Chapter Outline
Indications for Retropubic Procedures
Role of Hysterectomy in the Treatment of Incontinence
Since 1949, when Marshall et al. first described retropubic urethrovesical suspension for the treatment of stress urinary incontinence (SUI), retropubic procedures have proved to be consistently curative. Although numerous terminologies and variations of retropubic repairs have been described, the basic goal remains the same: to suspend and to stabilize the anterior vaginal wall, and thus the bladder neck and proximal urethra, in a retropubic position. This prevents their descent and allows urethral compression against a stable suburethral layer. Selection of a retropubic approach (versus a vaginal approach) depends on many factors, such as the need for laparotomy or laparoscopy for other pelvic prolapse or disease, the amount of pelvic organ prolapse, the status of the intrinsic urethral sphincter mechanism, the age and health status of the patient, any history of previous sling or mesh complications, desires for future fertility, the preference and expertise of the surgeon, and preferences of an informed patient.
Historically, few data differentiated one retropubic procedure from another. The three most studied and popular retropubic procedures were the Burch colposuspension, the Marshall–Marchetti–Krantz (MMK) procedure, and the paravaginal defect repair. We no longer perform the MMK procedure, so this operation will not be described. We prefer the Burch colposuspension for urodynamic stress incontinence with bladder neck hypermobility and adequate resting urethral sphincter function, and sometimes combine it with a paravaginal defect repair when the patient has stage II or III anterior vaginal prolapse or when a concurrent sacrocolpopexy is to be done. The surgical techniques described here are contemporary modifications of the original operations: described the modified Burch colposuspension; the paravaginal defect repair was described by and (paravaginal repair), and by and (vaginal obturator shelf repair). Although less critically studied until recently, the paravaginal defect repair was regionally popular and widely performed in the United States. The operations described do not represent one correct technique, but a commonly used and proven method.
This chapter describes only retropubic suspension procedures that use an abdominal wall incision for direct access into the space of Retzius. The use of laparoscopy and mini incision laparotomy to enter the retropubic space and perform these and similar procedures is certainly possible and occasionally preferred, and is usually based on whether other concurrent surgeries need to be done and on what is most desired by the surgeon and the informed patient. The reader is encouraged to see Chapter 21 for a thorough critique of the use of operative laparoscopy for urinary incontinence and prolapse.
Indications for Retropubic Procedures
Retropubic urethrovesical suspension procedures are indicated for women with the diagnosis of urodynamic SUI and a hypermobile proximal urethra and bladder neck. Although retropubic procedures can be used for intrinsic sphincter deficiency with urethral hypermobility, other, more obstructive operations such as a retropubic bladder neck or midurethral sling probably yield better long-term results.
To diagnose urodynamic SUI, clinical and urodynamic (simple or complex) tests must be performed to evaluate bladder filling, storage, and emptying. Clinically, the urethra is shown to be incompetent by visually observing loss of urine simultaneous with increases in intra-abdominal pressure (a positive cough stress test). Urodynamic or radiologic methods also may be used for diagnosis. Abnormalities of bladder-filling function, such as detrusor overactivity, can coexist with urethral sphincter incompetence in up to 30% of patients and may be associated with a lower cure rate after retropubic surgery.
Women with SUI should generally have a trial of conservative therapy before corrective surgery is offered. Conservative treatment comes in the form of pelvic muscle exercises, bladder retraining, pharmacologic therapy, and mechanical devices such as pessaries. Eligible and willing postmenopausal patients with atrophic urogenital changes should be prescribed vaginal estrogen before surgery is considered.
Surgical Techniques
Operative Setup and General Entry into the Retropubic Space
The patient is supine with the legs supported in a slightly abducted position, allowing the surgeon to operate with one hand in the vagina and the other in the retropubic space. The vagina, perineum, and abdomen are sterilely prepped and draped in a fashion that permits easy access to the lower abdomen and vagina. A three-way 16- or 20-French Foley catheter with a 20- to 30-mL balloon is inserted sterilely into the bladder and kept in the sterile field. The drainage port of the catheter is left to gravity drainage, and the irrigation port is connected to sterile water, with or without blue dye, as desired. One perioperative intravenous dose of an appropriate antibiotic should be given as prophylaxis against infection within 1 h before the incision is made. Appropriate antiembolic prophylaxis is given.
