International Urogynecology J (2002) 13: 253-255          

Abstract

Objective: Describe our experience with  Laparoscopic Burch and relate our results to traditional Open Burch procedures for the treatment of genuine stress incontinence.

Study design: Retrospective case series compared  to historical controls.

Results: Forty-six women, found to have only genuine stress incontinence by history, examination and clinical urodynamics, underwent a Mesh and Staple Laparoscopic Burch procedure.  Follow-up ranged from 3 to 50 months. Thirty-seven women were dry, 6 were improved and 3 showed no improvement. This compared to between 75 and 90% of women cured of stress incontinence by the traditional open Burch procedure.   

Conclusion: The results of a Mesh and Staple Laparoscopic Burch procedure in a carefully selected population of women with genuine stress incontinence appears comparable to that reported in the literature for an open Burch procedure.

In 1961 Burch published his seminal article describing his technique for treating stress urinary incontinence.¹ This procedure has become the gold standard to which all other procedures are compared. Over time new procedures and variations have been introduced in attempts to make this operation less morbid. During the last ten years, the laparoscopic approach has been used for Burch procedures as well as many other operations to try to shorten hospitalization and recovery times.  There is a wealth of literature about the innovative approaches to treating stress incontinence laparoscopically but there is notable lack of agreement about the techniques, the selection of patients and the comparative success rates. In this paper we describe our experience with a laparoscopic mesh and staple Burch procedure. 

It has been repeatedly stated that “there are over 100 operations for stress incontinence and only one for appendicitis.” Until the advent of laparoscopy this was certainly true, but now the appendix can be removed in the standard fashion or can be removed laparoscopically. It is obvious that a laparoscopic procedure, comparable to one traditionally done by laparotomy, is not equivalent unless the laparoscopic technique achieves the same results as that noted with laparotomy. ² Regardless of the approach, if a procedure suspends the paravessical tissues to Cooper’s ligament it is, for all practical purposes a Burch colposuspension.  Over the past ten years there have been several techniques used for this purpose, all of which use this same principle but different suspending materials.^{2, 3}  Some have advocated sutures placed laparoscopically in the traditional manner, while others have used staple fixation of sutures to try to ameliorate the awkwardness of laparoscopic suturing. ^4,5 Another technique, the one with which we are concerned today, involves the use of Prolene hernia mesh and helical hernia staples to perform the suspension. This procedure was described originally by Ou in 1993.⁶

  Despite, or perhaps because of, the rapid technologic change, there is little comparative data on the results of these methods.  This retrospective case series from one surgeon compares the results of a laparoscopic mesh and staple Burch to the standard open procedure.

Materials and Methods:

All patients were diagnosed as having genuine stress incontinence by history, examination, direct observation and/or cystometrogram. In the earlier part of this series cystometry was not available. At this time diagnosis was based on history of leaking with coughing, laughing, sneezing or physical activity.  All patients had hyper mobile urethra, demonstrated by a Q-tip test, which we defined as greater than 60 degrees change with Valsalva.  Patients with urge incontinence were excluded.   Since 1994 we have performed 50 cases, all done by the same surgeon and in the same facility. There have been improvements over the years in the equipment, specifically the availability of cystometry,  and in the surgeon’s experience. 

The procedures were done under general endotracheal anesthesia. A Foley catheter is inserted as well as a uterine manipulator, if needed.  The operation was done through three ports, a 10mm umbilical port for the laparoscope, a 10mm port in the lateral portion of the left lower quadrant and a 5mm port in the lateral right lower quadrant.  If a hysterectomy was to be done, it was accomplished first, either as an LAVH or LSH.  The space of Retzius was entered about an inch cephalic to the pubic bone by sharp and blunt dissection with scissors, cautery or harmonic scalpel. Coopers ligament was exposed and cleaned of areolar tissue and fat.  The surgeon’s left hand was inserted into the vagina and the Foley bulb palpated between the index and second fingertips.  The fingertips thus supported the bladder neck on either side of the catheter bulb and defined the area to be stapled. Using a laparoscopic Kitner dissector or a grasper the bladder was deflected medially and the pubovesicocervical fascia exposed.  A rectangular piece of Prolene mesh about 2x4 cm was prepared.  It was inserted through one of the ports and stapled into place, first to the paravaginal tissues and then, as the surgeon’s left hand supports the vagina, to Coopers ligament. Because of the dimensions of the mesh, this provided a gap of about 3 cms from the lower edge of Cooper’s ligament to the paravaginal staples. One side was completed before the other was begun. Little or no bleeding was encountered.  The area was lavaged with Ringer’s lactate, and the peritoneum reaproximated with the hernia stapler.  Indigo Carmine was injected intravenously and cystoscopy is done to exclude bladder perforation or stapling.  If staples were seen perforating the bladder they were removed with a rigid cystoscopy grasper. If removal of a staple was thought to compromise the repair, that is, if the perforating staple was in the lateral bladder,  the space of Retzius was reentered and the repair reviewed.  Most of the staples that have been removed were in the dome of the bladder and  had been placed at the time of peritoneal closure.

