Laparoscopic Burch colposuspension: intraperitoneal approach

The description of the laparoscopic Burch colposuspension: intraperitoneal approach covers all aspects of the surgical procedure used for the management of stress urinary incontinence without major sphincter insufficiency. Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: dissection, colposuspension. Consequently, this operating technique is well standardized for the management of this condition.

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Laparoscopic   Burch   colposuspension:   intraperitoneal   approach

Authors
J Raiga
Abstract
The description of the laparoscopic Burch colposuspension: intraperitoneal approach covers all aspects of the surgical procedure used for the management of stress urinary incontinence without major sphincter insufficiency.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: dissection, colposuspension.
Consequently, this operating technique is well standardized for the management of this condition.
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2002-10
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E-publication
WeBSurg.com, Oct 2002;2(10).
URL: http://www.websurg.com/doi-ot02en283.htm

Laparoscopic   Burch   colposuspension:   intraperitoneal   approach

1. Introduction
Burch first described the colposuspension technique (also called retropubic urethropexy) in 1961 (Burch, 1961). It has become an important technique for treatment of stress urinary incontinence without major sphincter insufficiency.

The development of minimally invasive surgery (Vancaillie and Schuesser, 1991) has made it possible to perform a Burch type urethropexy laparoscopically, using either an extraperitoneal or a transperitoneal approach. The transperitoneal approach allows the surgeon to perform an exploration of the pelvis and other therapeutic procedures (treatment of an adnexal pathology or a hysterectomy) during the same operation (Bruhat et al., 1995). The extraperitoneal approach avoids any breach in the integrity of the peritoneum, but the operative field is further reduced (Saidi et al., 1998).
2. Anatomy
1. Pubic symphysis
2. Lateral part of vaginal vault
3. Bladder with Foley catheter
4. Vesical vein
5. Obturator nerve
6. External iliac vein
7. Iliopectineal (Cooper’s) ligament
8. Tendinous arch of levator ani muscles

3. Indications
Burch colposuspension is one of the treatments suggested for stress urinary incontinence caused by a loss of the posterior urethrovesical angle.
Certain clinical and urodynamic criteria favor an improvement in the outcome of this procedure:
- positive Bonney test;
- absence of micturition during exertion on the flowmeter;
- absence of residual urine in the bladder after micturition;
- absence of major urethral sphincter deficiency (closure pressure >30 cm H2O).

Contraindications
The contraindications are the same as those for anesthesia and for laparoscopy in general.
4. Operating room set-up
• Patient
- bowel preparation not mandatory;
- indwelling Foley catheter;
- legs spread, 10° to 15° Trendelenburg;
- pneumoperitoneum with Palmer needle.
• Team
1. The surgeon is on the left side of the patient.
2. The assistant is on the right side of the patient.
3. The scrub nurse is on the patient’s left, next to the surgeon.
• Equipment
1. Laparoscopic unit
2. Second monitor
The laparoscopic unit and monitor are located at the patient’s feet. For ergonomic reasons, a second monitor should be placed opposite the assistant.
5. Trocar placement
• Landmarks
Four trocars are usually necessary. They are placed at the level of:
- the umbilicus;
- the pubis;
- the right anterior superior iliac spine;
- the left anterior superior iliac spine.
• Trocar placement
The sizes and positions of the trocars are as follows:
A: 11 mm, at the level of the umbilicus
B: 8 mm, above the pubis, at the pubic hairline
C: 5 mm, in the right iliac fossa, 3 cm medial to the right anterior superior iliac spine
D: 5 mm, in the left iliac fossa, 3 cm medial to the left anterior superior iliac spine
Uterine cannulation is not required, unless the Burch colposuspension is combined with a hysterectomy.
6. Instruments
1. Atraumatic graspers
2. Graspers
3. Scissors
4. Needle holder
5. Bipolar coagulating device
6. Monopolar coagulating device
7. Suction-irrigation device
7. Dissection
• Peritoneal incision
The procedure begins with the division of the supravesical peritoneum. The first assistant, on the patient’s right, pulls the prevesical peritoneum downwards with a grasper. For the incision of the peritoneum, we advise using monopolar laparoscopic scissors. The incision is made between the 2 umbilical arteries, above the bladder.
• Opening of Retzius’ space
a. Dissection of the retropubic (Retzius’) space on the right
b. Dissection of the retropubic space on the left
1. Pectineal (Cooper’s) ligament
2. Levator ani muscles
3. Insertion of the vagina on the levator ani muscles
4. Vagina
5. Vesical vein
Once the supravesical peritoneum has been incised, the correct dissection plane, situated between the abdominal wall and the bladder, must be found. A common error is to dissect too close to the bladder, which can lead to a vesical injury. The dissection plane should be avascular.