A small Pfannenstiel incision is made. During intraperitoneal surgery, the peritoneum is opened, the surgery is completed, and the cul-de-sac is plicated, if necessary. The retropubic space is then exposed. Staying close to the back of the pubic bone, the surgeon’s hand is introduced into the retropubic space and the bladder and urethra is gently moved downward. Sharp dissection is not usually necessary in primary cases. To aid visualization of the bladder, 100 mL sterile water with methylene blue or indigo carmine dye may be instilled into the bladder after the catheter drainage port is clamped.
If previous retropubic or other bladder neck suspension procedures have been performed, dense adhesions and/or mesh fragments from the anterior vaginal and bladder wall and urethra to the symphysis pubis are often present. These adhesions and/or mesh should be dissected sharply from the pubic bone until the anterior bladder wall, urethra, and vagina are free of adhesions and are mobile. Mesh strips from prior slings can be removed if necessary. If identification of the urethra or lower border of the bladder is difficult, one may perform a cystotomy, which, with a finger inside the bladder, helps to define the bladder’s lower limits for easier dissection, mobilization, and elevation.
Burch Colposuspension
After the retropubic space is entered, the urethra and anterior vaginal wall are depressed. No dissection should be performed in the midline over the urethra or at the urethrovesical junction, thus protecting the delicate musculature of the urethra from surgical trauma. Attention is directed toward the tissue on either side of the urethra. The surgeon’s nondominant hand is placed in the vagina, palm facing upward, with the index and middle fingers on each side of the proximal urethra. Most of the overlying fat should be cleared away, using a swab mounted on a curved forceps. This dissection is accomplished with forceful elevation of the surgeon’s vaginal finger until glistening white periurethral fascia and vaginal wall are seen ( Fig. 18.1 ). This area is extremely vascular, with a rich, thin-walled venous plexus that should be avoided, if possible. The position of the urethra and the lower edge of the bladder is determined by palpating the Foley balloon and by partially distending the bladder to define the rounded lower margin of the bladder as it meets the anterior vaginal wall.
Once dissection lateral to the urethra is completed and vaginal mobility is judged to be adequate by using the vaginal fingers to lift the anterior vaginal wall upward and forward, sutures are placed. No. 0 or 1 delayed absorbable or nonabsorbable suture is placed as far laterally in the anterior vaginal wall as is technically possible. We apply two sutures of no. 0 braided polyester on an SH needle (Ethibond; Ethicon, Inc., Somerville, NJ) bilaterally, using double bites for each suture. The distal suture is placed approximately 2 cm lateral to the proximal third of the urethra. The proximal suture is placed approximately 2 cm lateral to the bladder wall at or slightly proximal to the level of the urethrovesical junction. When placing the sutures, one should take a full thickness of vaginal wall, excluding the epithelium, with the needle parallel to the urethra ( Fig. 18.2 , inset). This maneuver is best accomplished by suturing over the surgeon’s vaginal finger at the appropriate selected sites. On each side, after the two sutures are placed, they are passed through the pectineal (Cooper’s) ligament so that all four suture ends exit above the ligament ( Fig. 18.2 ). Before the sutures are tied, a 1 × 4-cm strip of Gelfoam may be placed if desired between the vagina and obturator fascia below the Cooper’s ligament to aid adherence and hemostasis.
As noted previously, this area is extremely vascular, and visible vessels should be avoided when possible. When excessive bleeding occurs, it can be controlled by direct pressure, sutures, or vascular clips. Less severe bleeding usually stops with direct pressure and after tying the suspension sutures.
After all four sutures are placed in the vagina and through the Cooper’s ligaments, the assistant ties first the distal sutures and then the proximal ones, while the surgeon elevates the vagina with the vaginal hand. When tying the sutures, one does not have to be concerned about whether the vaginal wall meets the Cooper’s ligament, so one should not place too much tension on the vaginal wall. A suture bridge is usually found between the two points. After the sutures are tied, one can easily insert two fingers between the pubic bone and the urethra, thus preventing compression of the urethra against the pubic bone. Vaginal fixation and urethral support depend more on fibrosis and scarring of periurethral and vaginal tissues over the obturator internus and levator fascia than on the suture material itself.
Paravaginal Defect Repair
The object of the paravaginal defect repair is to reattach, bilaterally, the anterolateral vaginal sulcus with its overlying endopelvic fascia to the pubococcygeus and obturator internus muscles and fascia at the level of the arcus tendineus fasciae pelvis. The retropubic space is entered, and the bladder and vagina are depressed and pulled medially to allow visualization of the lateral retropubic space, including the obturator internus and levator muscles, and the fossa containing the obturator neurovascular bundle. Blunt dissection can be carried dorsally from this point until the ischial spine is palpated. The arcus tendineus fasciae pelvis is often visualized as a white band of tissue running over the pubococcygeus and obturator internus muscles from the back of the lower edge of the symphysis pubis toward the ischial spine. A lateral paravaginal defect representing avulsion of the vagina off the arcus tendineus fasciae pelvis or of the arcus tendineus fasciae pelvis off the obturator internus muscle may be visualized ( Fig. 18.3 ).
