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Table 14.1.1: The Tanagho Principles for Burch
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Colposuspension
Remove paraurethral fat out to lateral sidewalls
Keep dissection 2 cm from urethra and bladder neck
Elevate paraurethral tissue with vaginal hand during dissection and
suture placement
Clean off Cooper’s ligament
Place a right and left suture through the paraurethral tissue 2 cm
lateral to the mid-urethra and up through Cooper’s ligament
Keep paraurethral tissue elevated with vaginal hand while tying
Repeat bilateral suture placement 2 cm lateral to the bladder neck and
through Cooper’s ligament
Do not overcorrect when tying the sutures, leaving 2 cm between the
pubic ramus and the urethra
and pelvic support problems is essential. In addition, patients are
questioned about obstructive defecation and fecal incontinence.
In our clinic, 23% of the patients with severe GSI or pelvic organ
prolapse havefecalincontinence,whichisin agreement with findings of others.[12–15] Obstructive defecation is often associated
with rectal prolapse, rectocele, and intussusception.[16,17] When
either condition is present, anal manometry, anal ultrasound,
and pudendal nerve terminal motor latency studies should be
included in the evaluation.
Surgical Anatomy
Laparoscopic Burch Colposuspension — 367
Figure 14.1.1. Abdominal wall vessels and nerves at risk during
laparoscopy and trocar sites for laparoscopic Burch. A, superficial
circumflex artery; B, femoral artery; C, superficial inferior epigastric
artery; D, external iliac artery; E, inferior epigastric artery; F, iliohypogastric nerve; G, ilioinguinal nerve; H, 10-mm trocar sites; I, 5-mm
trocar sites.
There are several vessels and nerves that come into play with
laparoscopic pelvic procedures. The first vessels at possible risk
from trocar placement are thegreatvesselsunder the infraumbilical site. Theumbilicus is atthe L3-4 level, andin women with thin
to normal body habitus the aortic bifurcation is at L4-5. In obese
women, the umbilicus is lower. In thin to normal-size women,
the infraumbilical trocaris placed at a45
◦
angle toward the pelvis,
whereas in an obese female, the trocar can be placed close to a 90
angle. The left common iliac vein crosses over the lateral half of
the lower lumbar vertebrae and may be inferior to the umbilicus,
making it susceptible to injury at trocar insertion or when exposing the sacral promontory. The common iliac arteries course 5 to
6 cm lateral from the midline before bifurcating into the internal
and external common iliac vessels.
The inferior epigastric, coming off the distal portion of the
external iliac artery, crosses the medial border of the inguinal ligament and runs below and lateral to the rectus sheath to anastomose with the superior epigastric vessels comingfromtheinternal
mammary arteries in the upper abdominal wall (Figure 14.1.1).
Two inferior epigastric veins accompany the artery. The superficial epigastric artery arises from the femoral artery 1 cm below
the inguinal ligament and passes through the femoral sheath to
supply the superficialareaof the abdominal wallup to the umbilicus. If thepatient is thin, this vesselcan be transilluminated when
placing trocars through the abdominal wall.
The obturator artery is one of the terminal branches of the
internal iliac artery and is found on the lateral pelvic sidewall,
leaving the pelvis via the obturator canal along with the obtura-
tor nerve (Figure 14.1.2A). It gives off a pubic branch that anastomoses with the pubic branch of the inferior epigastric artery
to supply the posterior surface of the symphysis. An accessory
obturator artery is present 25% of the time, arising from the inferior epigastric (Figure 14.1.2B). In approximately 5% of patients,
both obturator and accessory obturator branches are present.
Care must be taken with these vessels because they complete an
◦
anastomotic circle of vessels between the internal and external
iliac arteries, referred to as the circle of death in surgical texts.
Damage to any vessel in this circle may result in significant hemorrhage.
Neuropathies may occur from nerve damage or entrapment
in laparoscopic surgery. Lateral trocar placement can damage the
iliohypogastric and ilioinguinal nerve, leading to sharp pain in
the suprapubic orgroinarea(Figure14.1.1).[18] Obturator nerve
damage may occur during dissection of the space of Retzius or
with paravaginal repairs, causing sensory loss to the medial thigh
and difficulty ambulating.
SURGICAL PROCEDURE
The patient’s legs are placed in low Allen stirrups, and the threeway Foley catheter is placed in the bladder. The patient should
be flat and not in Trendelenburg, as Trendelenburg positioning
can bring the pelvic vessels closer to the anterior abdominal wall.
The infraumbilical area is infiltrated with Marcaine (Hospira)
0.25% (as are all of the trocar sites), and an infraumbilical stab
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AB
Figure 14.1.2. Normal obturator artery and accessory obturator artery anatomy. (A) Normal obturator artery, present in 70% of patients.
