Dr Shavershree Govender
Specialist Obstetrician Gynaecologist
Netcare Margate, KZN, South Africa
 
Stress urinary incontinence (SUI), defined as the involuntary urinary leakage on effort or exertion, or on sneezing or coughing [1], with continence rates reported in the literature of 56% -88% [2 - 4]
The open Burch colposuspension was first described in 1961 and for almost 50 years, has been considered as the gold standard for the treatment of stress incontinence [2].
The Burch colposuspension can be performed nowadays by minimal access surgery, with less morbidity and a similar cure rates compared to the open procedure - 70-80% [5-8].
The first reported retropubic surgery performed via the laparoscopic approach was described by Vancaillie and Schuessler in 1991 [3]. In 1993, Liu and Paek reported on 107 laparoscopic colposuspension cases with an overall success rate of 97.2%, and an overall complication rate of 10.2%, concluding that the laparoscopic approach is a feasible and safe alternative to the abdominal procedure [9].

Complications of SUI surgery

There are certain complications that can occur after surgery for urinary incontinence regardless of the procedure used.

• Voiding dysfunctions are among the most frequently encountered complications after surgery for SUI, encountered in about 15% of patients  after TOT procedures [11].
• Persistent de novo urgency symptoms, 3.1 to up to 27% , at long term follow-up have been reported [12-16]. 
• Sling procedures, the location of the tape seems to be related to the development of de novo urgency [16-19], impacting on patients quality of life (QOL) [20].
• Dyspareunia, especially in young and sexually active women represents an important issue. It is more frequently encountered after sling procedures, due to the risk of mesh related complications (erosion, shrinkage or infection) or extensive fibrosis [20-22]. The reported incidence of dyspareunia after tape placement is approximately 6.2% [23, 24].
• Bleeding , the average incidence of perioperative haemorrhage in SUI procedures is estimated at 2.7%, and can be encountered as acute (arterial) or delayed (venous) hematomas. Serious bleeding usually occurs during surgery and is rare [25].
• Hematuria  - injury to the bladder and urethra can cause Persistent hematuria . Transitory hematuria is more frequent after Burch colposuspension due to bladder manipulation.
• Mesh related complications  - The incidence of mesh erosion (exposure, extrusion or perforation) varies widely from 0–33%, with a mean incidence of 10.3% [26, 27].

Tape infection incidence ranges from 0-8% and it can occur with or without mesh exposure [26, 28, 29].
The Burch colposuspension is an important minimally invasive treatment for urinary stress incontinence, with similar cure rates to open surgery and mesh repair, offers the benefits of minimal invasive surgery and avoids the complications caused by mesh implant.
 
Preoperative evaluation consists of: local examination, urodynamic study, assessment of urethral hypermobility (Q-tip test).
 
Preparing the patient

Obtain informed consent prior to the procedure.
Surgical risks  

• blood loss
• infection
• surgical injury
• failure rate
• thromboembolic complications
• potential postoperative voiding dysfunction
• de novo detrusor instability
• possible conversion to laparotomy

Administer a single intravenous dose of an appropriate broad-spectrum antibiotic no more than 1 hour prior to surgery
 
Administer general anaesthesia

Place the patient in a dorsal lithotomy position with both arms tucked. Support the patient’s lower extremities with stirrups and avoid excessive flexion of the knees or hips

Insert a 16F 3-way Foley catheter into the bladder—this allows intermittent bladder fill during the procedure—and inflate the bulb to 10 cc to facilitate identification of the UVJ throughout surgery
 
Position of surgical team:
 
Surgeon and scrub nurse on left side of patient, monitor target organ and surgeons visual axis in coaxial line, assistant surgeon on right side. You may consider another scrubbed assistant between the patient’s legs, if any uterine manipulation is required. Preparation of parts done, by scrubbing and draping under aseptic techniques.
 
Preparation of equipment:
 
Insufflator  is turned on to remove air from tubing and set pressure is set at 15mmhg, set flow rate set at 1 l/min, camera is turned on focusing to be done at 10cms, white balance to be adjusted. Set up the connections of required instrument bipolar/harmonic with electrosurgical generator.
 
Procedural steps
 
1. Remove paraurethral fat out to lateral sidewalls.
2. Keep dissection 2 cm from urethra and bladder neck.
3. Elevate paraurethral tissue with vaginal hand during dissection and suture placement.
4. Clean off Cooper's ligament.
5. Place a right and left suture through the paraurethral tissue 2 cm lateral to the midurethra and up through Cooper's ligament.
6. Keep paraurethral tissue elevated with vaginal hand while tying.
7. Repeat bilateral suture placement 2 cm lateral to the bladder neck and through Cooper's ligament.
8. Do not over-correct when tying the sutures, leaving 2 cm between pubic ramus and the urethra.
 