The surgeon’s nondominant hand is inserted into the vagina. While gently retracting the vagina and bladder medially, the surgeon elevates the anterolateral vaginal sulcus. Starting near the vaginal apex, a suture is placed, first through the full thickness of the vagina (excluding the vaginal epithelium) and then deep into the obturator internus fascia or arcus tendineus fasciae pelvis, 1 to 2 cm anterior to its origin at the ischial spine. After this first stitch is tied, additional (three to five) sutures are placed through the vaginal wall and overlying fascia and then into the obturator internus at about 1-cm intervals toward the pubic ramus ( Fig. 18.3 , inset). The most distal sutures should be placed as close as possible to the pubic ramus, into the pubourethral ligament; alternatively, Burch colposuspension sutures can be placed bilaterally at the level of the bladder neck and urethra if the patient has SUI. No. 2-0 or 0 nonabsorbable suture on a medium-sized, tapered needle usually is used for the paravaginal repair.
This procedure leaves free space between the symphysis pubis and the proximal urethra, but secure support so that rotational descent of the proximal urethra and bladder base is prevented with sudden increases in intra-abdominal pressure. According to , it avoids overcorrection and fixation of the periurethral fascia, which might compromise the functional movements of the urethra and bladder base and lead to obstruction and voiding difficulty. This principle may explain why the paravaginal defect repair usually results in spontaneous voiding on the first or second postoperative day. In fact, the vaginal obturator shelf repair was used to correct dysfunctional voiding symptoms in patients after previous retropubic surgery.
General Intraoperative and Postoperative Procedures
If the surgeon is concerned that intravesical suture placement or ureteral obstruction may have occurred, cystoscopy—either transurethrally or through the dome of the bladder—or a small cystotomy may be performed to document ureteral patency and the absence of intravesical sutures after retropubic procedures. Intravenous injection of indigo carmine before cystoscopy aids visualization of urine from the ureters.
Closed suction drains in the retropubic space are used only as necessary when hemostasis is incomplete and there is concern about postoperative hematoma. The bladder is routinely drained with a suprapubic or transurethral catheter for 1 to 2 days. After that time, the patient is allowed to begin voiding trials and postvoid residual urine volumes are checked, either with the suprapubic catheter or by intermittent self-catheterization.
Clinical Results
Many studies have reported clinical experiences with retropubic urethral suspension procedures for SUI. Quality studies, including prospective randomized trials, have been conducted comparing Burch colposuspension to synthetic midurethral and fascial slings. Only a few studies have been done assessing the paravaginal defect repair for SUI. Early studies using subjective outcome measures reported that over 90% of women were continent after this procedure. However, in a prospective randomized trial, found that only 61% of women were continent 3 years after a paravaginal defect repair, compared with 100% of women continent after a Burch colposuspension. We currently believe that the paravaginal defect repair should be used only selectively for anatomic correction of anterior vaginal wall prolapse but not as primary treatment of SUI.
Multiple studies with objective measures of cure reported that the Burch colposuspension is effective for women with urodynamically proven SUI. At 3 to 24 months after surgery, 59% to100% of patients became continent, for an overall average cure rate of about 85%. At 3 to 7 years, continence rates range from 63% to 89%, for an average rate of 77%. Although objectively incontinent, a small percentage of additional patients were judged to be improved and satisfied with the surgical results. The overall reported absolute failure rate is about 14% at 5 to 7 years.
In an excellent study, reported on 91 women with urodynamically proven SUI, with or without bladder stability, who had undergone Burch colposuspension. Urodynamic evaluation was done on 76 patients after 5 years. Stress incontinence was cured in 71% of patients with stable bladders preoperatively and in 57% of those with mixed stress incontinence and detrusor overactivity, a nonsignificant difference. After 5 years, only 52% of the study group was completely dry and free of complications; about 30% needed further incontinence therapy.
