Introduction

Great progress has been made in the surgical cure of stress urinary incontinence. In 1913, Kelly advocated simple plication of the sphincter, with or without cystourethrocele repair. Since that time, more than 100 abdominal, vaginal, or combined operative procedures have been described for the treatment of genuine stress urinary incontinence [1].

The general acceptance of laparoscopy in recent years has allowed many operative procedures formerly requiring a laparotomy to be performed successfully under laparoscopic control. This article describes a new approach to perform a bladder suspension via the laparoscope. [2] The technique is similar to that of the Marshall, Marchetti, Krantz (MMK)[3] or Burch [4] Retropubic suspension performed at laparotomy.

Patient Selection

The successful outcome of any surgical procedure for stress urinary incontinence (SUI) is dependent upon appropriate patient selection. A thorough history of the patient's incontinence allows the physician to determine the nature and severity of the patient's symptoms. A complete physical examination requires neurologic, gynaecologic, and urologic evaluation. Formal urodynamic evaluation provides objective and reproducible results. This is especially valuable if a patient's symptoms of stress incontinence cannot be reproduced during physical examination.

Operative Recommendations

Patient preparation

Prior to surgery, all patients should undergo a mechanical bowel preparation, which increases intra-abdominal volume. During surgery, gastric and Foley catheters are inserted. Because nitrous oxide has a tendency to accumulate in the bowel lumen, thereby reducing the usable operating space, its use should be avoided other than for induction or the first 30 minutes of the procedure.

Equipment/personnel set-up

The video equipment is placed at the foot of the operating table, which places the operative site in a straight line with the surgeon and the monitor. The ancillary hardware is usually mounted on the same cart as the video system. This allows the circulating nurse easy access to the controls. The optimal additional surgical team consists of a surgical assistant, an individual to hold the camera, and a surgical technician. This set-up allows the surgeon to operate with 2 hands. If a third person is not available, the assistant may operate the camera. The anaesthesiologist is usually at the head of the patient, along with the individual holding the camera. The surgical technician may stand between the patient's legs, with the instrument tray on the side opposite the surgeon. The surgical assistant is positioned opposite the surgeon.

Surgical Technique

Trocar placement may vary according to the preference of the surgeon. Usually, a 10mm trocar is placed through an infra-umbilical incision and another 10mm trocar is placed suprapubically, followed by two 5mm trocars placed laterally. Laparoscopes with different viewing angles are available. The selection of a straight or angled optic is the surgeon's personal choice. We prefer the straight, forward optic.

After establishment of the pneumoperitoneum and insertion of the trocars, the initial landmarks are visualized. The most important one is the left umbilical ligament, which delineates the lateral border of the dissection. The Foley catheter is easily visible and helps in locating the bladder. In a patient with multiple surgeries, locating the bladder is sometimes difficult. Normally, the pubic bone can be seen, even in very obese patients. Even if it is not well visualized, it can be located by gentle probing with a surgical instrument.

Use of the pubic bone as the inferior border of the initial incision into the peritoneum allows the surgeon to avoid the superior vesical artery, which runs anterior to the round ligament but slightly below the level of the pubic bone. Also, the venous plexus along the symphysis is a significant structure and will bleed profusely if incised. Avoiding these vascular structures is important because the bleeding may result in difficulty in visualizing the tissue planes, thereby increasing the difficulty of the procedure.

The initial incision is made immediately medial to the left umbilical ligament, above the pubic bone. The first step is to reach the pubic bone. Although it may seem that several tissue planes must be incised, the distance between the peritoneum and the pubic bone is short, even in obese patients. The surgeon should maintain a plane perpendicular to the pubic bone. There is a tendency to shift toward the midline too early, which leads to bladder injury.

Once the pubic bone is reached, the assistant inserts a blunt instrument into the incision and retracts the bladder to the right (mirror image for a left-handed surgeon). This facilitates entry into the space of Retzius. With minimal traction and blunt dissection, the entire space is opened, and all anatomic structures can be identified bilaterally. Occasionally, the urachus may interfere with the dissection and must be transected. The anatomic structures that can be identified at the completion of the dissection are the urethra, the bladder neck, the paravaginal tissue, the obturator muscles, the pubourethral ligaments, and the pubic bone and its symphysis and ligaments. Cooper's ligament is not as easily identified, and a wide dissection of the pubic bone may be required.

