of urologists. Laparoscopic Burch colposuspension has the following advantages: the retropubic space can be easily dissected; the vessels can be easily visualized and coagulated; it is essentially the same procedure as that performed through a large abdominal incision; it allows for precise suture placement; and it is associated with a short and moderately painless recovery. In addition, the transperitoneal
Abnormality
Treatment
Detrusor instability Type III Type III
Oxybutynin chloride Sling procedure None
approach allows for performance of other surgical procedures. In these women the procedure was associated with few complications. We believe that meticulous dissection, hemostasis, patience, transillumunation, and liberal use of the cystoscope contributed to low morbidity. Our initial long operating time has been significantly improved, a reflection of the learning curve. The procedure was associated with stabilization of the bladder base evidenced by a negative postoperative Q-Tip test in all patients. The overall success rate of 90.6% after 2 years makes transperitoneal laparoscopic Burch procedure an excellent surgical alternative for correcting GUSI. References
1. Consensus Development Panel, National Institute of Health: Urinary incontinence in adults: Consensus conference. JAMA 261:2685-2690, 1989 2. Diokno AC, Brock BM, Brown MB, et al: Prevalence of urinary incontinence and other urological symptoms in the noninstitutionalized elderly. J Uro1136:1022-1025, 1986 3. Wolin LH: Stress incontinence in young, healthy nulliparous female subjects. J Urol 101:545-549, 1969 4. Thomas TM, Plymat KR, Blannin J, et al: Prevalence of urinary incontinence. Br Med J 281:1243-1245, 1980 5. Holst K, Wilson PD: The prevalence of female urinary incontinence and reasons for not seeking treatment. Aust N Z Meal J 101:756-758, 1988 6. Hu TW: The economic impact of urinary incontinence. Clin Geriatr Med 2:673-687, 1986 7. Vancaillie TG, Schuessler W: Laparoscopic bladder neck suspension. J Laparoendosc Surg 1:169,1991 8. Liu CY: Laparoscopic retropubic colposuspension (Burch procedure): A review of 58 cases. J Reprod Med 38(7):526-530, 1993
FIGURE 3. Peritoneal closure is complete.
188
February 1997, Vol. 4, No. 2
The Journal of the American Association of Gynecologic Laparoscopists
12. Ramsey SD, Wagner TH, Bavendam TG: Estimated costs of treating stress incontinence in elderly women according.to the AHCPR clinical practice guidelines. Am J Manage Care 2:147-154,1996
9. Reich H, Clarke C: A simple method for ligating with straight and curved needles in operative laparoscopy. Obstet Gynecol 79:143-147, 1992 10. Cavallaro A, Sciacca V, Cisternino S, et al: Experimental evaluation of tissue reactivity to vascular sutures: Dacron, polypropylene, PTFE. Vasc Surg 21 (2):82-86, 1987
13. Bergman A, Ballard C, Koonings P: Comparison of three different surgical procedures for genuine stress incontinence: Prospective randomized study. Am J Obstet Gynecol 160:1102-1 t06, 1989
11. Tanagho EA: Colpocystourethropexy: The way we do it. J Urol 116:751-753, 1976
189
TheJournal of the American Association of Gynecologic Laparoscopists
Laparoscopic Bladder Neck Suspension Cristo Papasakelariou, M.D., and Beth Papasakelariou, R.N., B.S.N.
Abstract
Study Objective.
To determine the results of transperitoneal laparoscopic bladder neck suspension. Design. Prospective observational study. Setting. A university-affiliated hospital. Patients. Thirty-two consecutive women with the diagnosis of genuine stress incontinence and hypermobile proximal urethra and bladder neck. Interventions. Laparoscopic transperitoneal bladder neck suspension (Burch procedure) in combination with laparoscopic-assisted vaginal hysterectomy or other procedures. Measurements and Main Results. Success was defined as lack of leakage of urine, negative Q-Tip test, and good voiding control without need for drugs 6 weeks postoperatively. Over a minimum follow-up of 24 months, the procedure yielded satisfactory urethrovesical support in all patients and an overall success rate of 90.6%. Conclusions. Laparoscopic transperitoneal bladder neck suspension (Burch procedure) is an excellent endoscopic technique for the surgical treatment of genuine stress incontinence, although it awaits the test of time.
