Laparoscopic Burch colposuspension for stress incontinence: preliminary results

Laparoscopic colposuspension versus vaginal suburethral slingplasty: A randomised prospective trial

BACKGROUND

This study aimed to determine if laparoscopic colposuspension (LC) was as effective as vaginal suburethral slingplasty (SPARC).

METHODS

Ninety-seven women with urodynamic stress incontinence were prospectively randomised to LC (n=48) or SPARC (n=49). Outcome measures were measured at, baseline, six months (n=87) and two years (n=58), and comprised leakage episodes per week and visual analogue scale (VAS) of incontinence severity. The LC and SPARC groups at baseline had similar leaks per week (8.8 vs 9.8) and VAS (5.6 vs 5.9).

RESULTS

Laparoscopic colposuspension took longer to perform (48 vs 30 mins, P<0.001), had a slightly higher blood loss (104 vs 82 mL, P<0.01), had a longer hospitalisation (4.0 vs 1.5 days, P<0.001) and had a longer time to resumption of normal activities (3.6 vs 2.8 week, P<0.01). At six months there were no significant differences between LC and SPARC with regard to leaks per week (1.1 vs 2.6) and VAS (1.3 vs 0.7). The success rates were similar (88.3 vs 81.8%). These results again had no significant differences at two years (leaks per week 2.1 vs 3.5, and VAS 1.7 vs 2.2). At two years, the cure/improved rates again found no significant difference (81.5 vs 77.4%)

CONCLUSIONS

Laparoscopic colposuspension is as effective as vaginal suburethral slingplasty after two years' follow-up.

Laparoscopic versus open Burch colposuspension: a randomised controlled trial

OBJECTIVE

To compare perioperative characteristics, short-term, and long-term outcomes for laparoscopic Burch colposuspension (LBC) and open Burch colposuspension (OBC) for the treatment of urinary stress incontinence.

DESIGN

Randomised surgical trial with single blinding.

SETTING

Three tertiary level teaching hospitals involving seven surgeons of varying skill levels.

POPULATION

Two hundred women with urodynamic stress incontinence (USI).

METHODS

The two groups were treated in identical fashion, except for the laparoscopic or open approach to surgery. Attempts were made to blind the subjects and the observers obtaining outcome data to treatment group. Analyses were adjusted for surgeon experience.

MAIN OUTCOME MEASURES

Absence of USI 6 months following surgery, postoperative pain, time spent in hospital, and time to return to activities of normal daily living.

RESULTS

There were no significant differences in objective and subjective measures of cure and in patient satisfaction at 6 months, 24 months, or 3-5 years of follow up between laparoscopic and open colposuspension groups. Laparoscopic colposuspension took longer time to perform (87 versus 42 minutes, P< 0.0001) but was associated with less blood loss (P = 0.03), less pain (P = 0.02), and quicker return to normal activities (P = 0.01).

CONCLUSION

LBC has significant advantages over traditional OBC, without any apparent compromise in short-term and long-term outcomes. To compare perioperative characteristics, short-term, and long-term outcomes for laparoscopic Burch colposuspension (LBC) and open Burch colposuspension (OBC) for the treatment of urinary stress incontinence. Randomised surgical trial with single blinding. Three tertiary level teaching hospitals involving seven surgeons of varying skill levels. Two hundred women with urodynamic stress incontinence (USI). The two groups were treated in identical fashion, except for the laparoscopic or open approach to surgery. Attempts were made to blind the subjects and the observers obtaining outcome data to treatment group. Analyses were adjusted for surgeon experience. Absence of USI 6 months following surgery, postoperative pain, time spent in hospital, and time to return to activities of normal daily living. There were no significant differences in objective and subjective measures of cure and in patient satisfaction at 6 months, 24 months, or 3-5 years of follow up between laparoscopic and open colposuspension groups. Laparoscopic colposuspension took longer time to perform (87 versus 42 minutes, P < 0.0001) but was associated with less blood loss (P= 0.03), less pain (P= 0.02), and quicker return to normal activities (P= 0.01). LBC has significant advantages over traditional OBC, without any apparent compromise in short-term and long-term outcomes.

