Laparoscopic Paravaginal Repair Plus Burch Colposuspension: Review and Descriptive Technique

ELSEVIER

LAPAROSCOPIC PARAVAGINAL REPAIR PLUS BURCH COLPOSUSPENSION: REVIEW AND DESCRIPTIVE TECHNIQUE

JOHN R. MIKLOS ANDNEERAj KOHL!

ABSTRACT The objective of this article was to review the available literature on laparoscopic Burch urethropexy cure rates and describe the authors' laparoscopic technique and experience with Burch urethropexy and paravaginal repair. A MEDLINE search (1991 to 1999) was performed for articles describing the laparoscopic Burch urethropexy using suture to elevate and stabilize the paraurethral tissue. Also a retrospective chart review of the authors' 171 consecutive patients between January 1997 and December 1999 was done. The laparoscopic Burch urethropexy and paravaginal repair is described using an open laparoscopic technique with 3 accessory ports for access. A transperitoneal approach is taken to gain access to the space of Retzius. The anterior vaginal wall and its paravaginal defects, if present, are identified. Nonabsorbable sutures are placed in a conventional fashion. The paravaginal repair is used for support of the anterior vaginal wall proximal to the urethral vesical junction and the Burch urethropexy distal to the vesical neck. An average of 6 sutures are used for the paravaginal repair and 4 sutures for the Burch urethropexy. Cystoscopy is performed to ensure no breech of lower urinary tract integrity. In all, 20 articles describing a laparoscopic Burch urethropexy and postoperative cure rate were identified. Cure rates ranged from 69% to 100%. A review of our experience revealed 130 of 171 patients had a Burch urethropexy and paravaginal repair, 23 of 171 patients a Burch urethropexy alone, and 18 of 171 patients a paravaginal repair alone. Of the authors' 171 patients, 4 (2.3%) had injury to the lower urinary tract during laparoscopic Burch urethropexy or paravaginal repair. All 4 injuries were cystotomies, 2 in patients with previous open retropubic ure- thropexies. No ureteral ligations or intravesical placement of suture was diagnosed. Other surgical param- eters for the laparoscopic Burch uethropexy and paravaginal repair include an estimated blood loss of 50 mL, average hospital stay of less than 23 hours, and an average operative time of 70 minutes. All patients had their surgery completed via laparoscopy. The literature review and our personal experience suggests that the laparoscopic Burch urethropexy and paravaginal repair are safe and effective alternatives to traditional laparotomy for the treatment of genuine anatomic stress urine incontinence and cystourethrocele resulting from lateral vaginal wall defects. UROLOGY56 (SuppI6A): 64-69, 2000. @2000, Elsevier Science Inc.

S ince the introduction of the retropubic urethral shorten operative time, and reduce surgical mor- suspension in 1910, over 100 different surgical bidity. Despite the number of surgical procedures techniques for the treatment of genuine stress uri- developed each year, the Burch colposuspension nary incontinence (GSUI) have been described.1 and pubovaginal sling operations have remained Many have been modifications of original proce- the mainstay of surgical correction for GSUI be- dures in an attempt to improve clinical outcome, cause of their high long-term cure rates. However, these procedures do not address the concurrent anterior vaginal wall prolapse often associated with From Urogynecology and Reconstructive Pelvic Surgery, North- side Hospital, Atlanta, Georgia, USA, Medical College of Geor- GSUI secondary to urethral hypermobility. We gia, Augusta, Georgia, USA (J.R.M.), and Urogynecology and present a laparoscopic approach to anterior vaginal Reconstructive Pelvic Surgery, Mount Auburn Hospital, Harvard wall reconstruction using the paravaginal repair University, Boston, Massachusetts, USA (N.K.) and Burch colposuspension for treatment of cysto- Reprint requests:]ohnR. Miklos, MD, 3400 C Old Milton Park- way, Suite 330, Alpharetta (Atlanta), GA 30005. E-mail: cele and stress urinary incontinence, respectively, resulting from lateral vaginal wall support defects. j [email protected]

(Q 2000, ElSEVIERSCIENCE INC. 0090-4295/00/$20.00 64 ALL RIGHTS RESERVED PII50090-4295(00)00510-0 Emphasizing the principles of minimally invasive surgery, the laparoscopic approach has been successfully adopted for many procedures that previously relied on an abdominal or transvaginal route. First described in 1991, the laparoscopic retropubic colposuspension has rapidly gained popu- Superficial larity because of its many reported advantages, in- epigastric artery cluding improved visualization, shorter hospital stay, faster recovery, and decreased blood loss.2 Superficial circumflex Iliac artery OPERATIVE INDICATIONS