Urinary stress incontinence has a tremendous impact on the well-being of the affected individual. Its exact frequency is hard to estimate since a significant portion of patients suffer in silence. 1-4 They consider incontinence a normal event of aging or have poor expectations for the outcome of therapy. 5 However, stress incontinence is a significant health problem with an estimated annual cost of $10.3 billion. 1 In nursing homes, the cost is estimated at $2 billion annu-
ally, or about 10% of total nursing home care costs. 6 Despite advances in pharmacologic and behavioral therapies, surgery is effective, with potential longterm f'mancial advantages in the total cost of health care. Laparoscopic bladder neck suspension is one of the most recent surgical options in the management of genuine urinary stress incontinence (GUSI). 7' 8 The present study was undertaken to determine the effectiveness of the procedure in a prospective manner.
From the Department of Obstetrics, Gynecology and Reproductive Sciences, St. Joseph Hospital, Houston, Texas (both authors), and Department of Obstetrics and Gynecology, University of Texas Medical School, Houston, Galveston, Texas (Dr. Papasakelariou). Address reprint requests to Cristo Papasakelariou, M.D., 1315 Calhoun, Suite 1300, Houston, TX 77002; fax 713 756 5510. Presented at the 24th annual meeting of the American Association of Gynecologic Laparoscopists, Orlando, Florida, November 8-12, 1995.
185
Laparoscopic Bladder Neck Suspension Papasakelariouand Papasakelariou
Materials and Methods
From January 1992 to March 1993, 34 women (average age 50 yrs, range 34-68 yrs) with GUSI and a hypermobile proximal urethra and bladder neck were treated with transperitoneal modified Burch procedures. Two patients were lost to follow-up, leaving a study group of 32 subjects. Inclusion criteria were a diagnosis of GUSI and follow-up of at least 2 years. Women with a previous surgical procedure to correct stress incontinence, detrusor instability, and type III stress incontinence (nonmobile urethra and maximum urethral closure pressure <20 cm H20) were excluded. Preoperatively all patients underwent a detailed history and physical examination, Q-Tip test, stress test, voiding diary, urinalysis and culture, and postvoid residual and urodynamic testing in both supine and standing positions. Urodynamic studies helped identify four women, three with detrusor instability and one with type III stress incontinence, who were excluded from the study. The subjects were divided into two groups. Those in group A underwent laparoscopic-assisted vaginal hysterectomy (LAVH) plus laparoscopic bladder neck suspension (LBNS). Indications for hysterectomy were pelvic endometriosis (6 patients), menorrhagia (4), and symptomatic uterine myomas (2). Patients in group B underwent LBNS plus another procedure: salpingo-oophorectomy (6 patients), endometrial ablation (5), lysis of adhesions (4), enterocele repair (Halban procedure; 3), and liposuction (2). The women were followed at office visits every 6 months. A questionnaire was given by the office nurse followed by a pelvic examination, Q-Tip test, stress test, and postvoid residual test. A positive Q-Tip test was defined as a straining angle of over 30 degrees. Cure was defined as complete subjective relief of urinary incontinence and absence of loss of urine on physical examination. We did not include an "improved" group in this study. Patients who continued to complain of stress incontinence were defined as failures and were evaluated by videourodynamic testing. The data were stored on 4D First software on a Macintosh computer.