A, obturator artery; B, obturator vein; C, external iliac artery; D, external iliac vein; E, inferior epigastric artery; F, obturator branch anastomosing
with pubic branch of the inferior epigastric artery; G,pubic artery branch; H, obturator nerve. (B) Accessory obturator, present in 25% ofpatients.
Five percent of patients have a combination of a normal obturator artery and an accessory obturator. A, obturator artery; B, obturator vein;
C, external iliac artery; D, external iliac vein; E, inferior epigastric artery; F, pubic branch of the inferior epigastric artery; G, pubic artery branch
supplying pubic ramus; H, obturator nerve.
incision is made. Preemptive anesthesia significantly decreases
postoperative pain. The abdominal wall is elevated manually and
the Veress needleis passed into the abdominal cavity; if the initial
abdominal pressure is 8mm Hg or less,the gas is turnedon. Many
surgeons feel the open technique is safer if the patient has had
multiple surgical procedures. The literature shows that the open
procedure prevents great vessel injury, but there is no difference
in bowel injury.[19]
Once the abdominal pressure reaches 15 mm Hg, the
infraumbilical trocar is passed into the abdomen through the
umbilical aponeurosis. The laparoscope, with video camera, is
put in place. A left lateral 10-mm and right lateral and suprapubic 5-mm trocars are then introduced under direct visualization.
Now the patient can be placed in Trendelenburg to visualize the
pelvis. After an initial inspection of the abdomen and pelvis is
completed,approximately150 mLofsterilesalineorwaterstained
with indigo carmine (or methylene blue) is instilled through the
Foley to delineate the borders of the bladder. A transverse incision is made approximately 2 cm above the bladder reflection.
It is important to remember that the patient is in Trendelenburg position and to dissect in an upward fashion, or the bladder
may be entered. This will help prevent inadvertent cystotomy.
Identification of loose areolar tissue confirms dissection in the
correct plane (Figure 14.1.3A). The loose areolar tissue and fat
in this space are swept away with the spatula until the pubic
bone is reached. As small vessels are encountered, they are coagulated. Once the pubic bone is reached, the overlying loose tissue
is bluntly dissected away to expose the bone and Cooper’s ligament (Figure 14.1.3B). This dissection is carried out inferiorly to
the lateral attachments of the anterior vaginal wall and laterally
to the obturator notch.
The surgeon places his or her left hand in the vagina. The
Foley balloon and urethra are identified, and the paraurethral
tissue is cleared of its overlying adipose tissue, which is elevated
with the vaginal hand (Figure 14.1.3C). To minimize bleeding
and avoid damaging the nerve supply to the urethra, care is
taken to stay at least 2 cm lateral to the urethra, and the adipose tissue overlying the urethra is not removed. The rich venous
plexus adherent to pubocervical fascia can be coagulated as
necessary.
The first suture is placed 2 cm lateral to the mid-urethra as
this tissue iselevated with thevaginal hand. A largebite of tissue is
taken. A figure-of-eight suture is not necessary, as demonstrated
by Burch and Tanagho.[2,4] The needle is passed up through
Cooper’s ligament, and while the vaginal tissue is elevated, the
suture is tied with an extracorporeal knot. The vaginal tissue is
not pulledall the way upto Cooper’sligament as thiswill result in
overcorrection of the urethrovesical angle and possibly kink the
ureter. A suture bridge of approximately 2 cm and a similar space
between the urethra and pubic arch are the desired end point.
The second suture is placed 2 cm lateral to the bladder neck and
tied using the same technique. The contralateral sutures are then
placed in a similarfashion.Atcompletion,thefour sutures elevate
the pubocervical fascia to form “dog ears,” creating a hammock
of vaginal wall under the mid-urethra and bladder neck (Figures
14.1.3D, 14.1.4).
As the last two sutures are being placed, the anesthetist is
instructed to give intravenous indigo carmine. Once all sutures
have been tied down, cystoscopy is performed. It is essential
that dye is seen coming from both ureteral orifices and that
no sutures have penetrated the bladder wall. If no dye is seen,
the sutures must be removed from that side and replaced. Most
ureteral obstruction is the result of excessive elevation of the
trigone, which crimps the ureter, preventing flow.[20] After cystoscopy, the space of Retzius is closed with a continuous delayed
absorbable suture.
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A
C
Figure 14.1.3. (A) Opening of the space of Retzius. Notice the fine areolar tissue. This is an avascular plane. We use the adage “Fat is your friend.”