Laparoscopyshould be considered only as a Femoral mode of abdominalaccess and not a changein the ertery operative technique. Ideally the indications for a FIGURE I. Abdominal port placement: used for com- laparoscopicapproach to retropubic colposuspen- bined Burch procedure and paravaginal repair. (@ 2000 sion should be the sameas an open (laparotomy) by Miklos and Kohli.) approach.This would include patients with GSUI and urethral hypennobility. The authors believe the laparoscopic Burch colposuspensioncan be substituted for an open Burch colposuspensionin SURGICAL TECHNIQUE the majority of cases.Factors that might influence this decisioninclude any history of previouspelvic LAPAROSCOPICPARAVAGINAL REPAIR or anti-incontinencesurgery, the patient's ageand We routinely perform open laparoscopy at the weight, the need for concomitant surgery, contra- inferior margin of the umbilicus. A 10-mm access indications to generalanesthesia, and the surgeon's port is used at this site to introduce the laparo- experience.The surgeon'sdecision to proceedwith scope. The abdomen is insufflated with CO2 to a laparoscopic approach should be based on an IS mm Hg intra-abdominal pressure. Three addi- objective clinical assessmentof the patient as well tional ports are placed under direct vision (Fig. 1). as the surgeon'sown surgical skills. If the patient The choice of the individual port size depends on demonstratesa cystocelesecondary to a paravagi- what concomitant surgery is planned for that pa- nal defect diagnosed either pre- or intraopera- tient. tively, a paravaginaldefect repair should be per- The bladder is filled in a retrograde fashion with fonned before the colposuspension.This approach 200 to 300 mL normal saline, allowing identifica- combinesthe paravaginalrepair with Burch colpo- tion of the superior border of the bladder edge. suspensionfor treatment of anterior vaginal pro- Entrance into the space of Retzius is accomplished lapse secondaryto paravaginaldefects and stress by a transperitoneal approach using a harmonic urine incontinence secondaryto urethral hyper- scalpel. The incision is made approximately 3 cm mobility.3 above the bladder reflection, beginning along the medial border of the right obliterated umbilicallig- PREOPERATIVE CONSIDERATIONS ament. Immediate identification of loose areolar tissue at the point of incision confirms a proper We recommend that all patients have a modified plane of dissection. bowel preparation consisting of a full liquid diet 48 After the space of Retzius has been entered and hours before scheduled surgery and a clear liquid the pubic ramus visualized, the bladder is drained diet and one bottle of magnesium citrate 24 hours to prevent injury. The retropubic space is devel- before surgery. This regimen appears to improve oped by separating the loose areolar and fatty lay- visualization of the operative field by bowel de- ers using blunt dissection. Blunt dissection is con- compression and reduces that chance of contami- tinued until the retropubic anatomy is visualized. nation in case of accidental bowel injury. A single The pubic symphysis and bladder neck are identi- dose of prophylactic intravenous antibiotics is ad- fied in the midline and the obturator neurovascular ministered 30 minutes before surgery. Antiembolic bundle, Cooper's ligament, and the arcus tendi- compression stockings are routinely used. The pa- nous fascia pelvis are visualized bilaterally along tient is intubated, given general anesthesia, and the pelvic sidewall (Fig. 2). The anterior vaginal placed in a dorsal lithotomy position with both wall and its point of lateral attachment from its arms tucked to her side. A 16F 3-way Foley cathe- origin at the pubic symphysis to its insertion at the ter with a 5-mL balloon tip is inserted into the ischial spine is identified. If paravaginal wall de- bladder and attached to continuous drainage. fects are present, the lateral margins of the pubocer-

UROLOGY .56 (Supplement 6A), Decemb'T 2000 65 Urethra

FIGURE 2. Space of Retzius: normal anatomy. (@ FIGURE4. Paravaginal repair: reapproximation of 2000 by Miklos and Kohli.) vaginal wall to the obturator internus at the arcus ten- dineusfascia pelvis. ((9 2000 by Mixlos and Kohli.)

is begun by inserting the surgeon's nondominant hand into the vagina to elevate the anterior vaginal wall and the pubocervical fascia to their normal attachment along the arcus tendineus fascia pelvis. A 2-0 nonabsorbable suture with attached needle are introduced through the 12-mm port, and the needle is grasped using a laparoscopic needle ,. driver. The first suture is placed near the apex of the L I .vagina through the paravesical portion of the evaOT ani pubocervical fascia. The needle is then passed through the ipsilateral obturator intemus muscle and fascia around the arcus tendineus fascia at its origin 1 to 2 cm distal to the ischial spine. The suture is secured using an extracorporeal knot-tying technique. Good tissue approximation is accomplished without a suture bridge. Sutures are FIGURE3. Paravaginal defects: lateral vaginal wall placed sequentially along the paravaginal defects defects result in a cystourethroceleas seen from the from the ischial spine toward the urethrovesical space of Retzius.(@ 2000 by Miklos and Kohli.) junction. Usually, a series of 2 to 4 sutures is placed between the ischial spine and a point 1 to 2 cm proximal to the urethrovesical junction (Fig. 4). The laparoscopic colposuspension is performed vical fascia will be detached from the pelvic side- distal to the urethrovesical junction. The surgical wall at the arcus tendinous fascia pelvis (white procedure is repeated on the patient's opposite side line). The lateral margins of the detached pubocer- if bilateral defects are present. Upon completion of vical fascia and the broken edge of the white line the bilateral paravaginal repair, the Burch colpo- can usually be clearly visualized confirming the suspension is performed. By performing the para- paravaginal defect. Unilateral or bilateral defects vaginal defect repair first, normal anatomic sup- may be present (Fig. 3). port of the anterior vaginal segment is recreated, We recommend completion of the laparoscopic reducing the chance of overelevation of the para- paravaginal repair before the colposuspension. Af- urethral Burch sutures and subsequent voiding ter identification of the defect, the combined repair dysfunction.

