SUI is the most common type of incontinence-eminence and occurs almost exclusively in women. A recent survey by the National Association For Continence found that SUI affects approximately 16.5 million women in the United States. Nearly two-thirds of these women under 50 years.

However, there is a surgical procedure of choice for women with this condition. Actually, a new methodical appraisal of the literature by Black and Downs could not determine the "best practice" based on clinical evidence.

Among the many surgical options for the treatment of SUI bladder neck suspension by the board colposus laparoscopic Burch. When performed correctly, this procedure has a higher rate of long-term success, reducing morbidity and rapid recovery. This article describes how to perform laparoscopic Burch procedure (overview of both conventional techniques and end modification Tanagho) and discuss when considering laparoscopic approach. In addition, we explain why the procedure should be part of their surgical options for women SUI.

The Technique of Laparoscopic Burch

Patient preparation.

 As always, get informed consent before the procedure. Apart from the usual risks of surgical blood loss, surgical wound infections, and the failure rate of thromboembolic complications, patients can also face-operative voiding dysfunction, as mentioned above, and that de novo detrusor instability. Also inform their patients about the possible conversion of laparotomy.

To give a single intravenous dose of broad spectrum antibiotic suitable and not more than 1 hour before surgery. For patients who are laparoscopic additional reconstructive surgery, a modified to improve visualization decompressing preparation sigmoid colon is recommended.

General anesthesia and put the patient in the position of the spinal lie with both hands tucked. Support the lower extremities of patients with Universal Media Allen and avoid excessive bending of the knees and hips. 16F Foley catheter insertion into the bladder 3 channels, which allows filling of the bladder during the intermittent and inflate lamp 10 cc in order to facilitate identification during surgery VLU.

Enter the retropubic space. 

Our laparoscopic procedure regularly after inserting the needle Veress insufflation and through the umbilical incision. (Use open laparoscopy for patients who have undergone previous abdominal surgery and scarring paraumbilical).

Under direct visualization, place 2 optional 10 mm Trocars in the lower part, outside the inferior epigastric artery quadrant. Short raised above 20 mmHg intra-abdominal pressure facilitates safe entry for this side Trocars. Although you can opt for less Trocars, size 10 mm allows passage end without barriers, providing more opportunities to optimize ergonomics favor future surgical placement.

Although preperitoneal or extraperitoneal access has been described, we support transperitoneal enters the retropubic space. Extraperitoneal approach allows the use of regional anesthesia, avoid intra-abdominal adhesions, and eliminates the risks associated with peritoneal entry. The disadvantages are, however, important, including the lack of entering the retropubic space and secondary abdominal wall scar, inability to perform suspension bow and concomitant costs balloons available at the market dissection. With experience, transperitoneal approach does not extend the time of operation.

With experience, transperitoneal approach in the retropubic space will extend operating time.

Approaching the bladder. 

Expand the bladder in a retrograde style by 300 ml to 400 ml of normal saline. This allows the identification of the upper edge of the dome of the bladder and gives back to the ground train. Use urachus identify the center line; then enter the anterior abdominal wall and the peritoneum applied to pull down. Then create a transverse incision 3 cm to 4 cm above the reflection of the bladder, using endoscopic monopolar scissors to clean-cut frame 70 watts. The cut must be in the umbilical ligaments damaged, but can be extended a little beyond patients undergoing laparoscopic repair Burch paravaginal up. Using a combination of dissection and electrocoagulation, you can easily analyze the loose cellular tissue Prevesic space at the level of the symphysis pubis and the pubic symphysis ramus Locate and Rami using chest circumference as a landmark, As paravesical space is developed, pubocervical belt will be exposed to the VLU. You must carefully protect the urethra, avoiding aggressive median dissection and close the neurovascular bundle on the side. Medial traction on the bladder, perpendicular to the slope of the mandible, favors the identification of appropriate surgical plane. Use electrocautery to maintain meticulous hemostasis at any time. Identify Cooper's ligament and bluntly dissect the fat tissue or areolar obstruction. To encourage scarification and remove fat and periurethral perivesical excessive lie fascia pubocervical the neck of the bladder, while avoiding any dissection within 1 cm lateral to the urethra. 

Putting the seams. The use of extra long (36 inches), double-armed, nonabsorbable on SH needle, put stitches in a
coherent sequence.

First, introduce contralateral port and pass the needle through pubocervical belt in the middle of the urethra, using your index finger to keep transvaginal. If you think that the fabric does not bite buy almost the entire thickness of the anterior vaginal wall, try a different vortex. Then put the thread through the Cooper ligament and "trade" hooking peritoneum front wall. Place your other hand (needle) from the end of the Cooper ligament, but at different depths of the first passage of the ligament fibers thus indeed surrounded the end. Collect two hands, putting them in the same port, but does not bind another sewing.

Insert another seam over the ipsilateral port and place it in the same way UVJ. Again, using a spiral throws necessary. After both seams are set, fixing a row using extracorporeal knot pusher closed-loop. The correct voltage should create a small localized "wrist" of pubocervical belt laterally as close internal closure fascial. Repeat this procedure in the same order on the opposite side of the pool and close the retropubic space Race applies continuous 2-0 suture reapproximating peritoneum. Laparoscopic close connections to the belt using the Veress needle threaded with 0-Vicryl. Both ends of the thread are passed on either side of the fascia incision. Contralateral using tongs, place seam is released from the Veress needle and collected using ipsilateral pliers. This technique port closure is easy to implement and inexpensive.

Postoperative care. 

Put a suprapubic catheter to stop the clock 2-channel; which makes testing easier postoperative voiding patients and caregivers.

Most patients will be published on the day after surgery. If the patient still has residual high postvoid, probably will get to go home with a suprapubic catheter acceptable than intermittent self-catheterization or indwelling Foley running leg bag. For post-operative discomfort, acetaminophen and nonsteroidal anti-inflammatory preparations generally enough. Patients can resume normal activities of life in a few days, but they must be advised to postpone strenuous work or exercise for at least 8 weeks.

Look at the evidence

The learning curve for laparoscopic Burch is a little steep and long about 20 cases. The real question is whether the benefits justify the time it takes to master this process. In other words, there is no clinical evidence that one has reached the plateau of the curve, we can reduce the mortality rate of patients while maintaining efficiency compared to traditional open technique. Otherwise, there is little reason for surgeons to learn the technique. If, however, more doctors should include laparoscopic Burch in surgical arsenal.

The real question is whether the benefits of the laparoscopic Burch justify the time required to master the procedure.

When we limit the discussion to two comparable techniques of laparoscopic compared to open procedure 2-seam, there are moderately strong evidence that the laparoscopic approach reflects the efficiency with slight reduction in morbidity.