Dissection of the retropubic space is pursued until the pectineal ligaments on the posterior surface of the superior pubic rami can be seen. These ligaments have a characteristic pearly white color. The dissection of the pectineal ligaments is progressively performed medially to laterally from the pubic symphysis. The external iliac vein should be visualized laterally. More caudad, the pelvic wall with the lateral insertion of the vagina on the tendinous arch of the levator ani muscles should be visible. The dissection is pursued laterally. The lateral edges of the bladder are retracted medially to visualize the most external part of the vaginal vault on each side.
8. Colposuspension
• Principle
1. Bladder with balloon
2. Vaginal vault
3. Pectineal ligament
4. External iliac vein
Non-absorbable braided suture is used. The needle is introduced into the abdominal cavity through the 8 mm central suprapubic trocar. The surgeon makes 2 stitches on each side, from the pectineal ligament to the vaginal vault.
• Suture
On the left side:
1. Passage of needle through iliopectineal ligament
2. Passage of needle through vagina
3. Pectineal ligament
4. Vaginal vault suspended from the iliopectineal ligament
5. Bladder with balloon
The needle is passed through the pectineal ligament in a curved fashion, cranially to caudally. A first suture is placed 4 cm from the pubic symphysis.
A second suture is then placed lateral to the first. The needle is grasped with the needle holder to perform the vaginal passage.
The surgeon inserts a finger into the vagina to facilitate identification of the area where the needle is to pass. The needle should incorporate the entire thickness of the vaginal wall, but should not go through it. The finger placed in the vagina is used to make sure that this is done correctly.
The knots are tied using half hitches pushed down with a knot pusher. The knots are tightened to obtain a simple suspension. If they are too tight, the urethrovesical junction will lose its mobility.
• Final view
1. Bladder with balloon catheter
2. Suspension of vaginal vault from iliopectineal ligaments
3. Pectineal ligaments
On each side, the 2 suspension sutures are seen between the pectineal ligaments and the ipsilateral vaginal vault. The balloon in the bladder is elevated in the retropubic space due to the subjacent tension created by the colposuspension. Certain authors end the procedure by closing the peritoneum with absorbable running or interrupted suture. We do not close the peritoneum.
9. Complications
1. Anastomotic vein
Intraoperative complications are rare if the dissection is performed carefully. By dissecting between the embryologic planes, bleeding can be avoided. Meticulous hemostasis is required during all steps of the procedure to correctly identify each structure and to avoid injuring the lateral structures (especially the external iliac vein and the obturator nerve). A small anastomotic vein between the inferior epigastric veins and the obturator vein, called the corona mortis, may be present. It crosses the pectineal ligament about 6 cm from the pubic symphysis. The surgeon must identify this vein and avoid it. Vesical injuries are a possible complication at the beginning of the dissection, between the abdominal wall and the bladder, if the surgeon does not take care to dissect anteriorly against the abdominal wall.
10. Results
Results
Comparisons of the open Burch technique with other frequently used ones have been carried out. A randomized study of Bergman (Bergman and Elia, 1995) compares the results of Burch colposuspension, modified Peyrera needle suspension, and Kelly plication at 1-year and 5-year post-procedure, with a higher cure rate for the Burch technique. Objective criteria were used (absence of stress urinary incontinence).

A British study (Alcalay et al., 1995) cites a 69% cure rate for the Burch technique 10 to 12 years after the procedure. In laparoscopic colposuspension, the use of 2 single-bite sutures on each side of the urethra seems to have better results than 1 double-bite suture on each side (Persson and Wolner-Hanssen, 2000).
For some authors, the results of the laparoscopic Burch procedure are less favorable. In a randomized study of 100 patients, McDougall (1999) compared the laparoscopic Burch technique to the transvaginal colposuspension of Raz. With a 45-month follow-up, McDougall reported a 30% cure rate for the Burch technique, as compared to a 35% cure rate for the Raz technique.
Long-term complications include voiding difficulty with a risk of recurrent urinary tract infection and de novo detrusor instability (Alcalay et al., 1995). The existing risk of subsequent rectocele or colpocele has led certain authors to combine colposuspension with a transvaginal myorrhaphy of the levator ani muscles.

Conclusion
Burch colposuspension has proven to be effective in treating stress urinary incontinence. When performed laparoscopically, the patient benefits from minimal postoperative pain and decreased hospital stay.
Because it is difficult to objectively assess results pertaining to urinary incontinence, long-term results remain subject for debate.
Several randomized studies comparing the laparoscopic Burch technique and tension-free vaginal tape insertion are currently underway. They should provide new criteria for choosing treatments for stress urinary incontinence.
11. Reference
Alcalay M, Monga A, Stanton SL. Burch colposuspension: a 10-20 year follow up. Br J Obstet Gynaecol
1995;102:740-5.
Bergman A, Elia G. Three surgical procedures for genuine stress incontinence: five-year follow-up of a
prospective randomized study. Am J Obstet Gynecol 1995;173:66-71.
Bruhat MA, Glowaczower E, Raiga J, Wattiez A, Pouly JL, Canis M, Mage G. Coeliochirurgie Encycl Méd
Chir (Paris-France), Gynécologie, 71-A-10, 1995 16p.
Burch JC. Urethrovaginal fixation to Cooper's ligament for correction of stress incontinence, cystocele and
prolapse. Am J Obstet Gynecol 1961;81:281-90.
McDougall EM, Heidorn CA, Portis AJ, Klutke CG. Laparoscopic bladder neck suspension fails the test of
time. J Urol 1999;162:2078-81.
Persson J, Wolner-Hanssen P. Laparoscopic Burch colposuspension for stress urinary incontinence: a
randomized comparison of one or two sutures on each side of the urethra. Obstet Gynecol 2000;95:151-5.
Saidi MH, Gallagher MS, Skop IP, Saidi JA, Sadler RK, Diaz KC. Extraperitoneal laparoscopic
colposuspension: short-term cure rate, complications, and duration of hospital stay in comparison with
Burch colposuspension. Obstet Gynecol 1998;92:619-21.
Vancaillie TG, Schuessler W. Laparoscopic bladderneck suspension. J Laparoendosc Surg 1991;1:169-
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