66 UROLOGY 56 (Supplement6A). December2000 furosemide intravenously, and a 70-degree cysto- scope is used to visualize the bladder lumen, assess for unintentional stitch penetration, and confirm bilateral ureteral patency. After cystoscopy, atten- tion is returned to laparoscopy. We recommend routine closure of the anterior peritoneal defect using a multifire hernia stapler. All ancillary trocar sheaths are removed under direct vision to ensure hemostasis and exclude iatrogenic bowel hernia- tion. Excess gas is expelled and fascial defects of 10 mm or more are closed using delayed absorbable suture. Postoperative bladder drainage and voiding trials are accomplished using either a transurethral catheter, suprapubic tube, or intermittent self- catheterization.

CLINICAL RESULTS C Mikk>slKohli Since Vancaillie and Schuessler2 published the first laparoscopic colposuspension case series in FIGURE 5. Paravaginal repair plus Burch urethropexy. 1991, many other investigators have reported their (@ 2000 by Miklos and Kohli.) experience. Review of the literature reveals a lack of uniformity in surgical technique and surgical materials used for colposuspension. This lack of LAPAROSCOPICBURCH COLPOSUSPENSION standardization is also noted with the conventional This laparoscopic technique parallels our open open (laparotomy) technique. Because of this lack technique and has previously been described.4The of standardization and the steep learning curve as- laparoscopic colposuspension is performed using sociated with laparoscopic suturing, surgeons have nonabsorbable No. 0 sutures; we routinely use attempted to develop faster and easier ways of per- polytrifluoroethlyene. The surgeon's nondomi- forming a laparoscopic Burch colposuspension. nant hand is placed in the vagina and a finger is These modifications have included the use of sta- used to elevate the vagina. The endopelvic fascia pling devices,s bone anchors,6 synthetic mesh,7 on both sides of the bladder neck and midurethra is and fibrin glue.8 However, we believe the laparo- exposed using an endoscopic blunt dissector. The scopic approach should be identical with the open first suture is placed 2 cm lateral to the urethra at technique to allow comparative studies. the level of the midurethra. A figure of 8 suture, There are several reported laparoscopic Burch incorporating the entire thickness of the anterior colposuspension case series that have used con- vaginal wall excluding the epithelium, is taken, ventional surgical technique and suture materials. and the suture is then passed through the ipsilat- Published cure rates range from 69% to 100°;("with eral Cooper's ligament. the majority of the studies reporting cure rates With an assistant's fingers in the vagina to elevate greater than 80% (Table 0.10-29 Although there the anterior vaginal wall toward Cooper's liga- have been no studies regarding the long-term re- ment, the suture is tied down with a series of ex- sults of the laparoscopic paravaginal plus colpo- tracorporeal knots using an endoscopic knot suspension procedure, one would assume that pusher. An additional suture is then placed in a there is a higher cure rate for the paravaginal plus similar fashion at the level of the urethrovesical Burch colposuspension (8 to 12 sutures) compared junction, approximately 2 cm lateral to the bladder with the Burch colposuspension only (4 sutures) edge on the same side. The procedure is repeated for the treatment of stress urinary incontinence, on the opposite side. Excessive tension on the vag- because more sutures results in a greater distribu- inal wall should be avoided when tying down the tion of force to the pelvic floor during episodes of sutures. We routinely leave a suture bridge of ap- increased abdominal pressure. proximately of 2 to 3 cm (Fig. 5). Most authors have reported decreased blood Upon completion of the paravaginal repair and loss, shortened hospitalization, and decreased Burch urethropexy, the intra-abdominal pressure postoperative pain and recovery time. Our experi- is reduced to 10 to 12 mm Hg, and the retropubic ence of 171 laparoscopic paravaginal repair and space is inspected for hemostasis. Cystoscopy is Burch urethropexy procedures has seen an average performed to rule out urinary tract injury. The pa- operative time of 70 minutes, hospital stays of less tient is given 5 mL of indigo carmine and 10 mL than 23 hours, estimated blood loss of less than 50

