TABLE 31.1 Landmark Articles for Burch Colposuspension
Sean L. Francis
The International Continence Society defines stress urinary incontinence (SUI) as involuntary leakage on effort, exertion, sneezing, or coughing.1 SUI can be treated by surgical options including Burch colposuspension; pubovaginal slings; urethral bulking; and retropubic, transobturator, or single-incision midurethral slings (MUS).2 Although synthetic MUS have been the procedure of choice for several years,3 the use of surgical mesh has become a public health problem and, as of writing this chapter, its use has been suspended in the United Kingdom.3,4 Therefore, the well-trained pelvic floor surgeon should be comfortable offering nonmesh options for SUI including retropubic colposuspensions.
Described in 1949, the Marshall-Marchetti-Krantz was the first retropubic procedure for SUI and involved placement of interrupted sutures into the periosteum of the pubic symphysis.5 This procedure was modified by John Burch in 1961. Dr. Burch described the bilateral placement of three interrupted sutures between the periurethral tissue and the iliopectineal (Cooper) ligament which is the thick band of fibrous tissue found on the superior surface of the superior ramus of the pubic bone.5,6 Most surgeons will recognize the Tanagho modification, first described in 1976, that involves bilateral placement of two sutures in the anterior vaginal wall, one in the midurethra and the second at the level of bladder neck, avoiding the urethral sphincter complex (Figs. 31.1 and 31.2).5,7 Since these early descriptions, the Burch colposuspension has waxed and waned in popularity.3 The open Burch colposuspension was long considered the gold standard of treatment for SUI, although its popularity decreased after the widespread adoption of MUS.2,8,9,10,11 The advent of minimally invasive surgery and the scrutiny around the use of mesh has led to an increase in safe and effective use of minimally invasive techniques for Burch colposuspension.8,12 The landmark articles for the Burch colposuspension have been listed in Table 31.1.
The choice of surgical treatment for SUI varies based on clinical scenario, coexisting conditions, and specialty or preference of the surgeon.8,9 Although Burch colposuspension may be offered to any patient, the ideal clinical scenario is a mesh-averse patient, a history of mesh infection, or previous mesh complication. The surgery may also be appropriate for women with stress incontinence and a hypermobile urethra undergoing abdominal surgery for other indications.9 The addition of Burch colposuspension at the time of abdominal sacral colpopexy in continent women should be individualized.13,14 This decision is more challenging in patients with intrinsic sphincter deficiency (ISD) where surgical outcomes data is conflicting.15,16,17 In the surgical treatment of ISD, experts recommend MUS or pubovaginal sling over Burch colposuspension.16
MECHANISM OF ACTION
To maintain continence, the urethral closure pressure must exceed the pressure within the bladder. A common theory postulates that the transmission of intraabdominal pressure to the bladder, and bladder neck can only be maintained when the urethra remains above the pelvic floor.18 Displacement of the urethra outside the abdomen may occur secondary to changes around the bladder neck due to pelvic organ prolapse or tissue damage.11,19 By resuspending the anterior vaginal wall, the Burch colposuspension is thought to restore the hypermobile urethra to its normal anatomy.20 This has been corroborated by imaging studies where shorter distance between the bladder neck and levator ani muscles was associated with surgical success.21 An additional mechanism is the mechanical compression provided to the urethra by a stable anterior vaginal wall and the pubic symphysis. Older studies have suggested that the Burch procedure may affect urethral resistance or increase obstruction as a mechanism for stress continence.22,23 In a large multicenter study, Kraus et al.24,25 demonstrated increased urethral resistance and obstructive changes on urodynamics 2 years after a Burch procedure.
The retropubic space is an extraperitoneal, avascular, potential space commonly encountered during anti-incontinence surgery. It is also known as the “space of Retzius” and lies between the pubic symphysis and the bladder, behind the transversalis muscle but in front of the peritoneum.11 It is bound laterally by the pubic bone and obturator internus muscle, whereas the arcus tendinous fascia pelvis (ATFP) forms the posterolateral boundaries, and the floor is formed by the anterior vagina and its endopelvic attachments, inserting in to the ATFP.11,26 Specific to the Burch procedure, the points of interest include the midurethra, the urethrovesical junction, and the Cooper or iliopectineal ligament which can be found lateral to the pubic tubercle beneath the superior margin of the pubic ramus (Fig. 31.3; Video 31.1). Vascular landmarks in this space include the external iliac vessels which are approximately 2.9 cm from the lateral Cooper ligament and the obturator neurovascular bundle which lies 2.6 cm away.27 The obturator neurovascular bundle exits the pelvis at the level of the obturator foramen and can contribute to the “corona mortis” which is an anastomosis between the obturator and inferior epigastric vessels and can be a source of bleeding during retropubic surgery.11 The anterior vaginal wall is composed of fibroadipose tissue, nerves, and blood vessels which can also bleed while placing sutures through the vaginal fibromuscular layer as recommended by Tanagho.7,26
As previously described, the original technique involved placement of three sutures via laparotomy and was modified by Tanagho7 to two sutures placed on each side. With the advent of laparoscopic colposuspension in 1991, modifications to this technique were described using some combination of suture, staples, or mesh to compensate for the steep learning curve associated with laparoscopic suturing.10,28,29 However, the use of these modifications, including placement of clips, surgical mesh, and one suture instead of two, have all demonstrated inferior outcomes to the original modification described by Tanagho.7,10,30,31,32,33,34