(B) The pubocervical fascia (PCF) has been elevated with the vaginal hand and the adipose tissue has been removed, staying 2 cm lateral to the
urethra and bladder neck. Elevation aids in the placement of the Burch sutures. (C) Cooper’s ligament is cleaned off before suture placement. The
Foley bulb is seen elevating the bladder proximal to the bladder neck. A, Cooper’s ligament; B, bulge of the Foley bulb at the bladder neck. (D)
The completed Burch colposuspension with the typical “dog ears” created by elevation of the pubocervical fascia.
Most surgeons believe thatthe Burch procedure should be the
last repair if it is being done with concomitant procedures. Other
repairs done after the Burch may affect the urethrovesical angle,
secondary to changes in the pelvic axis. In any patient demonstrating vaginal support weakness, we usually perform some type
of colpopexybeforetheBurchtoprevent prolapse at the vault or in
the posterior pelvic compartment. Laparoscopic Burch has been
combined with anterior and posterior support procedures, paravaginal repair, sacrocolpopexy [9], laparoscopic hysterectomy,
external anal sphincteroplasty [12], and rectopexy.
B
D
Suggestedadvantages of the extraperitoneal approach include
the avoidance of entering the intraperitoneal cavity, better visualization [21], decreased risk of vascular and bowel injury, the
bypassing of intra-abdominal adhesions, and the ability to use
regional anesthesia.[21–23] Additionally, decreased blood loss
has been reported by some and is thought to be the result of
instillation of CO
gas at 20 mm Hg into the extraperitoneal
2
space, causing compression of capillaries.[23] The extraperitoneal approach alsoallows lower placement of trocars, makingit
easier to reach the operative field. At one center, extraperitoneal
BurchwascheaperthanopenBurch($3100vs.$6000).[21]Inseveral reports, this technique is considered faster and cheaper, with
ENTRY INTO THE SPACE OF RETZIUS
cure ratescomparable to those of open or laparoscopic transperitoneal Burch and high patient satisfaction.[22,24–26]
Both intraperitoneal (or transperitoneal) and extraperitoneal
approaches to the space of Retzius have been described and may
be used for performing the laparoscopic Burch procedure. The
choice of approach depends on the surgeon’s preference and on
whether concomitant procedures will be performed requiring
intraperitoneal access.
Potential drawbacks and complications of the extraperitoneal approach include higher rates of cystotomy, subcutaneous emphysema, inadvertent entry into the peritoneal cavity,
conversion to open or intraperitoneal Burch, and exclusion of
patients with prior retropubic surgery.[21,22,25] Prior surgery
is not a contraindication in some centers.[26,27] Additionally,
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A
Figure 14.1.4. (A) The laparoscopic view of a completed Burch, with the classic two sutures per side elevating the pubocervical fascia up toward
Cooper’s ligament. (B) A parasagittal view of a Burch colposuspension.
extraperitoneal laparoscopy may result in greater degrees of
carbon dioxide absorption than with transperitoneal surgery,
increasing the chance of pneumomediastinum and pneumothorax.[25,28]
Extraperitoneal access can be via balloon dissector (Origin
Medsystems, Menlo Park, CA), operative laparoscope, directvision trocar (Visaport, U.S. Surgical Corp., Norwalk, CT), regular trocar or the surgeon’s finger (Origin Medsystems, Menlo
Park, CA; Spacemaker, General Surgical Innovations, Cupertino,
CA; Visaport, U.S. Surgical Corp, Norwalk, CT). The technique
involvesmaking a small incision in the abdominalmidline that is
opened down to the preperitoneal space. Then, a balloon or trocar is placedin this potentialspaceand carbon dioxideis instilled,
opening the space of Retzius. Two 5-mm ports are placed 3 cm
above the suprapubic bone and 2 cm lateral to midline, avoiding
the inferior epigastric vessels. The remainder of the procedure
is carried out in the same fashion as if by the intraperitoneal
approach.
As it is uncommon to see a patient who requires only a
Burch colposuspension and no other procedure, the intraperitoneal approach is more common in most centers.[10,29–31]
Most patients requiring pelvic reconstructive surgery need additional procedures, such as a vault suspension, paravaginal repair,
anterior and/or posterior vaginal repair,orotherintra-abdominal
procedure.[32]
B
called “Burch” procedures. The lack of differentiation accounts
for the varied outcomes reported for the laparoscopic “Burch.”
The following studies represent the Burch–Tanagho procedure
done laparoscopically. The importance of thisdistinction is made
clear by a randomized,controlledstudyof161 patients by Persson
and Wolner-Hanssen [33] that demonstrated the importance of
placing two sutures per side,asopposedtoonly one, in the laparoscopic Burch colposuspension. In their randomized, controlled
trial, one group of 78 had a single suture placed on each side and
the other group of 83 had two sutures on each side. At 1 year, the
objective cure rate was 58% and 83%, respectively (P = 0.001).