At this point, either the MMK or Burch procedure can be performed. The placement of the suture into the paravaginal tissue is identical for either procedure. The operator places the left hand into the patient's vagina, displacing the bladder neck toward the left of the patient for application of the right-sided suture. The vaginal wall is only minimally elevated with the vaginal hand; otherwise, the space between the vagina and the pubic bone is reduced. The suture is placed at the urethrovesical (UV) junction just as in the open procedure. The needle (Ethibond 2/0 - 36 inches) is introduced through the suprapubic 10mm trocar and the needle holder is passed through the left lateral trocar; then the needle is grasped and inserted into the space of Retzius. The right-sided stitch is placed first as described above.

Because the laparoscope is situated exactly on top of the bladder neck, visualization of the anatomical detail is excellent and allows this suture to be placed with extreme precision. Because of the inherent limitations of laparoscopy with lack of depth perception and restricted access, the next step is the most difficult. This is the placement of the suture into Cooper's ligament or into the symphysis, depending upon the procedure. The problem is that because of the lack of depth perception, the suture may be anchored too low onto the bone, thereby achieving only minimal elevation of the bladder neck. Manipulation of the bladder neck with the left hand in the patient's vagina will compensate for the lack of depth perception to a certain extent.

Knotting is best performed using the extracorporeal technique. Elevating the vaginal wall during tightening of the knot minimizes tension on the suture. The surgical assistant may tie the knot, or the surgeon may change gloves and tie the knot. The right-sided stitch is placed and tightened before placement of the left-sided suture. A stitch is placed on each side at the level of the UV junction. In patients with a moderate cystocoele, 2 sutures may be placed, with the second suture placed lateral to the first as described by Burch. There is no technical difficulty in placing more than 1 suture on each side. The number of sutures placed depends upon the surgeon's preference and the patient's anatomy. Burch [4] described the original procedure with placement of 3 sutures. The number of supporting sutures required in relation to outcome has not been studied.

Postoperative Care

Postoperative care is similar to that following open surgery, except that the patient may tolerate activity and diet sooner. Bladder training may start the morning after surgery. The catheter is removed and voiding trials are undertaken. If the residual is < 150cc, the catheter is removed. A suprapubic catheter is placed in patients in whom history and urodynamic testing indicate that a longer period of bladder atony is possible.

Postoperative hospital stay is between 1 and 3 days, depending upon the extent of the procedures performed. A laparoscopic Burch may be done in conjunction with other gynaecologic procedures such as hysterectomy and enterocoele repair. Patients who only underwent a retropubic suspension are usually discharged the day following surgery. Postoperative office visits are scheduled at 10 days and at 3 months following surgery. Patients who are experiencing more difficulty in voiding are seen more often, depending upon the clinical situation. At the 3-month postoperative visit, the patients are instructed in a pelvic-floor-muscle-exercise program, which is monitored at 3-week intervals until the patient is comfortable with the routine. Thereafter, the patient is monitored annually.

The complications of a laparoscopic bladder neck procedure are the same as those that may be encountered in an open procedure [5]. There is also the possibility that laparotomy must be performed in order to complete the procedure if the surgeon is unable to do an adequate suspension under laparoscopic control.

Results

In 1991, Vancaillie and Schuessler [2] reported a series of 22 patients who underwent a laparoscopic bladder neck suspension. In this series, the average operating time ranged from 35 minutes to 175 minutes (mean, 65 minutes). Eighteen patients were discharged from the hospital in less than 18 hours. Nine patients were discharged with a Foley catheter, while 13 required catheter placement for 3 days. Of the 22 women, 19 resumed normal activity within 5 days of surgery. Cure of stress incontinence was reported in all 22 patients. However, follow-up was short (mean, 9.5 months). The reported complications in this series included urinary retention in 2 patients and laparotomy in 3 patients.

Since the original report, 92 additional patients underwent a Burch type procedure. The overall cure rate, defined as resolution of the stress incontinence, was 85%, with a median follow-up period of 18 months.

Discussion

In general, the laparoscopic bladder neck suspension offers the patient a less morbid alternative to an open procedure, along with improved visualization of bladder-neck anatomy. The procedure, which at first may be more time-consuming, usually allows a shorter hospitalisation and convalescence. The biggest disadvantage is the steep learning curve associated with a successful laparoscopic bladder-neck suspension. Additionally, a longer follow-up period is required to fully evaluate the laparoscopic procedure compared with the standard open procedure.

Conclusion