Modified Burch Colposuspension: Laparoscopy versus Laparotomy

February 2001, Vol. 8, No. 1

The Journal of the American Association of Gynecologic Laparoscopists

Modified Burch Colposuspension: Laparoscopy versus Laparotomy Hisham Fatthy, M.D., MRCOG, Mounir El Hao, M.D., Ibrahim Samaha, M.D., and Khaled Abdallah, M.D.

Abstract Study Objective. To compare results of laparoscopic Burch colposuspension with those of classic Burch colposuspension, and to assess complications, results, and morbidity associated with each procedure. Design. Prospective, randomized study (Canadian Task Force classification I). Setting. Minimal access surgery unit. Patients. Seventy-four women with genuine stress incontinence. Intervention. Laparoscopic and classic Burch colposuspensions. Measurements and Main Results. Mean operating times for laparoscopic and open surgery were 70.18 ± 16.54 and 53± 10.05 minutes, respectively (p <0.001). Mean blood loss was 42.75 ± 7.2 and 240.5 ± 35.5 ml, respectively (p <0.001). Postoperative analgesia requirement was significantly less with laparoscopy (p <0.001). Mean postoperative hospital stay was 36 ± 6.3 hours for the laparoscopic group and 76± 10.4 hours for the open group p<0.001). Average time to return to light work was 8.5 and 31.5 days, respectively. Success rates were 90.9% at 6 months and 87.9% at 18 months in the laparoscopic group, compared with 90% and 85%, respectively, in the open group. Conclusion. Given equal efficacy of the two procedures, we prefer the laparoscopic approach since it is associated with lower morbidity, shorter hospital stay, and fewer complications. (J Am Assoc Gynecol Laparosc 8(1):99–106, 2001)

associated with Pereyra, long-needle suspension under endoscopic control associated with Stamey, sling procedures, and periurethral injections.2 Retropubic urethral suspension was performed laparoscopically.3,4 This approach is ideally suited to surgery in the retropubic space. It provides excellent retropubic exposure, and videolaparoscopic magnification enhances the surgeon’s ability to place sutures precisely. Improved exposure enables restoration of support with limited mobility and avoids urethral obstruction and compression. The objectives of this study were to compare laparoscopic and open modified Burch colposuspensions with respect to outcomes, complications, and morbidity.

Urinary incontinence is becoming more prevalent as the population ages. Conservative estimates indicate that it affects nearly 20% of women age 40 to 60 years and 35% of noninstitutionalized women older than 60 years.1 In most of these women the disorder is secondary to genuine stress incontinence, detrusor instability, or a combination of both. No general agreement exists about the surgical procedure of choice for women with genuine stress incontinence. Many different techniques have been described but most are variations on seven basic themes: bladder buttress operations associated with Kelly and Pacey, the Marshall-Marchetti-Krantz procedure, colposuspension as described by Burch, long-needle suspensions without endoscopic control

From the Department of Obstetrics and Gynecology, Minimal Access Surgery Unit, Ain Shams University School of Medicine, Abbassia, Cairo, Egypt (all authors). Address reprint requests to Hisham Fatthy, M.D., Central Heliopolis Office 11757, P.O. Box 344, Cairo, Egypt; fax 202 274 9603. Accepted for publication August 23, 2000.

99

Modified Burch Colposuspension Fatthy et al

Materials and Methods

Patients were randomized into two groups: 34 women (mean age 40.29 yrs) in group 1 (laparoscopic) and 40 (mean age 42.90 yrs, p >0.05) in group 2 (open). Distribution of patients by clinical features is shown in Table 1. Fifteen menopausal women were not receiving hormone-replacement therapy, eight in the laparoscopic group and the rest in the open group. They were prescribed hormone replacement therapy for 3 months before their scheduled surgery. Pelvic relaxation was present in 22 patients (29.7%); 8 in group 1 and 14 in group 2. Cystorectocele was the most common type in both groups, occurring in 14.7% and 15%, respectively. Table 2 shows preoperative urodynamic data. Randomization was done using random number table balanced randomization with blinding and disguised block length. This method ensured that the number of patients allocated to each group was approximately equal during the entire study. The statistician did not allow surgeons or patients to know which type of operation was next.