These findings support the necessity of two sutures per side for
optimum resultsand giveapossible reason for the high failure rate
reported by many with a single suture per side. Persson stopped
this study early because of the poor outcome with one suture per
side.
Laparoscopic Burch success rates of 89% to 100% with 1- to
2-year follow-up have been reportedin several series. [6–8,31,34–
38] Liu [6] reported on 107 cases with a 97% subjective cure rate
over a follow-up of 3 to 27 months. He had a 10% complication
rate, including four cystotomies and one kinked ureter. Patient
satisfaction was high.
Extracting data from six different studies [8–10,12,39,40],
we had an objective cure rate of 91% at 1 year in 178 patients
(Table 14.1.2). The majority of these patients were assessed postoperatively by multichannelurodynamic testing. In mostof these
studies, patients with detrusor instability and ISD were excluded.
OUTCOMES AND COMPLICATIONS
Outcomes
When assessing colposuspension outcomes, it is important that
one differentiate between procedures done with the true Burch–
Tanagho technique and those done using surgical modifications
The de novo detrusor instability rate was less than 9% at 1to 2-year follow-up, which is lower than that reported in most
open Burch colposuspension studies.[41–44] Urodynamic testing demonstrated a significant increase in pressure transmission
ratio, functional urethrallength, and maximumbladder capacity.
There was no significant change in maximal flow rate. Multiple
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Table 14.1.2: Laparoscopic Burch Colposuspensions with Sutures
Suture Cure
Study Study Type∗Patients, No. F/U, Months Type†No. Type of F/U
Abala et al. [5] R 10 7 P 2 S 100 0
Liu [6] R 107 3–27 P 4 O 97 7.4
Nezhat et al. [7] R 62 8–30 P 4 O 100 10
Radomski &
Herschorn [36]
Papasakelariou &
Papasakelarious [31]
Saidi et al. [22] P 70 12.9 P 4 S 91 NR
Ross [8] P 32 12 DA 4 O 94 6.3
Ross [39] P 35 12 DA 4 O 91
Ross [9] P 19 12 DA 4 O 93
Ross [10] P 48 24 DA 4 O 89
Ross [12] P 40 12 DA 4 O 89
Ross [40] P 87 >60 DA 4 O 84
P 34 17 P 4 S 85 11.8
P 32 24 P 4 S 91 6.3
‡
% Major Comps,%
Comps, complications; F/U, follow-up; NR, not reported.
∗
Study type: R, retrospective; P, prospective.
†Suture type: P, permanent; DA, delayed absorbable.
‡Type of follow-up: S, subjective; O, objective.
concomitant laparoscopic procedures for total vaginal vault prolapse and GSI wereperformed in these patients [9], including the
first reported laparoscopic paravaginal repair. With Burch alone,
97% of patients were discharged home in less than 24 hours and
93% voided spontaneously before discharge. When combined
with multiple repairs, including laparoscopic hysterectomy, posterior vaginalrepair, apical vault repair,and sacrocolpopexy, 91%
of patients were discharged in less than 48 hours. There were two
common factors in the few patients who experienced delayed
voiding: substantial posterior repairsor a preoperative maximum
flow rate of 15 mL per second or less.
In their retrospective study of 113 women, Cooper et al. [38]
reported an 87% subjective cure rate with transperitoneal (93
patients) or extraperitoneal colposuspension (20 patients) after a
mean follow-up of 8 months. Fourteen percent of these patients
had mixed incontinence preoperatively. Complications included
10 cystotomies, one inferior epigastric vessel injury, one vaginal tear, one suture in the bladder, and one possible enterotomy.
A subjective cure rate of 91% at 2 years has been reported by
Papasakelariou.[31] Using a gasless extraperitoneal approach,
Flax [45] obtained a 90% cure rate (defined as no pad usage)
in 47 patients, with a mean follow-up of 8.2 months. We have
a 83% objective cure rate at 5 years in 163 patients (Ross JW,
unpublished data).
Complications
Most studies do not differentiate between major and minor
complications. Overall complication rates range from 0% to
greater than 20%.[5,34,38,46]Majorcomplications include bladder injury, ureteral damage or kinking, abscess formation in the
space of Retzius, failed procedure requiring additional surgery,
de novo detrusor instability, new-onset ISD, urinary retention,
voiding dysfunction, and a possible increase in posterior compartment prolapse.
In a studyof 171 patientswho underwent laparoscopic colposuspension, Speights etal. [47] founda2.3% rate oflowerurinary
tract (LUT) injury. All fourinjuries noted were inadvertent cystotomies, two following prior MMK and staple–mesh procedures.