Suprapubic catheterisation: A retrospective comparison of two insertion systems

Abstract This study compares two suprapubic catheter insertion systems available for postoperative bladder drainage. We performed retrospective analysis of patients who underwent laparoscopic colposuspension and postoperative suprapubic catheterisation with either the Bonanno (Becton, Franklin Lakes, NJ, USA) or the Lawrence Add-a-Cath (Femcare, Nottingham, UK) mini-Foley catheters (Bard, Covington, GA, USA). There were no statistically significant postoperative outcome differences between the two catheter groups. We prefer the Add-a-Cath mini-Foley suprapubic catheter for its ease of insertion and fixation.

Laparoscopic treatment of urinary incontinence

The optimal surgical management of stress incontinence in women remains a contentious issue. Retropubic urethropexies such as the Burch procedure are regarded as having excellent long-term success rates. The learning curve for transvaginal tape procedures is by far shorter and easier than for the laparoscopic Burch procedure. Data from the few randomized trials published thus far show that both procedures are associated with high success rates and patient satisfaction.

A prospective multisite study of radiofrequency bipolar energy for treatment of genuine stress incontinence

STUDY OBJECTIVE

To assess the efficacy of radiofrequency electrothermal energy to treat genuine stress incontinence (GSI).

DESIGN

Multicenter, prospective, single-arm, longitudinal study (Canadian Task Force classification II-1).

SETTING

Six North American university-affiliated and private clinic sites.

PATIENTS

Ninety-four women undergoing laparoscopic treatment for GSI.

INTERVENTION

Radiofrequency bipolar treatment of paravaginal tissue to induce tissue shrinkage causing bladder neck elevation.

MEASUREMENTS AND MAIN RESULTS

Patients underwent complete urogynecologic evaluations, with urodynamic testing, including Valsalva leak point pressure, to confirm the diagnosis of GSI. Paravaginal tissue was treated lateral from the urethra and bladder neck out to the arcus white line, with bipolar electrothermal energy to shrink bladder-supporting connective tissue. Treatment resulted in 30% shrinkage in paravaginal endopelvic fascia surface area by direct measurement. At 1 year the objective cure rate was 79% by urodynamic testing, improvement in quality of life by questionnaire was 81%, decrease in leaking episodes and pad use was significant (p <0.001), and patient satisfaction was 83%. Complications (7%) were secondary to laparoscopy. There were no injuries from the radiofrequency probe.

CONCLUSION

Radiofrequency bipolar electrothermal energy appears to be a safe an efficient means of treating mild to moderate GSI. It results in shrinkage and elevation of paravaginal connective tissue, stabilizing the urethra and bladder neck, thereby restoring continence. Long-term follow-up is necessary.

Laparoscopic versus open Burch retropubic urethropexy: comparison of morbidity and costs when performed with concurrent vaginal prolapse repairs

OBJECTIVE

The purpose of this study was to determine the morbidity and cost that are associated with laparoscopic and open Burch retropubic urethropexy when they are performed with concurrent vaginal prolapse repairs.

STUDY DESIGN

We conducted a retrospective study of all patients who had undergone laparoscopic (n = 76) or open (n = 143) Burch retropubic urethropexy with at least 1 concurrent vaginal repair for symptomatic prolapse. We compared demographic data, level of prolapse, operative and postoperative details, medical and surgical histories, complications, and hospital charges.

RESULTS

The group with open retropubic urethropexy had an older age, greater degree of prolapse, fewer concurrent hysterectomies, and a greater number of vaginal procedures than the group with laparoscopic retropubic urethropexy. There were minimal differences in complications and no differences in the estimated blood loss, operative time, hemoglobin change, hospitalization, or hospital charges between the 2 groups.

CONCLUSION

Traditional benefits of laparoscopic retropubic urethropexy were not apparent when vaginal prolapse repairs were performed.

Laparoscopic colposuspension

Laparoscopic urogynaecology started to develop following the first report of a laparoscopic colposuspension in 1991. The place of laparoscopic treatment of urinary incontinence has yet to be established and, as for all new techniques, case reports, case series and small randomized studies have been reported. Larger randomized studies with adequate power have yet to be reported. Current opinion is divided as to the success of these new operations. Assessment of outcome is further clouded by large variations in technique, such that like is not always compared with like. The present review assesses the recent literature and the place of the traditional colposuspension performed via the laparoscopic route.

The efficacy of laparoscopic mesh colposuspension: results of a prospective controlled study

OBJECTIVE

To investigate the efficacy of laparoscopic mesh colposuspension as an equivalent approach to the 'gold standard' open Burch colposuspension.