Seventy-four women with urodynamically diagnosed genuine stress incontinence were recruited in this prospective, randomized study. Preoperative evaluations were history and physical, gynecologic, and neurologic examinations. Urinalysis and urine culture and sensitivity were done to exclude infection. The Q-tip test was performed to reproduce and quantify hypermobility of the urethra and bladder neck. While in the sitting position, patients underwent multichannel substracted urodynamic study using Duet MultiP system (Medtronic, Denmark) with 10F triple-lumen water-filled catheter. Medium-fill (60 ml/min) normal saline at room temperature was the distending medium. Resting and stress (cough and Valsalva) urethral closure pressure profiles in sitting position were obtained in all patients. Sphincter function was assessed by abdominal leak point pressure with Valsalva maneuver and/or cough at bladder volume of 150 to 200 ml. Measurements and definitions conformed to standards recommended by the International Continence Society unless otherwise stated.5 Patients with detrusor instability, underactive detrusor, intrinsic sphincter deficiency (Valsalva leak point pressure <90 cm H2O6), limited vaginal mobility, stages III and IV vaginal prolapse, or contraindications to laparoscopy and surgery in general were excluded from the study.

Operative Procedures Modified Burch Colposuspension After induction of anesthesia, a 16F Foley catheter was placed in the bladder to allow continuous drainage during the operation and to facilitate delineation of the

TABLE 1. Patient Characteristics

Median (range) age (yrs) Median (range) weight (kg) Median (range) parity Menopausal status, no. (%) Premenopausal Menopausal with HRT Menopausal without HRT Pelvic relaxation, no. (%) Cystorectocele Cystocele Rectocele Previous surgery, no. (%) Anterior colporrhaphy Retropubic urethropexy Other abdominal operationa

Laparoscopic Group (n = 34)

Open Group (n = 40)

40.29 (30–55) 71.18 (60–80) 4.03 (1–11)

42.90 (30–65) 74.55 (65–90) 5.05 (1–10)

8 (23.5) 18 (53) 8 (23.5)

11 (27.5) 22 (55) 7 (17.5)

5 (14.7) 2 (5.9) 1 (2.9)

6 (15) 5 (12.5) 3 (7.5)

4 (11.8) 3 (8.8) 6 (17.6)

6 (15) 3 (7.5) 4 (10)

HRT = hormone replacement therapy. No values reached significance. aIncludes cesarean delivery and adnexal surgery.

100

February 2001, Vol. 8, No. 1

The Journal of the American Association of Gynecologic Laparoscopists

TABLE 2. Preoperative Urodynamic Data

Volume of 1st sensation (ml) Cystometric capacity (sec) Maximum detrusor activity (cm H2O) Voiding time (sec) Flow time (sec) Time to maximum flow (sec) Maximum flow rate (ml/sec Residual volume (ml) Max. urethral pressure (cm H2O) Max. closure pressure (cm H2O) Functional length (mm) Valsalva leak point pressure (cm H2O), no. (%) No leak Leak at ≥ 90

Laparoscopic Group (mean and range)

Open Group (mean and range)

163.38 (135–190) 384.76 (320–586) 39.29 (20–60) 20.51 (17–33) 18.92 (16–30) 4.58 (3–6) 31.18 (20–57) 26.65 (20–40) 34.03 (27–46) 30.53 (21–43) 38.74 (18–47)

154.85 (101–215) 368.40 (280–586) 38.95 (15–80) 22.05 (15–30) 19.35 (10–24) 5.15 (2–10) 28.82 (16–49) 23.90 (15–45) 34.35 (19–49) 26.86 (21–44) 37.1 (10–48)

5 (14.7) 29 (85.3)

3 (8.8) 37 (92.5)

No values reached significance.

