Minimally Invasive Surgery for Stress Urinary Incontinence:  Laparoscopic Burch Colposuspension

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 invasive techniques.

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 escapes. 

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 "open" surgery.

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 Colposuspension?

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 reconstructive surgery.

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 urethra itself.     

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.  

Conclusion

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 here.

For more information on SUI, click here.

To get to Dr. Lucente's website, click here.

Created: 9/22/2003  -  Vincent Lucente, MD, F.A.C.O.G.