PATIENTS AND METHODS

A prospective controlled study of laparoscopic mesh colposuspension was conducted over 2 years; 87 patients with genuine stress incontinence (GSI) were recruited. The preoperative evaluation included a history, examination, midstream urine analysis, urinary voiding diary, a Urilos pad test, and twin-channel subtracted cystometry, including urethral profilometry and measurement of the postvoid residual volume. The study included patients who had undergone previous incontinence surgery, but those with detrusor instability or neurogenic bladder were excluded. The patients were assessed at 6 weeks, 6 months and 1 year after surgery and then yearly thereafter. The urodynamic assessment was repeated 3 months after surgery.

RESULTS

Forty-nine patients underwent laparoscopic colposuspension using Prolene mesh and titanium tacks to elevate the bladder neck, while 38 patients had open Burch colposuspension. There was no difference between the groups in age, parity, body mass index, menopausal status, medical history, previous bladder neck surgery and prolapse. At 6 weeks the cure rate was similarly high in the two groups (91% laparoscopic and 94% open). After a mean follow-up of 32 months, both groups showed a decline in efficacy, which was more marked in the laparoscopic group. Cure rates were 62% for laparoscopy and 79% for open surgery, and the improvement rates were 77% and 89%, respectively (P < 0.05).

CONCLUSION

Laparoscopic colposuspension using a mesh and tacker technique reduces the technical difficulty and operating time of the endoscopic procedure, but the long-term cure rates are inferior to open Burch colposuspension.

Laparoscopic management of urinary incontinence, ureteric and bladder injuries

The present review focuses on the most recently published English language literature, and addresses results and complications associated with the laparoscopic approach to urinary incontinence, anterior vaginal wall prolapse, and lower urinary tract injury. Laparoscopic Burch procedures continue to show equal efficacy, but lower morbidity as compared with conventional open techniques. Lower urinary tract injuries may also be managed effectively using the same techniques as those employed in open procedures. Laparoscopy continues to be considered a mode of surgical access, and is effective in treating urinary incontinence, anterior vaginal wall prolapse, and lower urinary tract injuries.

Simplification of laparoscopic extraperitoneal colposuspension: results of two-port technique

PURPOSE

The aims of the present prospective study were to apply a new simplification for Laparoscopic Burch Colposuspension and to assess the postoperative results of this treatment modality for stress urinary incontinence.

MATERIALS AND METHODS

Twenty-four patients underwent simplified laparoscopic procedure via two ports, utilising endoscopic tacker and two stripes of prolene mesh. Patients were evaluated for operative time, duration of urethral catheter, length of hospital stay, complications and continence status.

RESULTS

The technique was successful in 21 patients after 24 months follow-up. Average operative time was 39 minutes. The lengths of urethral catheterisation and hospital stay were 22 and 45 hours, respectively. One operative complication and three postoperative recurrences were recorded.

CONCLUSION

Laparoscopic bladder neck suspension continues to develop as the instruments and techniques are improved. In carefully evaluated patients, it provides safe and minimally invasive procedure. We report the results of a new technique to simplify and speed up a laparoscopic extraperitoneal colposuspension.

Laparoscopic paravaginal repair plus burch colposuspension: review and descriptive technique

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 urethropexies. No ureteral ligations or intravesical placement of suture was diagnosed. Other surgical parameters 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.

Controlled balloon dilatation for laparoscopic extraperitoneal bladder neck suspension in patients with previous abdominal surgery

PURPOSE

The balloon dilator is used in a variety of minimally invasive preperitoneal and retroperitoneal operations. In this study, we compared the ability to create an extraperitoneal cavity using a balloon spacer in patients with and without previous abdominal surgery undergoing laparoscopic bladder neck suspension.

PATIENTS AND METHODS

This prospective study included 38 patients in total, 15 of whom had had previous abdominal wall surgery and 23 who had not. A balloon spacer technique was used to develop the extraperitoneal space.

RESULTS

In 80% of the patients with previous surgery, the introduction of the balloon spacer was recorded as simple; in 20%, it was considered difficult. In 78% of the patients without previous surgery, the introduction of the balloon spacer was recorded as simple, in 17% it was difficult, and in 4% it failed. In 80% of the patients with previous surgery, the extraperitoneal view was good or acceptable, in 20% it was poor, and in 13% it failed. In 92% of the patients without previous surgery, the extraperitoneal view was good or acceptable, in 4% it was poor, and in 4% dilatation failed. Morbidity was equally divided between the groups.