A number 1 nonabsorbable polypropylene suture on an HR 27 needle was used for colposuspension. It was first driven through Cooper’s ligament from a superior to inferior point. Guided by the assistant’s first and second fingers in the elevated vaginal fornix and using atraumatic grasping forceps, a portion of the paravaginal tissue was elevated and suture passed at the level of urethrovesical junction approximately 1 to 2 cm from the urethra. The suture was driven through tissue mediolaterally to minimize the chance of urethral injury, and perpendicular to the vaginal axis without penetrating vaginal mucosa. It was tied extracorporeally with endoscopic knot pusher by passing five to six alternating hitches to secure vaginal elevation without undue tension. The urethra was observed during knot pushing to avoid its compression against the pubic bone. Suturing was repeated on the opposite side. Flexible cystoscopy was performed to ensure no suture material was inside the bladder and to check ureteral patency. Insufflation pressure was reduced and the retropubic space was evaluated for bleeding, which was controlled with bipolar coagulation. The Foley catheter was removed 24 hours later if postvoid residual urine was less than 100 ml. The catheter was left for 7 days in women with bladder injury.

urethra and bladder neck. A 2-cm subumbilical skin incision was made transversely and carried into subcutaneous tissue. The rectus fascia was cleared and incised transversely and a suture was tagged at both edges for countertraction and to affix a Hasson cannula. With the index finger, the subrectus preperitoneal space was bluntly dissected toward the symphysis pubis in the midline. This facilitated introduction of the distention balloon system (Origin Medsystems, Menlo Park, CA) and prevented unintended peritoneal entry. We modified this system to allow its repeated use by replacing the inflatable balloon with the middle finger of a size 8 sterile glove, tightened and knotted with 0 silk suture. The distention system was withdrawn after 2 minutes of maximum distention and replaced with Hasson cannula that was secured to the rectus sheath. The dissected space was insufflated with CO2 at a pressure of 8 to 10 mm Hg and a 10-mm laparoscope was introduced. Two 10-mm lateral ports were inserted 7 to 8 cm above the symphysis pubis. Dissection of the space of Retzius was completed both bluntly and sharply with grasping forceps and scissors until the symphysis pubis and the two Cooper’s ligaments were exposed. An assistant then placed two fingers in the patient’s lateral vaginal fornix, thereby displacing the bladder neck toward the opposite side of dissection. The vagina was also minimally elevated to avoid reduction in the distended space. Blunt dissection was carried out to mobilize the bladder and expose paravaginal tissue.

Open Burch Colposuspension Patient preparation and insertion of a 16F Foley catheter were the same as for the laparoscopic

101

Modified Burch Colposuspension Fatthy et al

ing in the lithotomy position and with coughing and jumping in the standing position. Valsalva leak point pressure was defined as total abdominal pressure measured as total vesical pressure in the absence of detrusor contraction required to cause urinary incontinence at a bladder volume of 150 to 200 ml. Subjective outcome was defined as dry—completely continent or only rarely requiring a pad with exertion with which the patient was completely satisfied, and failure—change in the amount of leakage with which she was not satisfied. Objective success was defined clinically as a negative cough provocation test, and urodynamically as absence of leakage during Valsalva maneuver and repeated coughing, as well as a significant improvement in maximum closure pressure. Postoperative de novo detrusor instability was considered a failure.