All were in the dome of the bladder, and all were repaired laparoscopically at the time of surgery. No ureteral injuries were seen.
These authors pointout that thisinjury rate islowerthan the 10%
injury rate observed in a series of open colposuspensions.[48] A
French center [49] reported a 3% injury rate in 104 laparoscopic
Burch procedures: two cystotomies and one partial ureteral transection. Ferland and Rosenblatt [20] reported ureteral obstruction in two patients. Cystoscopy revealed a transmural passage of
suture anterior and lateral to the urethral orifice in one patient
and puckering and lateral displacement of the right trigone causing ureteral obstruction in the other. Both these injuries were
on the patient’s right side, similar to other reports.[50,51] Ferland suggests that when the surgeon stands on the patient’s left
side, suture placement tends to be lateral to medial with the right
sutures, increasing the risk ofentrapmentof the right bladderwall
and intramural ureter (Figure 14.1.5A). He recommends passing
the right sutures medial to lateral to prevent this complication
(Figure 14.1.5B), not seen on the left side because the natural
suture placement is medial to lateral, away from the bladder for
a right-handed surgeon.
Dwyer et al. [52] reported three bladder sutures and three
ureteral obstructions by suture in 178 patients, giving an overall LUT injury rate of 3.4%. Cooper et al. [38] reported
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A
Figure 14.1.5. (A) The incorrect lateral-to-medial placement of a Burch suture, increasing the likelihood of ureteral compression.[19] (B)The
correct medial-to-lateral placement of a Burch suture, decreasing the chance of ureteral or trigone injury.
10 cystotomies and one bladder suture in 113 patients, resulting
in a 9.7% LUT injury rate. The overall laparoscopic injury rate
for the LUT in all gynecologic cases ranges from 0.02% to 1.70%,
which is not different from that seen in open gynecologic procedures. The inadvertentcystotomies reported were more common
in patients with prior surgery in the space of Retzius and were
bladder dome injuries easily recognized and repaired at the time
of surgery. Several of these reports were made in the early development of these surgeons’ laparoscopic skills. It is essential that
intraoperative cystoscopy be performedtoidentify occult bladder
and ureteral injuries.
Data on de novo detrusor instability are scant and not well
reported in most studies. The range appears to be approximately
3% to 13%.[30,38,53–55] Cardozo et al. [44] reported a rate of
18.5% de novo detrusor instability in open Burch, supported by
others.[42,56,57] Jarvis [58] reported a 9.6% mean incidence of
laparoscopic de novo detrusor instability in a meta-analysis, with
a range of 4% to 18%, and suggests this is less than that seen
in open procedures. One possible explanation is less scarring in
B
ones (0.83%).[62] Majorbleeding requiring transfusionhas been
reported after injury to these vessels.[63]
A major advantage oflaparoscopic surgery is thesignificantly
lower ventral hernia formation.[62] Most hernias that develop at
trocar sites are the result of lack of closure and are entirely preventable. The majority of these hernias are extraumbilical, the
contents are usually small bowel (84.2%) and less often colon
and omentum, and they often involve less than full herniation
(Richter’s hernia).[64] Margossian et al. [65] reported a preperitoneal herniation of the terminal ileum through the right lateral 10-mm port in which the fascia had been closed (Figure
14.1.6). We had a similar experience with a left 10-mm trocar
site. To prevent this complication, it is necessary to close the peritoneum, muscle, and fascia at largetrocarsites.Severalcompanies
have simple devices to use for this purpose (Inlet Closure CarterThomason Closure, Inlet Medical,Inc.,Trumbull, CT; Endoclose,
U.S. Surgical Corp., Norwalk, CT; Storz reusable fascial closure,
Karl Storz, Culver City, CA), and the closure adds very little time
to the operative procedure (Figure 14.1.7).
the laparoscopic procedure, although this has not been clearly
demonstrated. In more than 300 cases, our de novo detrusor
instability rate following laparoscopic Burch has been 8% (Ross
JW, unpublished data, 2004).
Several published series report no significant voiding dysfunction with laparoscopicBurch.[6,10,37]Lavin etal.[55]found
significantly less subjective voiding dysfunction after 2 years in
laparoscopic versus open Burch: 16% and 52%, respectively. Su
et al. [59] reported 4.3% voiding dysfunction in both laparoscopic and open Burch. No good long-term follow-up studies
are available. As many as 20% of our patients report positional
changes to empty their bladders in the first 6 months following
laparoscopic Burch, usually with resolution by the end of the
first year. Many studies have found less blood loss with laparoscopicBurch[22,55,59,60],early spontaneousvoiding[22,59,61],
and decreased length of stay in the hospital with laparoscopic
Burch.[60]
Abdominal wall vascular injury is usuallysecondary to lateral
trocar placement, resulting in inferior epigastric vessel damage
[8], with a reported incidence of 0.5% and less frequentwith coneshaped or blunt trocars (0%) as compared with sharp-cutting
Figure 14.1.6. An example of a Richter’s hernia with small bowel
entrapped between the abdominal muscles and fascia after improper
closure of the trocar site.