Black and Downs published a systematic review in 1996 describing the effectiveness of surgery for stress incontinence in women. The methodological quality of studies was assessed, including all of the randomized controlled trials up to that time. Only two randomized controlled trials of colposuspension were available. The study noted that different methods of performing colposuspension (e.g., Burch colposuspension and MMK procedure) have not been shown to be associated with significant differences in outcome. There was preliminary evidence that laparoscopic colposuspension and open paravaginal defect repair may have somewhat lower cure rates than open Burch procedures. Colposuspension appeared to be more effective than anterior colporrhaphy and needle urethropexy procedures in curing and improving stress incontinence. About 85% of women can expect to be continent 1 year after colposuspension, compared with 50% to 70% after anterior colporrhaphy and needle suspension. Primary procedures are generally more effective than repeat procedures. The benefit of Burch colposuspension is maintained for at least 5 years, whereas the benefits from anterior colporrhaphy and needle suspension diminish rapidly. Of the four prospective studies (done before 1996) comparing Burch colposuspension and sling procedures, none reported a difference in cure, however defined, regardless of whether the operations were carried out as primary or secondary operations.
Several studies assessed women more than 10 years after undergoing a Burch procedure. followed a cohort of 109 women (out of a group of 366 eligible women) who underwent Burch colposuspension between 1974 and 1983. The mean follow-up interval was 13.8 years. Both subjective and objective outcome measures were collected during the follow-up period. The cure of incontinence was found to be time-dependent, with a decline for 10 to 12 years and then a plateau at 69%. Cure rates were significantly lower in women who had had previous bladder neck surgery. Approximately 10% of patients required at least one additional surgery to cure stress incontinence. Confirming this, showed that after 9 years, only 10.8% of women had repeat surgery for stress incontinence after a Burch procedure.
In the first prospective, multicenter, randomized trial of open Burch colposuspension and tension-free vaginal tape (TVT) for urodynamic stress incontinence, found no significant difference between surgeries in objective cure rates. Bladder injury was more common during the TVT procedure; delayed voiding, operation time, and return to normal activity were all longer after colposuspension. When these authors analyzed their data at 2 years and ignored subject withdrawals, no differences were seen between procedures with objective cure rates of 81% for TVT and 80% for colposuspension. reported that laparoscopic Burch also had similar long-term efficacy as TVT sling after 4 to 8 years’ follow-up.
In 2007, Albo et al., representing the Urinary Incontinence Treatment Network, published a definitive multicenter, randomized, clinical trial comparing Burch colposuspension with autologous rectus fascia pubovaginal sling. A total of 655 women were randomized and observed for 24 months. Cure rates of SUI were lower for women who underwent the Burch colposuspension (49% versus 66%; P < 0.001). However, more women who underwent the sling procedure had complications such as urinary tract infections, voiding dysfunction, and postoperative urge incontinence.
The Cochrane review from 2012 concluded that open Burch colposuspension is effective for SUI, especially in the long-term. Continence rates at 1 year are approximately 85% to 90%, and at 5 years are about 70%. In 2010, Novara et al. published an updated systematic review and meta-analysis of the comparative data on colposuspensions compared with all slings. They concluded that patients treated with retropubic midurethral slings experienced slightly higher continence rates than those treated with Burch colposuspension, but bladder perforations were more common with retropubic slings.
For years, Burch colposuspension was the anti-incontinence procedure of choice in women who had an open abdominal sacrocolpopexy (ASC). There has been a recent reevaluation of this, both for women with clinical or occult SUI and those who are continent. showed improved continence rates when a Burch colposuspension was done with ASC, whether or not the patient had SUI. This advantage of adding Burch to ASC has not been universally reported, so the use of prophylactic anti-incontinence procedures at ASC remains controversial. Midurethral slings are now frequently combined with ASC to treat clinical and occult SUI. A cohort study from Korea ( ) showed that transobturator sling resulted in higher cure rates and better functional outcomes than Burch colposuspension with ASC.
Clinical conditions that increase the risk of surgical failure for retropubic colposuspension are shown in Box 18.1 . They include baseline urge symptoms, obesity, menopause, prior hysterectomy, prior anti-incontinence procedures, and more advanced prolapse. Advanced age and concomitant hysterectomy do not appear to be associated with lower rates of cure after colposuspension. Urodynamic findings that increase the risk of surgical failure include signs of intrinsic urethral sphincter deficiency (however defined), abnormal perineal electromyography, and concurrent overactive bladder. Patients with intrinsic sphincter deficiency probably are better treated with a more obstructive operation such as a sling procedure if the urethra is hypermobile, or with urethral injections of a bulking agent if the urethra is nonmobile.