approach. Access to the retropubic space was obtained through a low Pfannenstiel or Cherney incision (8–10 cm long). Visualization of the space of Retzius was enhanced by use of a Dennis-Browne self-retaining ring retractor. The bladder was carefully dissected from the symphysis. With an assistant’s forefinger in the vagina, the lateral vaginal fornix was elevated. The bladder base was dissected medially off paravaginal tissue using combined sharp and blunt dissection. A number 1 nonabsorbable polypropylene suture was placed into paravaginal tissue at the level of the urethrovesical junction on each side and inserted into the ipsilateral ileopectineal ligament. Once sutures were in place, they were tied approximating paravaginal tissue to Cooper’s ligament. When adequate hemostasis was achieved, the incision was closed. A suction drain was left in the retropubic space. A Bonanno catheter (Becton-Dickinson Ltd.) was placed two finger-breadths above the incision after the bladder had been filled through the Foley catheter, which was then removed. The suprapubic drain and catheter were left in place for 48 hours. The catheter was removed when postvoid residual urine was less than 100 ml. After completion of the modified Burch colposuspension (laparoscopically or openly), rectocele was repaired in 15 patents; 6 in the laparoscopic group and 9 in the open group. Prophylactic cephradine 1 g 3 times/day for 24 hours was given to patients in both groups. On discharge, patients were instructed to avoid intercourse, strenuous exercise, and heavy lifting for 8 weeks.

Data Analysis Data entry and statistical analysis were done with SPSS under Windows version 7.5. Student’s t test and χ2 analysis were used where appropriate. Fisher’s exact test with a 5% significance level was used to compare categoric data. Paired t test was used to compare differences in mean urodynamic parameters before and after surgery in the same group. McNemar nonparametric test was used to detect changes in response rates of the leak point pressure test before and after surgery in each group. Statistics were considered significant if the probability of a chance finding was less than 5% (p <0.05). Results

Follow-up Patients were seen 4 weeks postoperatively and every 6 months for 18 months. Before each visit they were asked to keep a 24-hour symptom diary in which they recorded intake and output, urge to void, and leakage. Multichannel urodynamic studies were done at 6- and 18-month visits by an independent urologist who was blinded to the procedure performed. Subjective success was ascertained by a questionnaire about urine leakage, lack of need to wear pads at rest and at different activity levels, and comparison of preoperative and postoperative symptoms. Objective success was assessed by cough provocation test, Valsalva leak point pressure, maximum urethral pressure, and maximum closure pressure. Cough provocation test was performed with a symptomatically full bladder (250 ml) and patients were tested with vigorous cough-

Mean operating time for group 1 was 70.18 ± 16.54 minutes and for group 2 was 53 ± 10.05 minutes (p <0.001). In the laparoscopy group mean operating times for patients with and without previous laparotomy were 73.16 ± 17.54 and 67.20 ± 15.67 minutes, respectively (p >0.05), and 50 ± 8.65 vs 65 ± 5.77 minutes for patients in the open group (p <0.05). Two bladder injuries occurred during dissection, one in each group, and both were repeat interventions. In group 1 the bladder was repaired laparoscopically in one layer using 0 polyglactin interrupted sutures. Bladder perforation, diagnosed cystoscopically, occurred in another patient in group 1. No specific management was necessary other than undoing the stitch. Mean blood loss for group 1 was 42.57 ± 7.2 ml versus 240.5 ± 35.5 ml for group 2 (p <0.001; Table 3).

102

February 2001, Vol. 8, No. 1

The Journal of the American Association of Gynecologic Laparoscopists

TABLE 3. Surgical Outcomes Laparoscopic Group Mean ± SD operating time (min) Mean ± SD blood loss (ml) Complications, no. (%) Bladder injury Bladder perforation Analgesia frequencya 1 2 3 Mean hospital stay (hrs) Wound infection, no. (%) Retropubic hematoma, no. (%) Spontaneous voiding, no. (%)

Open Group

70.18 ± 16.54 42.75 ± 7.2

53 ± 10.05 240.5 ± 35.5

1 (2.9) 1 (2.9)

1 (2.5) 0 (0)

33 (97) 0 1 (2.9) 36 ± 6.3 0 0 31 (91.2)

6 (15) 28 (70) 6 (15) 76 ± 10.4 2 (5) 1 (2.5) 36 (90)

