Retropubic Urethropexy for Stress Incontinence and Retropubic Paravaginal Repair

Modified Burch Colposuspension

After the retropubic space is entered, the urethra and anterior vaginal wall are depressed. Dissection at the midline is avoided, thus protecting the delicate musculature of the urethra and urethrovesical junction from surgical trauma. Attention is directed to the tissue on either side of the urethra. The surgeon’s nondominant hand is placed in the vagina with the index and middle fingers on one side of the proximal urethra. Two sponge sticks are used to gently mobilize the bladder to the opposite side ( Figs. 34.1 to 34.3 ). Most of the overlying fat can be cleared away with the use of 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 (see Figs. 34.1, 34.4, and 34.5 ). This area is extremely vascular, with a rich, thin-walled venous plexus, and should be avoided if possible. The positions of the urethra and the lower edge of the bladder are determined by palpating the Foley balloon or by partially distending the bladder if necessary to find the rounded lower margins of the bladder as it meets the anterior vaginal wall.

FIG. 34.1, Burch colposuspension. The bladder is gently mobilized to the opposite side with sponge sticks. The anterior vaginal wall is elevated by the middle finger of the surgeon’s nondominant hand, and fat is mobilized medially (see inset ) with a swab mounted on a curved forceps or suction tip. The position of the sutures (indicated with an X ) ideally should be at least 2 cm lateral to the proximal urethra and bladder neck, usually on the lateral downslope of the tissue elevated by the vaginal finger.

FIG. 34.2, Lateral view of the retropubic space in a live patient. Note: The tissue has been cleaned off over Cooper’s ligament on the left side. This is the area through which the suspension sutures will be passed during performance of a Burch colposuspension.

FIG. 34.3, The lateral retropubic space on the left side is shown. Note the obturator internus muscle, which inserts into the arcus tendineus fasciae pelvis.

FIG. 34.4, Sutures have been appropriately placed on each side of the proximal urethral and bladder neck. Note that figure-of-8 bites are taken through the vagina. Double-armed sutures are used so that the end of each suture can be brought up through the ipsilateral Cooper’s ligament, thus allowing the sutures to be tied above the ligament.

FIG. 34.5, The first step of the Burch colposuspension is to elevate the vagina and mobilize the fat in a medial direction. Note: A sponge stick is used to initially mobilize the bladder medially, and then the fat is cleaned off with a small Kitner-type instrument. Elevating the vagina reveals the muscular lining of the vaginal wall through which sutures will be passed lateral to the midurethra and lateral to the bladder neck.

Dissection lateral to the urethra is completed bilaterally, and vaginal mobility is judged to be adequate by using the vaginal finger to lift the anterior vaginal wall upward and forward (see Figs. 34.1 and 34.5 ). Either 0 or 1 delayed-absorbable or nonabsorbable sutures are then placed lateral in the anterior vaginal wall. I apply two sutures of graded polyester on an SH needle (Ethibond by Ethicon, Inc., Somerville, NJ) bilaterally, using double bites for each suture. These sutures are double-armed so that each end of the suture can subsequently be brought up through Cooper’s ligament (see Figs. 34.4, 34.6, and 34.7 ). Proper placement of these sutures is important to provide adequate support and to avoid undue urethral kinking or elevation leading to postoperative voiding dysfunction or retention. I prefer to place the sutures in the lateral portion of the vagina just lateral to the tip of the vaginal finger, which should be elevating the most mobile and pliable portion of the vagina lateral to the bladder neck (see Figs. 34.1 to 34.8 ). The distal suture is placed 2 cm lateral to the proximal third of the urethra, and the proximal suture is placed approximately 2 cm lateral to the bladder wall or slightly proximal to the level of the urethrovesical junction (see Figs. 34.4 and 34.7 ). In placing the sutures, one should take a full-thickness bite of the vaginal wall, excluding the epithelium. This maneuver is accomplished by suturing over the surgeon’s vaginal finger at appropriate selected sites (see Figs. 34.4 and 34.5 ). On each side, after the two sutures are placed, they are passed through the pectineal or Cooper’s ligament so that all four suture ends exit above the ligament (see Figs. 34.4 and 34.7 ). The retropubic space can be extremely vascular, and visible vessels should be avoided if possible. When excessive bleeding occurs, it can be controlled by direct pressure, sutures, or vascular clips. Severe bleeding usually stops with direct pressure or after the fixation sutures are tied. After all four sutures are placed in the vagina and through Cooper’s ligament, the assistant ties first the distal sutures and then the proximal ones while the surgeon elevates the vagina with the vaginal hand (see Fig. 34.8 ). If desired, a suprapubic catheter is placed through the extraperitoneal portion of the dome of the bladder. In tying the sutures, one does not have to be concerned about whether the vaginal wall meets Cooper’s ligament, because there will almost always be a suture bridge present.