Surgical Technique Patients were administered general and endotracheal anesthesia and an orogastric tube was inserted. They were placed in dorsolithotomy position using
Mendtec stirrups (Mend Technologies Inc., Dallas, TX). The arms were positioned at the sides and properly padded. Prophylactic cefazolin sodium 2 g was administered intravenously just before the procedure. An 18F Foley catheter with 30-ml balloon was inserted into the bladder. In cases in which LAVH was performed, a Valtchev uterine mobilizer or the Pelosi uterine manipulator was placed into the uterus. A Veress needle was inserted through an intraumbilical incision, creating adequate pneumoperitoneum, followed by insertion of an 11-mm cannula and the laparoscope. The abdominal cavity was inspected and the patient placed in steep Trendelenburg position. Two accessory cannulas were placed in the lower abdomen on the left and right sides at the level of the anterior and superior iliac spine and lateral to the inferior epigastric vessels. The diameter of accessory ports ranged from 5 to 12 mm depending on the instrumentation required during the procedure. In rare instances a 12-mm cannula was placed in the suprapubic region. On completion of other scheduled procedures, we proceeded with bladder neck suspension. The bladder was filled with 200 to 300 ml sterile water to delineate its lateral and superior borders. The urachus was grasped by the assistant at a point that usually corresponded to a distance 3 to 4 cm from the symphysis pubis, and pulled in the direction of the sacral promontory. Using bipolar forceps that were introduced through the left lower port, superficial peritoneal vessels were coagulated and the peritoneum transected in a transverse manner using the carbon dioxide laser at 15 W of power. The laser was introduced through the umbilical port; it is an excellent cutting instrument, and decreases the number of instrument exchanges. With blunt and sharp dissection and the aid of the pneumoperitoneum, the space of Retzius was identified. Two essential aspects of this operation consisted of meticulous hemostasis and patience. Blood can stain the tissue and to a great extent alter anatomic landmarks. On identifying left and fight Cooper's ligaments, the bladder was drained and dissection was continued in the paraurethral and paravesical spaces. The fatty pads were mobilized, exposing the glistening paravaginal fascia. Dissection was limited around the paraurethral space to avoid potential denervation and devascularization. When the dissection was completed, the Pelosi illuminator (Apple Medical, Bolton, MA) was introduced through the vagina and manipulated
186
February 1997, Vol. 4, No. 2
TheJournal of the American Association of GynecoLogic Laparoscopists
by the surgeon or assistant. This provides excellent delineation of the anatomy (Figure 1), and is a good backstop for suture placement. Needles were introduced through a 5-mm cannula as described elsewhere. 9 We used 2-0 monofilament polypropylene suture for the first five cases, and switched to CV-0 THX-36 Gore-Tex suture (W. L. Gore, FlagStaff, AZ) due to its specific characteristics and biocompatibility. 1~Two sutures were placed on each side, the distal suture approximately 2 cm lateral to the midurethra and the proximal suture just lateral to the urethrovesical angle. When suture placement was complete (Figure 2) the surgical site was inspected for potential bleeding and the parietal peritoneum was closed with a purse-string suture (Figure 3). A
diagnostic cystoscopy was performed if there was any question with regard to correct suture placement. The Foley catheter was removed 30 to 36 hours postoperatively and voiding trials were begun. If the residual urine was over 150 ml the patient was discharged from the hospital with a Foley catheter in place for 1 week. In essence the surgical technique was a Burch colposuspension with the Tanagho modification.U The procedure consists of minimal dissection within 2 cm of the urethrovesical junction and urethra; placement of sutures through full thickness of shiny white paravaginal fascia; placement of two sutures on each side, one opposite to the urethrovesical junction and another at the level of the midurethra; removal of adipose tissue lateral to the site of suture placement to facilitate fibrosis; and attaching sutures to Cooper's ligament with tying facilitated by elevating the anterior vaginal wall. Results
None of the patients in this study required laparotomy to complete the procedure, and none suffered a cystotomy. There was one instance of inadvertent placement of suture through the bladder, which was recognized intraoperatively by diagnostic cystoscopy, and the suture was removed. We have not encountered a similar event since we incorporated transillumination into the surgical technique. The operating time for group A was 195 minutes (range 145-260 min) and for group B 204 minutes (range 140-330 min). Blood loss for group A was 290 ml (range 50-800 ml) and for group B was 153 ml (range 50-700 ml). Four women required bladder drainage for only 1 week and none required self-catheterization. Five developed urinary tract infections that were treated successfully with oral antibiotics. All subjects had a negative Q-Tip test. Three women, two from group A and one from group B, complained of leakage of urine. They were defined as failures, and underwent follow-up urodynamic studies (Table 1). All the failures occurred 12 months after colposuspension. The first patient was treated with oral oxybutynin chloride 5 mg 3 times/day on alternate days to minimize the anticholinergic side effects, mainly dry mouth; she is currently asymptomatic. The second underwent a sling procedure, but developed detrusor instability that was partially controlled with oxybutynin
FIGURE 1. Transvaginal illumination of the paraurethral and paravesical spaces.