Laparoscopic Burch Colposuspension — 373
A
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B
Figure 14.1.7. A trocar closure device needle passes a suture through the abdominal wall into the peritoneal cavity on one side of the trocar site.
The needle is removed and passed through the opposite site, and the suture is grasped and pulled out to be tied extracorporeally.
COMPARATIVE RESULTS
Ideally, comparisons among surgical procedures should be based
on the long-term results of direct, head-to-head studies in which
cohorts of similar patients are prospectively randomized to
undergo one ofthedifferentprocedurestobe studied, and followup evaluation is conducted by practitioners blinded as to which
procedure the patients have undergone. Unfortunately, it is often
hard to get patients to agree to randomization, making randomized, controlled studies difficult. The following studies compare
the clinical outcomes of the laparoscopic Burch colposuspension to (1) open Burch colposuspension, (2) laparoscopic colposuspension with mesh and staples, (3) tension-free vaginal
tape (TVT) suburethral sling, and (4) bone anchor suburethral
slings.
Laparoscopic versus Open Burch Colposuspension
Six prospective randomized, controlled studies comparing open
and laparoscopic colposuspension have been reported. Four of
these studies used the classic Burch–Tanagho technique, and two
modified the technique by usingonesutureper side inmostcases.
In 2003, Cheon et al. [66] published results of a prospective
randomized trialcomparing laparoscopic andopen Burch colposuspension. Forty-three patients were included in the open arm
and 47in the laparoscopicarm. In botharms, suture numberand
placement technique were identical. The authors found no difference in subjective or objective outcomes at 1-year follow-up,
with subjective successof 86% versus 81% and objective successof
86% versus 85% in the open and laparoscopic arms, respectively.
The three other studies using the Burch–Tanagho technique
were reported in abstract form only. Burton [67,68] published a
randomized, controlled trial comparing open and laparoscopic
Burch using absorbable suture (Table 14.1.3). In each arm of the
study, 30patients with moderatetosevere GSI were followed for 3
years postoperatively. Superior results,interms of both subjective
and objective cure, were noted in the open arm during follow-up
at both 1 and 3 years. At 1 year, objective cure, defined as no GSI
on video cystourethrography, was observed in 97% of the open
cases and 73% of the laparoscopic cases. The open procedure
maintained a 93% objective cure rate at 3 years, whereas the
laparoscopic cure rate dropped to 60%. One criticism of this
study is that Burton reported doing fewer than 20 laparoscopic
procedures before the onset of the study – a rather small number
given the steep and longlearning curveof this relativelyadvanced
procedure.
Two multicenter studies subsequently demonstrated no significant difference in outcomes between the two procedures.
Carey et al. [69] randomized 200patientswithprovenGSItoopen
or laparoscopic Burch colposuspension. He reported 6-month
objective urodynamic cure rates of 80% and 69% and subjective
success rates of 95% and 100% for the two procedures, respectively. Neither difference was statistically significant. In another
multicenter trial involving 28 laparoscopic procedures and 34
open procedures, Summitt et al. [70] observed objective 1-year
success rates of 92.9% for the laparoscopic Burch and 88.2%
for the open Burch.[70] Saidi et al. [22] compared 70 patients
with extraperitoneal laparoscopic Burchto 87 patients with open
Burch and reported 91% and 92% objective cure rates, respectively, at 12 months.
Prospective randomized studies in which one stitch per side
was used inthelaparoscopiccolposuspensionshaveshown mixed
results. Su et al. [59] used two to three stitches per side for
open colposuspensions but only one stitch per side in most
of their laparoscopic colposuspensions. They reported objective
cure rates – defined as dry on urodynamic testing – of 80.4%
and 95.6% for laparoscopic and open colposuspensions, respectively, with a minimum 1-year follow-up. Interestingly, on a 1hour extended pad test, the laparoscopic group showed a slightly
greater improvement than the open group, though there was no
statistically significant difference between the groups pre- or postoperatively. As discussed earlier in this section, the difference
between one stitch and two per side likely accounts for the differences in outcomes. The Su group stated the reason for only
one suture in the laparoscopic group was lack of room for suture
placement through the laparoscope.