The operating time varied from around 20 to 45 minutes. Obviously, the operating times were longer at the beginning of the series. Patients were kept overnight and the Foley removed within 12 to 24 hours.  Residual urines were checked for the first two voidings and self-catheterization was taught if necessary.  Cefotan was given preoperatively. Prophylactic antibiotics were continued if self-catheterization was required. All patients were discharged in less than 48 hours, and most in less than 36. No patient required immediate re-operation for a complication and no patient had urinary retention lasting beyond 7 days. There were no abscesses, transfusions, hematomas requiring drainage, or osteitis pubis. Bladder perforations were sustained during dissection in less than ten percent of cases.  These were sutured laparoscopically and the catheter was left in for up to 7 days. 

Results:

There were 50 patients in this series. 47 had follow-up of between 3 and 50 months.  Age ranged from 27 to 88 years, average 49.  The weight ranged from 107 to 253 lbs, average 158.  Follow up was by telephone call from a nurse (KS).  The follow-up consisted only of the following subjective question: “Are you dry, improved or not improved?  Of the 50 patients operated in this time, 47 were available for evaluation at greater than 3 months since surgery. Of this number, 38 or 80.8 % were dry; 6, or 12.8%, were improved and 3 or 6.4 % were not improved.   

There were 10 patients followed 40 to 50 months. 8 of them were dry and 2 were improved. Of 13 patients followed from 20 to 39 months, 9 were dry and 4 were improved.  There were 24 patients followed from 1 to 19 months. Of these 21 were dry and 3 failed. Once a patient failed her follow up was terminated.  Of the three failures, two occurred within one month of operation and one was after 7 months dry. No patient had to have an operation to remove the mesh for erosion, pain or dyspareunia. One patient was found to have staples in the muscularis of the bladder two years postoperatively. These were removed cystoscopically.   

Discussion:

Obviously the goal of therapy is to render the incontinent patient dry.  Genuine stress urinary incontinence is a major health problem in women as they age.  The surgical goal is to provide the best outcome with the least morbidity at the most reasonable cost.  Literature reports have compared the costs involved in open and Laparoscopic Burch procedures.⁸   It is obvious that the significance of financial analysis is dependent on the surgeon’s preference for single-use instruments, as well as a changing and competitive marketplace, with the surgeon’s experience reducing operating time.   A decrease in hospital time coupled with a shorter time to return to work may be more important benchmarks if the results are not compromised. While these factors are not compared in this paper, there is an obvious benefit to the laparoscopic approach because of the shorter hospitalization required.  It is, however, moot unless the success of the procedures is comparable.  It is unlikely that many surgeons will elect to use an operation just because it has a shorter recovery time, if it has more complications or a lower success rate.  Determining the success of laparoscopic Burch procedures remains difficult because of the continuously evolving technique, and operator experience.  There is great variation in the criteria used in selecting the patients, and evaluating success.

 The purpose of this case series is to describe our results with this technique. We hope that this will stimulate further interest in pursuing minimally invasive anti-incontinence procedures.

            The success of the Burch procedure has been quoted as 75 to 90 per cent ^8,10,11,12 Our results of 86% dry and 92% improved compare favorably with this range. We found no immediate complications that increased hospitalization or resulted in immediate re-operation. One patient required re-operation after two years for a complication.    Morbidity rates are low and most complications are minor for both the open and laparoscopic techniques but it is unarguable that hospitalization is longer for open surgery than for the endoscopic approach.⁹    Previously, it was common to keep patients in hospital for 5 to 7 days following laparotomy and to encourage rest and recuperation for 4 to 6 weeks.  In the current reimbursement environment, patients with laparotomy are commonly discharged in 48 hours or less with little to suggest patient satisfaction with the shorter hospitalization time.  Women undergoing laparoscopic procedures are discharged in 24 to 36 hours or less. They generally return to their normal activities sooner because there is less incisional discomfort.  A shorter hospital stay, less pain, and more rapid return to normal activity is obviously a saving in cost.  Patients in this series had a hospital stay of less than 48 hours in all cases.  The success rate of 94% for patients both dry and improved, compares favorably with the open operation, with no higher rate of complications and with less short-term morbidity.  These results argue that it is reasonable to continue to investigate laparoscopic techniques of Burch retropubic colposuspension in larger series with a more rigorous study design, particularly regarding patient selection, complications and results.

Bibliography

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