 
Executive steps

Take veress needle and check for its spring action and patency
Connect the veress needle with CO2 tubing and flush out the dead space
Connect Veress needle to CO2 tubing and flush out dead space
Take 2 Allis forceps to evert and hold each side of umbilicus ((Use open laparoscopy for patients with prior abdominal surgery and paraumbilical scarring.)
Use number 11 blade to place small horizontal stab wound to inferior crease of umbilicus
Mosquito clamp to dissect away subcutaneous adipose and expose rectus sheath 
Measure abdominal wall thickness and add 4cm for distance to hold Veress needle
Hold Veress needle at calculated length like a dart
Assistant and surgeon to hold the lower abdomen up
Surgeon to place Veress needle in sub-umbilical incision at 45 degrees down into pelvis towards anus and also perpendicular to abdominal wall
Insert Veress needle until two clicks felt and Maintain 45 degree angle
Confirm correct Veress needle placement –irrigation test, aspiration test, plunger test, and hanging drop test
Connect CO2 gas tube to Veress needle and  Turn on CO2 and allow flow rate of 1L/min
Observe quadro-manometric indicators to rise in parallel for volume of gas and actual pressure and observe for general distension of abdomen.  Percuss for obliteration of liver dullness
Once pneumoperitoneum is achieved with set pressure of 15mmHg, extend skin incision horizontally
Hold 10mm port like a gun and insert it perpendicular to abdomen & tilt to 60 degrees towards pelvis when there is loss of resistance
Confirm intra-abdominal placement of primary port with escaping air sound and audible click. Take out trocar    
Set the pressure rate at 12mmhg and flow rate at 6 l/min
Connect  gas tubing to primary port
Insert telescope and inspect entry point
Request for Trendelenburg of 30 degrees position
Camera cable should be at 6 o’clock and light source should be at 12 o’clock
Apply baseball diamond shape principle for lateral port insertion
Transilluminate at target organ, the bladder
Make a diamond shape with thumbs at umbilicus and index fingers towards target organ
Incise skin along Langer lines for secondary ports x 2
Insert lateral ports (5mm x 2 at LIF and RIF) at position of snuff box which is about 8cm from umbilicus should be placed high and outside the epigastric vessels. (After the opening of the space of Retzius a third 10mm trocar is inserted suprapubically on the midline (at the level of the opened space of Retzius)
All ports should be inserted perpendicular to the abdomen.

 
Once all lateral ports inserted, then reduce set pressure to 12mmHg
Atraumatic graspers to perform systematic inspection of entire abdomen and pelvis in clockwise fashion

Description of the procedure

Approaching the bladder - distend the bladder in a retrograde fashion with 300 mL to 400 mL of normal saline. This allows identification of the superior margin of the bladder dome and provides mass traction posteriorly
Using a grasping forceps, grasp the anterior abdominal wall peritoneum and apply downward traction.  Use the urachus to identify the midline.

Next, using harmonic or monopolar endoscopic scissors on a 40-watt pure-cut setting, create a transverse incision 3 cm to 4 cm above the bladder reflection. 

Extend incision laterally between the two obliterated umbilical arteries (the lateral limit of incision), above the bladder. Identify the correct dissection plane, which should be avascular. This is a crucial in avoiding haemorrhagic complications.
 
Dissect the loose areolar tissue of the prevesicle space, using blunt dissection,  down to the level of the pubic symphysis and ramus.

Develop the paravesical space to expose the pubocervical fascia, at the level of the UVJ. Avoid aggressive midline dissection to ensure urethral protection as well as the obturator neurovascular bundle laterally.
Identify the external iliac vein laterally. Visualize the pelvic wall with the lateral insertion of the vagina to the arcus tendineus of the levator ani muscles caudally. Continue the dissection laterally.
Identification of the proper surgical plane is maintained by medial traction on the bladder, perpendicular to the slope of the pubic ramus.

Cooper’s ligament should be identified and any obstructing fat or areolar tissue should be bluntly dissected away (FIGURE 4)

Removal of excessive periurethral and perivesical fat from pubocervical fascia at the level of the bladder neck, encourages scarification.  Avoid any dissection within 1 cm lateral to the urethra.

Placing the sutures

Use a 90cm, nonabsorbable suture on an SH needle
First, introduce a needle from the contralateral port and at the level of the midurethra, pass it through the pubocervical fascia, using your index finger for transvaginal guidance.

Next, bring the suture up  and place through Cooper’s ligament.

Retrieve needle, bringing it out through the same port, but do not yet tie the suture
Introduce the second suture through the ipsilateral port and place it in the same fashion at the level of the UVJ
Once both sutures have been placed, tie them extracorporeally in sequence. (Waiting until both sutures are placed before tying allows exposure for easy placement of the second suture.
 
With the appropriate tension, a small, localized “knuckle” of pubocervical fascia is created, that approximates laterally to the obturator internus fascia.
 
This part of the procedure is repeated in the same sequence,  on the opposite side of the pelvis (FIGURE 11)

Simple suspension is thus achieved when the knots are tied. In order to maintain the mobility of the uretrovesical junction, the sutures should not be too tight
 
The retropubic space can be closed by reapproximating the peritoneum, using a running continuous 2-0 suture (FIGURE 12)

The  10mm laparoscopic ports should be closed at the fascia level using a Veress needle threaded with a 0-Vicryl.
Both ends of the suture are passed on either side of the fascial incision.
The suture end is freed from the Veress needle, using a contralateral grasping forceps. It is then retrieved using an ipsilateral forceps.

Postoperative care  

Most patients will be discharged the day after surgery.
For postoperative discomfort, acetaminophen and nonsteroidal anti-inflammatory preparations are usually sufficient.
Normal living activities can resume within days, and patient should be cautioned to delay strenuous work or exercise,  for at least 8 weeks.

 
References
 
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2.Burch JC. Urethrovaginal fixation to Cooper’s ligament for correction of stress incontinence, cystocele, and prolapse. Am J Obstet Gynecol. 1961;81:281–290 5.
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