In 2001, Fatthy et al. [54] published a study in which one
stitch per side was used for both the open and laparoscopic colposuspensions. There was no statistically significant difference
in objective cure by urodynamic testing at 18-month follow-up,
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Table 14.1.3: Comparison of Laparoscopic versus Open Burch Colposuspension
Months Follow-up
Author
(Reference no.)
Study
Type LSC Open LSC Open LSC Open p value LSC Open p value
N Mean (range) Objective Cure (%) Subjective Cure (%)
Burton (67,
68)
Ross(8) R 323012129493NSNRNR
Polascik (60) R 12 10 20.8
Su (59) P 46 46 >12 >12 80
Lavin (55) R 116 52 6 6 73 77 81 73
Miannay (72) R 36 36 12/24 12/24 NR NR 79/68
Saidi (22) R 70 87 12.9
Summitt (70) P 28 34 12 12 93 88 NS NR NR
Carey (69) P 96 104 6 6 69 80 0.1 100 95 0.12
Fatthy (54) P 34 40 18 18 88
Huang (71) R 82 75 12 12 NR NR 84 89 0.49
∗
Modified Burch with one suture per side
Study Type: P = Prospective, R = Retrospective
NR, Not reported
with no leakage reported in 87.9% of the laparoscopic cases and
85% of open cases.
P 30 30 12/36 12/36 73/60 97/93 <0.05/<0.05 NR NR
(8–29)
(2–24)
35.6
(11–50)
16.3
(6–30)
83 70 NS NR NR
∗
NR NR 91.4 91.9 NS
∗
96 0.04 NR NR
∗
69/64 NS/NS
∗
85
NS NR NR
been noted in most laparoscopic groups.[8,54,72,73] Complications do not differ statistically where reported.
Three published retrospective cohort studies compared open
with laparoscopic Burch, and one used a one-suture-per-side
technique for the laparoscopic colposuspensions. In a cohort
study involving 30 patients followed prospectively in the laparoscopic arm and 32 patients reviewed retrospectively in the open
arm, we reported objective cure rates at 1-year follow-up of
94% and 93%, respectively (Table 14.1.2).[8] That same year,
Polascik et al. [60] published the results of a retrospective cohort
study showing a subjective cure rate of 83% using the laparoscopic approach, with a mean follow-up of 20.8 months, versus
70% via the abdominal route, with a mean follow-up of 35.6
months. More recently, a retrospective cohort study by Huang
and Yang [71] found subjective cure rates of 84% and 89% at 1
year for laparoscopic and open Burch colposuspensions, respectively. There were no statistically significant differences in cure
rates between the two approaches in any of these three studies.
Miannay et al. [72] also found no difference in subjective cure
rates at 1- and 2-year follow-up between open and laparoscopic
colposuspension, even though only one stitch per side was used
in the laparoscopic cases.
Where reported, data seem to support the general perceived benefits to the patient of laparoscopy versus laparotomy. A shorter length of stay with the laparoscopic approach
was noted in all but one study in which this parameter was
investigated.[8,54,60,66,70–73] Likewise, less postoperative pain
[54,60,66,72,73] and a quicker return to normal activity have
Laparoscopic Burch versus Tension-free Vaginal
Tape Suburethral Sling
Ten years have passed since Ulmsten et al. [74] described their
tension-freevaginaltape(TVT)mid-urethralslingprocedureand
reported on its early successes. The rapid rise in popularity of the
TVT procedure coincided with, and has now mostly surpassed,
the rise in popularity of the laparoscopic Burch colposuspension.
Both procedures have their proponents. Advocates of the laparoscopic Burch colposuspension cite the longer track record of the
Burch procedure, the ability to visualize the surgical field, and
the lack of concern over erosion, whereas TVT advocates point
to shorter duration of surgery, slightly shorter recovery, relative
ease of the procedure, and perceived lower cost. To date, three
prospective randomized, controlled trials have been published
comparing the two procedures. Additionally, one large prospective randomized, controlled trial comparing TVT with the open
Burch procedure has been published.
Persson et al. [75] in a prospective randomized trial comparing laparoscopic Burch with TVT, with 31 patients in the
laparoscopic arm and 37 patients in the TVT arm, found
no significant difference in efficacy between the two procedures (Table 14.1.4). Objective cure rates (defined as a negative short pad test) were 87% for the laparoscopic Burch and
89% for the TVT. Interestingly, subjective cure rates based on a
Laparoscopic Burch Colposuspension — 375
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Table 14.1.4: Comparison of Laparoscopic Burch versus TVT
Months Follow-up
No. of Patients Mean (range) Objective Cure (%) Subjective Cure (%)
Author (year) LSC TVT Type LSC TVT LSC TVT p value LSC TVT p value
Persson (76) 31 37 P 12 12 87 89 NS 52 57 NS
Usten (77) 23 23 P 13.5 11.3 82.6 82.6 NS NR NR
Ward (78) 108
∗
137 P 24
∗
24 80
∗
81 NS 62
∗
60 NS
questionnaire were markedly lower in both groups − 52% and
57%, respectively.