Significance <0.001 <0.001 NS

<0.001

<0.001 NS NS NS

NS = not significant aTotal number of Pethidine 50-mg ampules.

postoperatively and 3 patients (7.5%) preoperatively (p <0.001). The mean of maximum urethral closure pressure was 41.00 and 40.90, respectively. One patient was lost to follow-up and seven had symptomatic leakage at 6 months. Repeat urodynamic testing in five women, two in group 1 and three in group 2, confirmed de novo detrusor instability that responded to bladder retraining and oxybutynin. The remaining two women, one in each group, were considered treatment failures as they had recurrence of symptoms less than 3 months after the procedure. The laparoscopic approach was associated with a success rate of 90.9% at 6 months and 87.9% at 18 months; values for the open approach were 90% and 85%, respectively (Table 5). Six patients (8.2%), one in the laparoscopic group and five in the open group, developed annoying lower abdominal pain within 8 weeks postoperatively. This was diagnosed as postcolposuspension syndrome and it resolved with nonsteroidal antiinflammatory drugs. Average time for return to light work in group 1 was 8.5 days and 31.5 days in group 2 (p <0.001). Seven women (9.6%) developed asymptomatic grade I pelvic relaxation within 18 months, none of which was a recurrence. Of those, three were in the laparoscopic group and developed rectocele; in the open group two patients developed rectocele and two had enterocele. Eight patients (10.96%), four in each group, complained of some dys-

Immediate postoperative pain was controlled by one ampule of meperidine 50 mg in 33 patients (97%) in the laparoscopy group, but 34 patients (85%) in the open group required more than one ampule. In group 2, two women (5%) developed superficial wound infection that resolved with antibiotics and one (2.5%) had a retropubic hematoma that was managed conservatively. Six women (8.1%), four in the laparoscopic group and two in the open group, had dysuria without infection that resolved with phenazophridine treatment. Sixty-eight women (91.9%), 31 (91.2%) in group 1 and 37 (92.5%) in group 2, voided after removal of either the Foley catheter or suprapubic catheter. Other than women with bladder injury, two in each group required self-catheterization for inability to void. All four were able to void within 8 weeks. Mean hospital stay was 36 ± 6.3 and 76 ± 10.4 hours, respectively (p <0.001). Follow-up assessment for 18 months evaluated subjective and objective success. Cough provocation test was negative in 59 women (80.8%), 28 (84.8%) in the laparoscopic group and 31 (77.5%) in the open group, versus 10 patients (13.5%) preoperatively, 3 (8.8%) and 7 (17.5%), respectively (p <0.001; Table 4). Twenty-nine women (87.9%) in the laparoscopy group did not leak during Valsalva maneuver and repeated coughing postoperatively, versus four (11.8%) preoperatively (p <0.001). In the open group 34 patients (85%) had negative leak point pressure test

103

Modified Burch Colposuspension Fatthy et al

TABLE 4. Preoperative and 18-Month Postoperative Urodynamic Data Laparoscopic Group

Open Group

Preoperative (n = 34)

18 mo. Postoperative (n = 33)

Preoperative (n = 40)

18 mo. Postoperative (n = 40)

163.38 384.76 39.29 20.51 18.92 4.58 13.18 26.65 34.03 30.53 38.74

164.6 403.5a 30.70a 21.10 18.90 4.75 33.20 32.85a 45.85a 41.00a 42.2

154.85 368.40 38.95 22.05 19.35 5.15 28.82 23.90 34.35 26.8 37.1

162.55 384.10a 26.55a 22.20 19.90 4.80 30.15a 30.95a 55.60a 40.90a 49.3a

4 (11.8%)

29 (87.9%)b

3 (7.5%)

34 (85%)b

Volume of 1st sensation (ml) Cystometric capacity (sec) Maximum detrusor activity (cm H2O) Voiding time (sec) Flow time (sec) Time to maximum flow (sec) Maximum flow rate (ml/sec) Residual volume (ml) Max. urethral pressure (cm H2O) Max. closure pressure (cm H2O) Functional length (mm) Leak point pressure test No leak ap < 0.001, paired t test. bp < 0.001, McNemar nonparametric t test.