CONCLUSIONS

Previous abdominal surgery is not a contraindication to laparoscopic extraperitoneal surgery using a balloon spacer. The approach carries low morbidity, similar to that in patients without previous abdominal surgery.

Laparoscopy or open Burch colposuspension?

The laparotomy Burch has long been considered the gold standard for the repair of genuine stress incontinence. With the advent of laparoscopic Burch, many have argued that possibly this should be the new gold standard. However, when many laparoscopic bladder series were examined, there was some question of whether these should be considered Burch procedures and there is still a lack of long-term laparoscopic data.

Comparison of open retropubic and laparoscopic colposuspension for treatment of stress urinary incontinence

The aim of this study was to compare the results of open retropubic (OC) and laparoscopic (LC) colposuspension to the Cooper's ligament (Burch operation). We matched retrospectively 72 LC and OC subjects according to their ages, the type of associated operations and the clinical stages of their urinary incontinence. We excluded associated prolapsus, previous surgical procedure for urinary incontinence, maximal urethral closure pressure lower than 30 cm of water, and instability of the detrusor. We estimated the comparability of our two series for other criteria which have an effect upon the postoperative results in the literature. The mean follow-up was 17 months for LC and 46 months for OC. LC operative time was longer than OC (mean: LC, 89 min; OC, 42 min), women considered LC less painful than OC. They needed less postoperative analgesia, mostly given only just the day of the procedure. LC length of hospitalization and return to normal activity was shorter than OC (mean: LC, 3 days; OC, 6.7 days; LC, 15 days; OC, 21 days). The graphs of the subjective cure and improvement rates made according to the Kaplan-Meier method could be compared with the log rank test (cure after 1 year: LC 79%; OC 69%; improvement after 1 year: LC 85%; OC 82%; cure after 2 years: LC 68%; OC 64%; improvement after 2 years: LC 80%; OC 75%).

Laparoscopic colposuspension in women with previously failed anti-incontinence surgery

OBJECTIVES

To assess the effectiveness of laparoscopic colposuspension after previously failed anti-incontinence surgery.

METHODS

Retrospective review of 10 cases, all with urodynamically proven grade 2 genuine stress incontinence.

RESULTS

All patients were subjectively cured at 3 months or more follow-up. The mean hospital stay was 2.9 days, the mean time until normal voiding was 1.7 days, and the mean blood loss was 39 ml.

CONCLUSION

Laparoscopic colposuspension may be useful after failed anti-incontinence surgery. However, larger numbers are needed with objective longer term follow-up.

A review of results in a series of 113 laparoscopic colposuspensions

The case records of 113 women having laparoscopic retropubic colposuspensions (Burch procedure) performed for the treatment of genuine urinary stress incontinence between December, 1992 and April, 1995 were retrospectively reviewed. The mean age of the group was 49.4 (30-80) years, mean weight 72.1 (44.5-114) kg, and mean parity 2.7 (0-8). All patients had preoperative urodynamic study to confirm genuine stress incontinence (GSI). Sixteen patients (14%) had dual pathology (GSI and detrusor instability). A transperitoneal approach was used in 93 operations and extraperitoneal in 20. The mean operating time was 108 (30-320) minutes and mean hospitalization 3.3 (1-10) days. In 13 women the operation was converted to laparotomy; 10 due to adhesions and diminished bladder mobility, 1 for inferior epigastric vessel injury, 1 for an ovarian tumour discovered incidentally at the procedure and 1 for equipment problems. Operative complications included 10 cystotomies (5 repaired laparoscopically), 2 extraperitoneal cases converted to transperitoneal, 1 inferior epigastric vessel injury, 1 vaginal tear, 1 suture through the bladder and 1 case of possible enterotomy oversewn at laparoscopy. The mean follow-up period was 8.4 (1-28) months. All patients were reviewed postoperatively and then contact was attempted either by telephone or in consultation. There was an overall 87% subjective success rate. Two patients felt sutures tear out at 4 and 6 months and were deemed failures; 4 felt their incontinence was improved but had ongoing stress incontinence of urine; 9 had symptoms of detrusor instability and one developed an enterocele 9 months after surgery.