IJROLOGY 56 (Supplement 6A), December2000 67 TABLE I. Review of laparoscopic Burch urethrocystopexy conventional suturing technique No. of Follow-up Objective Cure Rate Author (year) Patients (mo) Data (%) AIbalaeta/(1992)1O 10 .7 Yes 100 Burton (1993)11 30 12 73 Polasciketa/(1994)12 12 20..8 83 Liu (1994)13 132 18 Yes 96 Gunneta/(1994)14 15 4-9 Yes 100 Nezhat et a/ (1994)15 62 8-30 Yes 100 Lyons (1995)16 10 >12 90* McDougal et a/ (1995)17 10 12 78* Ross (1995)18 32 12 Yes 94 Langebrekke et a/ (1995)19 8 3 Yes 88 Radomski et a/ (1995)20 34 17.3 85 Ross (1996)21 35 12 Yes 91 Cooper et a/ (1996)22 113 8 87 Lam et a/ (1997)23 107 16 Yes 98 Su et a/ (1997)24 46 12 Yes 80* Papasakelariou and Papasakelariou25 32 24 91 Lobel and Davis (1997)26 35 34 69* Ross (1998)27 48 24 Yes 89 Miannay et a/ (1998)28 36 24 69 Saidi et a/ (1998)29 70 15.9 91 .Some or all urethrocyslopmesperformed using onlyone suture on eachside mL, and an overall lower urinary tract injury rate of atomic stress urinary incontinence as well as ante- less than 3°;c,without an incidence of ureteral com- rior vaginal segment prolapse. promise. Although some have reported subsequent laparotomy to repair the cystotomy, in all caseswe REFERENCES have been able to repair the bladder laparoscopi- 1. GoebellR: Zur operativenbeseillgung der angeharenen cally. This is performed using a delayed absorbable incontinence vesicae.Incontinentia VesicaeGynakol Urol 2: suture in an interrupted single-layer fashion. Be- 187-191, 1910. 2. Vancaille TG, and SchusslerW: Laparosocpicbladder- cause all cystotomies were found in the dome of neck suspension.] LaparoendoscSurg 1: 169-173, 1991. the bladder, prolonged bladder catheterization was 3. Miklos]R, and Kohli N: "ParavaginalPlus" Burch pro- not necessary. The Foley catheter was removed cedure: a laparoscopicapproach. ] Pelvic Surg 4: 297-302, when the patient could empty 80°;c,of her total 1998. bladder volume. Early recognition of bladder in- 4. Kohli N, and Miklos]R: LaparoscopicBurch colposuspension: a modem approach. Contemp abstet Gynecol42: jury and proficiency in laparoscopic suturing tech- 36-55,1997. niques are critical elements in this approach. Re- 5. HenleyC: The Henleystaple-suture technique for lapa- ports suggest this complication depends on the roscopic Burch colposuspension.] Am Assoc Gynecol Lapa- learning curve and declines with increasing surgi- roscopists2: 441-444,1995. cal experience.16 6. Das S,and Palmer]K: Laparoscopiccolpo-suspension. ] Uro1154: 1119-1121,1995. 7. au CS,Presthus], and BeadleE: Laparoscopicbladder CONCLUSION neck suspensionusing hernia mesh and surgical staples.] LaparoendoscSurg 3: 563-566, 1993. Despite its recent introduction and lack of long- 9. Kiilholma P,Haarala M, Polvi H, Makinen], and Chan- term data, the laparoscopic Burch colposuspension cellor MB: Sutureless colposuspensionwith fibrin sealant. has become popular for treatment of urinary stress TechUroll: 81-3, 1995. incontinence. Although initial data suggest this 10. Albala DM, SchuesslerWW, and Vancaillie TG: Lapa- technique is a safe and effective alternative to tra- roscopic bladder suspensionfor the treatment of stressincontinence. SeminUroll0: 222-225, 1992. ditionallaparotomy, surgeons should approach it 11. Burton G: A randomized comparison of laparoscopic with caution. Laparoscopic suturing and a thor- and open colposuspension(abstract). Neurourol Urodyn 16: ough knowledge of anatomy are essential if we are 353-354, 1993. to have long-term outcome data equivalent to the 12. PolascikT], Moore RG, RosenbergMT, and Kavoussi traditional open technique. Future prospective LR: Comparisonof laparoscopicand open retropubic colposuspensionfor treatment of stressurinary incontinence. Urol- randomized clinical trials may establish the lapa- ogy45: 647-652, 1995. roscopic approach as a minimally invasive method 13. Liu CY: Laparoscopic treatment of genuine urinary for successful long-term treatment of genuine an- stressincontinence. Clin abstet Gynecol8: 789-798, 1994.

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