TABLE 5. Follow-up Findings Subjective and Objective Findings, No. (%) Cure At 6 mo At 18 mo Return to work (wks) <2 2–8 >8 Detrusor instability Postcolposuspension pain Pelvic relaxation Dysparunia (at 6 mo.)

Laparoscopic Group (n = 33)

Open Group (n = 40)

30 (90.9) 29 (87.9)

36 (90) 34 (85)

32 (96.96) 1 (3) 0 2 (6.1) 1 (3) 3 (9.1) 4 (12.1)

0 2 (5) 37 (92.5) 3 (9.1) 5 (12.5) 4 (10) 4 (10)

Significance

NS NS <0.001

NS <0.05 NS NS

NS = not significant.

Mean operating times were statistically longer in the laparoscopic group (70.8 ± 16.87 min) than in the open group (53 ± 10.05 min, p < 0.001). This difference can be attributed to the steep learning curve associated with the former approach. Endoscopic suturing in the space of Retzius is hampered by restrictions in instrument mobility and angle of freedom, tenacity of Cooper’s ligament, and loss of depth of field and peripheral vision from monocular vision. Nevertheless, our operating times compare favorably with those in some reports but not in others.8,9 Previous lapa-

pareunia at 6 months. This complaint had disappeared at 18 months. Discussion Great strides have been made in managing stress urinary incontinence.6,7 Innovative pioneers and technologic advances have brought us to a point at which surgery for the disorder is included in the list of procedures that can be performed laparoscopically.

104

February 2001, Vol. 8, No. 1

The Journal of the American Association of Gynecologic Laparoscopists

accessory cannula positions hamper instrument mobility. They are associated with considerable risk of peritoneal entry in obese patients due to deep rectus dissection. The space of Retzius may become physically obstructed by a protuberant pneumoperitoeum accidentally created by peritoneal entry during dissection. Nevertheless, these disadvantages can be minimized with refinement of technique and increasing experience. Ability to perform culdoplasty is an obvious advantage to the intraperitoneal route. The cost of disposable instruments is a major detriment, especially in less privileged centers. However, our modification of the mechanical distention system tremendously reduced the cost. Conversely, laparoscopic extraperitoneal approach has certain advantages. It permits unhindered entry into the retropubic space in the presence of substantial intraabdominal adhesions. The risk of herniation at cannula sites is virtually eliminated. Also, it avoids peritoneal entry, which reduces postoperative pain and hospital stay.

rotomy significantly prolonged mean operating times in the open group only (65 ± 5.77 vs 50 ± 8.56 min, p <0.05). Our data support other reports that laparoscopic Burch colposuspension results in less blood loss than open approach. The mean blood loss of 45.75 ± 7.2 ml in our laparoscopic group was in accordance with that reported elsewhere.4 In laparoscopic approach, obviously, visual clarity and magnification of tissue permit more precise dissection and refined hemostasis as a result of identification of blood vessels before transection. The frequency of complications during laparoscopy was consistent with that reported elsewhere.3 Women undergoing laparoscopy had less postoperative analgesic requirement than the open group, also consistent with the literature.10 Mean postoperative hospital stay for the two groups is in agreement with others.11 Subjective and objective cure rates were similar in both groups (~ 90%) by 18 months. Cough provocation test and urodynamic assessment were done as objective measures of success. Both cough provocation test and the leak point pressure test were significantly more often negative postoperatively in both groups than preoperatively. However, cut-off values, methodology, and clinical applicability of the leak point pressure test are controversial and remain to be standardized with respect to catheter size and placement, bladder volume, patient position, and provocative maneuvers.7 Postoperative urethral functional length significantly increased in the open group only. Previous studies12,13 were contradictory with respect to the value of urethral pressure profiles in predicting the severity of incontinence. However, both studies used a single subjective, nonstandard, nonvalidated method for assessing genuine stress incontinence.14 The objective cure rate of 87.9% at 18 months in our laparoscopic group was consistent with that reported elsewhere15 and more than reported in other series.8 The frequencies of postcolposuspension syndrome, de novo bladder dysfunction, dyspareunia, and pelvic relaxation in our series were similar to those in the literature.16 However, these disorders were more frequent, but not statistically significantly, in the open than in the laparoscopic group. The extraperitoneal approach has certain disadvantages compared with intraperitoneal access. Lower

