Vincent Lucente, MD, F.A.C.O.G., is a board
certified obstetrician and gynecologist and a fellowship trained urogynecologist
and reconstructive pelvic surgeon. Dr. Lucente is Chief of the Section
of Female Pelvic Medicine and Reconstructive Surgery at Abington Memorial
Hospital, Associate Professor of Obstetrics & Gynecology at Pennsylvania
University College of Medicine/Hershey Medical Center, and Medical Director
for the Institute for Female Pelvic Medicine and Reconstructive Surgery.
Dr. Lucente founded the Institute in 2001 as a center of excellence for
female pelvic floor disorders that integrates medical training, innovative
clinical research and service oriented patient care. Dr. Lucente is an
avid researcher with over 12 years of experience in surgical research,
medical device, and pharmaceutical clinical trials in the fields of both
gynecology and urogynecology. He has published numerous articles in peer
review journals and authored several textbook chapters. www.fpminstitute.com/
Minimally Invasive Surgery for Stress Urinary Incontinence: Laparoscopic
The second in a three-part series on surgical treatment options for Stress
Urinary Incontinence (SUI)
If you suffer from stress urinary incontinence (SUI) you are not alone. This
condition affects more than 16.5 million women in the United States and these
numbers are increasing annually. More often than not, women who suffer from
this condition cope quietly, while their quality of life slowly deteriorates.
It has been said that incontinence doesn't kill you, it just takes your life
away. Fortunately, surgical treatment is now available through several minimally
To summarize Part One of this series, SUI is not truly a problem
of the bladder, as many people think. It is caused by an improperly functioning
urethra, the thin muscular tube-like structure that runs from the bladder to
the outside of your body where urine is expelled. Normally, a healthy urethra
- when properly supported by strong pelvic floor muscles and intact connective
tissue - maintains a "water tight" seal to prevent involuntary loss of urine
during physical stress (coughing, sneezing, and lifting). Most commonly when
a woman suffers from SUI, weakened muscles and tissues in the pelvic floor,
caused by factors such as childbirth, loss of estrogen and repetitive pelvic
muscle straining, are unable to support the urethra in its correct position.
As a result when sudden abdominal as pressure (such as that from a cough or
sneeze) is exerted on the bladder, the urethra cannot remain closed and urine
The urethra is primarily supported by the vagina.
It lies atop the vagina, which acts like a hammock. The urethra lies on top
of this hammock and is supported, like you would be if you were lounging comfortably
on a hammock. Two things are important to support you lying on the hammock:
the ropes that tie it to the base (connective tissue) and the strength of the
actual canvas (vaginal wall muscle). When SUI occurs, this hammock effect is
weakened and can no longer offer the proper support, causing urine leakage with
physical activity such as running, jumping, sneezing or coughing.
In Part one of this series we reviewed a minimally
invasive surgical approach for treating SUI, called a trans-vaginal tape (TVT)
procedure. This article will discuss bladder-neck (where the urethra exits
the bladder) suspension via a procedure called a laparoscopic Burch colposuspension.
Remember, the treatment approach that is best for
you will depend on a complete physical examination and evaluation by your physician.
Make sure to engage in a frank discussion with him or her on the benefits and
risks of all your options.
Bladder Neck Suspension: Laparoscopic Burch Colposuspension
During a standard bladder neck suspension (the classic Burch colposuspension),
the surgeon places, on each side, two non-absorbable sutures (or stitches) partially
through the segment of the vagina located under the junction where the bladder
joins the urethra, called the bladder neck. Colposuspension refers to the
suspension of the vagina "colpo." Dr. Burch was the first to describe the procedure,
so it's named after him. The two sutures on each side (four total) are then
attached to Cooper's ligament -- a thick, strong connective tissue located along
the top brim of the pelvic bone. If you think of the hammock illustration,
this is putting new ropes on the vaginal hammock and tying them to the support
base (the pelvic brim).
This procedure has traditionally been performed using
an open abdominal incision to access the surgical area. Now, thanks to advances
in minimally invasive procedures, this surgery can be performed using a laparoscopic
approach, which has many advantages for the patient compared to traditional
What is Laparoscopic Surgery?
A laparoscope is a tiny telescope that allows the
surgeon to see inside the body. This tiny instrument has transformed many types
of surgeries from traumatic ordeals into relatively minor procedures. This
fiber optic telescope provides magnification and illumination to the surgical
site that is far greater than a standard large incision, so the surgeon can
literally see better during the surgery.
A laparoscopic Burch is done using three small punctures
less than one-half inch each. One puncture is at the navel, for the actual laparoscope,
which is connected to a video camera. The other two puncture sites are usually
placed on each side of the lower abdomen to permit the introduction of instruments
to do the surgery. After the surgery is completed, these small puncture sites
are closed with fine stitches and covered with a Band-Aid.
When the Burch colposuspension is done laparoscopically, the surgery is performed
under general anesthesia and takes about 60 to 90 minutes. Using this approach
offers patients less pain and scarring and shorter recovery times. Several
studies have now confirmed that when performed step for step the same as the
open incision technique, the laparoscopic approach offers the same success rate.
Am I a candidate for Laparoscopic Burch
For patients with both SUI and additional pelvic-support
defects such as uterine prolapse, vaginal vault inversion or lateral cystoceles,
the laparoscopic Burch is performed for correction of SUI along with other laparoscopic
This procedure is not recommended for patients with
intrinsic sphincter deficiency (ISD), a more severe form of SUI. In this condition
there is a deficiency in the sphincter muscle within the tubular wall of the
Urodynamic testing is routinely performed on patients
who are at risk for ISD. Some risk factors include age greater than 60, a history
of prior incontinence surgeries or pelvic radiation. Only a complete physical
examination and consultation with your physician can determine if a laparoscopic
Burch is right for you.
What Does Recovery Involve?
After the surgery you may stay in the hospital for
one night. Many patients return to normal daily living activities within a
few days and return to non-laborious work in three weeks. During this time
there should be very little interference with daily activities but you will
have to avoid heavy lifting, strenuous exercise and intercourse. Most patients
completely recover in a six to eight-week period.
What is the Success Rate?
Studies show cure or improvement rates as high as
94% among patients undergoing laparoscopic Burch colposuspension. Most surgery
outcomes depend greatly on the skill level and experience of the surgeon. Be
sure to inquire about your physician's experience with this approach and their
clinical success rates as opposed to quoting medical literature that
may or may not be representative.
What are the Risks?
All surgical procedures present some risks. Although
extremely rare, complications associated with the procedure include injury to
blood vessels of the pelvic sidewall and abdominal wall, nerve damage, difficulty
urinating and bladder or bowel injury.
In the past, many women accepted SUI as an inevitable
part of the aging process. This is no longer the case. Today's women have
a much different outlook on quality of life than their parents and grandparents.
They are unwilling to accept limitations on their health or lifestyle and are
demanding convenient treatments with high success rates. For many patients
with this embarrassing and troublesome condition, the laparoscopic Burch procedure
meets these expectations.
For Dr. Lucente's first article on minimally invasive surgery for SUI, click
For more information on SUI, click here.
To get to Dr. Lucente's website, click
Created: 9/22/2003  - Vincent Lucente, MD, F.A.C.O.G.