FIGURE 2. Inspection of the surgical site.
187
Laparoscopic Bladder Neck Suspension Papasakelariouand Papasakelariou
TABLE 1. Profiles of Women with Negative Results
Patient Age (yrs), Gravidity, Parity
Time of Failure (mo)
34, 2, 2002 62, 3, 2012 54, 2, 1011
12 16 18
chloride and imipramine hydrochloride. The third was diagnosed with breast cancer approximately 12 months after her colposuspension and elected not to receive any further treatment for GUSI. Discussion Despite advances in behavioral and pharmacologic therapies, surgical correction is the cornerstone treatment of GUSI. In fact some evidence suggests that initial surgical correction may be even more cost effective than the other modalities.12 The literature is abundant with descriptions of surgical procedures for correcting the disorder, but Burch colposuspension seems to be associated with the best results. 13 It and its variations are preferred by many gynecologists and a growing number of urologists. Laparoscopic Burch colposuspension has the following advantages: the retropubic space can be easily dissected; the vessels can be easily visualized and coagulated; it is essentially the same procedure as that performed through a large abdominal incision; it allows for precise suture placement; and it is associated with a short and moderately painless recovery. In addition, the transperitoneal
Abnormality
Treatment
Detrusor instability Type III Type III
Oxybutynin chloride Sling procedure None
approach allows for performance of other surgical procedures. In these women the procedure was associated with few complications. We believe that meticulous dissection, hemostasis, patience, transillumunation, and liberal use of the cystoscope contributed to low morbidity. Our initial long operating time has been significantly improved, a reflection of the learning curve. The procedure was associated with stabilization of the bladder base evidenced by a negative postoperative Q-Tip test in all patients. The overall success rate of 90.6% after 2 years makes transperitoneal laparoscopic Burch procedure an excellent surgical alternative for correcting GUSI. References
1. Consensus Development Panel, National Institute of Health: Urinary incontinence in adults: Consensus conference. JAMA 261:2685-2690, 1989 2. Diokno AC, Brock BM, Brown MB, et al: Prevalence of urinary incontinence and other urological symptoms in the noninstitutionalized elderly. J Uro1136:1022-1025, 1986 3. Wolin LH: Stress incontinence in young, healthy nulliparous female subjects. J Urol 101:545-549, 1969 4. Thomas TM, Plymat KR, Blannin J, et al: Prevalence of urinary incontinence. Br Med J 281:1243-1245, 1980 5. Holst K, Wilson PD: The prevalence of female urinary incontinence and reasons for not seeking treatment. Aust N Z Meal J 101:756-758, 1988 6. Hu TW: The economic impact of urinary incontinence. Clin Geriatr Med 2:673-687, 1986 7. Vancaillie TG, Schuessler W: Laparoscopic bladder neck suspension. J Laparoendosc Surg 1:169,1991 8. Liu CY: Laparoscopic retropubic colposuspension (Burch procedure): A review of 58 cases. J Reprod Med 38(7):526-530, 1993
FIGURE 3. Peritoneal closure is complete.
188
February 1997, Vol. 4, No. 2
The Journal of the American Association of Gynecologic Laparoscopists
12. Ramsey SD, Wagner TH, Bavendam TG: Estimated costs of treating stress incontinence in elderly women according.to the AHCPR clinical practice guidelines. Am J Manage Care 2:147-154,1996
9. Reich H, Clarke C: A simple method for ligating with straight and curved needles in operative laparoscopy. Obstet Gynecol 79:143-147, 1992 10. Cavallaro A, Sciacca V, Cisternino S, et al: Experimental evaluation of tissue reactivity to vascular sutures: Dacron, polypropylene, PTFE. Vasc Surg 21 (2):82-86, 1987
13. Bergman A, Ballard C, Koonings P: Comparison of three different surgical procedures for genuine stress incontinence: Prospective randomized study. Am J Obstet Gynecol 160:1102-1 t06, 1989
11. Tanagho EA: Colpocystourethropexy: The way we do it. J Urol 116:751-753, 1976
189