Conclusion Given the results of this study, laparoscopic Burch colposuspension appears to be a safe and effective procedure. The laparoscopic approach resulted in less intraoperative blood loss, less postoperative analgesic requirement, shorter hospital stay, and earlier return to work than the open procedure. Multicenter, randomized, controlled trials are required to standardize indications for surgery, approach employed, materials used, and postoperative complications. References 1. Thomas TM, Plymatt KR, Blanin J, et al: Prevalence of urinary incontinence. Br Med J 281:1243–1245, 1980 2. Jarvis GJ: Surgery for genuine stress incontinence. Br J Obstet Gynaecol 101:371–374, 1994 3. Vancaillie TG, Schuessler W: Laparoscopic bladder neck suspension. J Laparoendosc Surg 1:169, 1991 4. Nezhat C, Nezhat F, Nezhat C: Operative laparoscopy (minimally invasive surgery): State of the art. J Gynecol Surg 8:111–141, 1992

105

Modified Burch Colposuspension Fatthy et al

5. Abrams P, Blaivas JG, Stanton SL, et al: The standardization of terminology of lower urinary tract function recommended by the International Continence Society. Int Urogynecol J 1:45–58, 1990

11. McDougall EM, Klutke CG, Cornell T: Comparison of trans-vaginal versus laparoscopic bladder neck suspension for stress incontinence. Urology 45:641–646, 1995

6. Nitti VW, Comb AJ: Correlation of Valsalva leak point pressure with subjective degree of stress urinary incontinence in women. J Urol 155(1):281–285, 1996

12. Hilton P, Stanton SL: Urethral pressure measurement by microtransducer: The results in symptom-free women and in those with genuine stress incontinence. Br J Obstet Gynaecol 90:919–933, 1983

7. Kholi N, Karram M: Urodynamic evaluation for female urinary incontinence. Clin Obstet Gynecol 41(3): 672–690, 1998

13. McGuire EJ, Fitzpatrick CC, Wan J, et al: Clinical assessment of urethral sphincter function. J Urol 150: 1452–1454, 1993

8. Lobel RW, Sand PK: Long term results of laparoscopic Burch colopsuspension. Neurourol Urodynam 15: 398–399, 1996

14. Theofrasrous JP, Bump RL, Elser DM, et al: Correlation of urodyramic measures of incontinence severity in women with pure GSI. Am J Obset Gynecol 173 (2):407– 412, 1995

9. Nezhat C, Nezhat F, Nezhat C, et al: Reconstructive pelvic surgery. In: Operative Gynecologic Laparoscopy. Edited by W Lamsbach, MJ Wonsiewicz, S Finn. New York, McGraw-Hill, 1995, pp 225–270

15. Ross JW: Multichannel urodynamic evaluation of laparoscopic Burch colposuspension for genuine stress incontinence. Obstet Gynecol 91:55–59, 1998 16. Smith ARB, Stanton SL: Laparoscopic colposuspension. Br J Obstet Gynaecol 105:383–384, 1998

10. Liu CY: Laparoscopic retropubic colposuspension (Burch procedure). J Reprod Med 38:526–530, 1993

106