Ustun et al.[76] reported resultsof a study of 46patients with
GSI randomized to undergo laparoscopic Burch (n = 23)orTVT
(n = 23) who were followed for up to 24 monthspostoperatively.
An objective curerate of 82.6% was seen in both the laparoscopic
Burch group, with a mean follow-up of 13.5 months, and the
TVT group, with a mean follow-up of11.3 months.Patients were
considered “cured” if they were subjectively dry, had a negative
stress test, and had had no leakage on urodynamic testing performed at 3 months. TVT patients did have a significant decrease
in maximum urinary flow, suggesting more obstruction.
Most recently, Paraiso et al. [77] published the results of a
randomized prospective trial comparing laparoscopic Burch colposuspension with TVT. Thirty-five patients wereenrolled in the
colposuspension arm and 36 in the TVT arm. At1 year, 33 and 30
patients were available for follow-up in the colposuspension and
TVT arms, respectively; at 2 years, 17 and 16 patients were evaluated in the respective arms. Objectively, urodynamic testing at
1 year demonstrated a higher rate of stress urinary incontinence
(SUI) inthecolposuspensiongroup(18.8%vs.3.2%)andahigher
rate of detrusor overactivity in the TVT group (19.3% vs. 6.2%);
however, neither result achieved statistical significance. Subjectively, although Kaplan–Meiersurvival curveanalysisshowedstatistically significant earlier development of both stress and urge
incontinencesymptomsin the colposuspension group,therewere
no differencesnotedwith regardtopatientsatisfaction,padusage,
Urinary Distress Inventory/Incontinence Impact Questionnaire
(UDI/IIQ) scores, or incontinence episodes per weekateither 1 or
2 years. Theactual percentages ofpatients experiencing recurrent
SUI symptoms at 1 and 2 years were not reported.
There are few studies reporting direct comparisons of complication rates, costs, length of stay, and perioperative convalescence between laparoscopic Burch colposuspension and TVT. In
all three prospectivecomparisontrials, a statistically shorter operative time was noted in the TVT group. For the most part, these
data are consistent with noncomparative data on TVT, which
typically show operating time shorter than that reported in most
studies for laparoscopic Burch. In general, the more experienced
the laparoscopist, the smaller the difference in time between the
two procedures. Despite the shorter operating room (OR) time,
Persson et al. [75] found the total cost of TVT to be higher than
that of the laparoscopic Burch because ofthe high costof the TVT
set. Cost comparisons are notoriously difficult, not only because
of differences in surgery times among different surgeons but also
because OR costs per minute differ among different locations.
In the Paraiso study [77], overall complication rates were
not significantly different between the two procedures, but it
was noted that the TVT complications were of a more serious
nature. Estimated blood loss, change in hematocrit, and days to
catheter removal were similar between the TVTandcolposuspension groups. There was a strong trend toward increased detrusor
overactivity in the TVT group, but it did not reach statistical
significance. There were no differences in voiding dysfunction.
Persson et al. [75] did not address complications in their study.
Numerous internal discrepancies inthe Ustun group’spaper [76]
preclude making any conclusions regarding complication rates
between the two procedures, although complications appeared
to be few in both.
In a prospective randomized study comparing immediate
outcomes of laparoscopic mesh colposuspension and TVT, Valpas et al. [78] noted no major differences in intraoperative or
postoperative complications. They did find that return to normal voiding was quicker and pain medication use lower in the
TVT group. Similarly, in a retrospective review of all 800 female
anti-incontinence procedures performed at their hospital over 13
years,Debodinanceetal.[79]foundnomajor differencesinintraoperative or immediate postoperative complications between
TVT and laparoscopic Burch colposuspension; they did note,
however, higher de novo voiding difficulties (18.5% vs. 0%) and
de novo urgency (11.0% vs 4.8%) in TVT when compared with
laparoscopic Burch colposuspension.
In summary, laparoscopic Burch colposuspension and the
TVT sling appear to have similar efficacy, at least over the short
to medium term. There are no published long-term data beyond
2 years. Operative time andtimeto resumption of normal voiding
appear to be slightly shorter with TVT versus laparoscopic Burch
colposuspension. Complication rates appear to be low with both
procedures, though good comparative data are lacking.
Although TVT – and more recently, tension-free obturator
tape (TOT) – have become the procedures of choice for many
physicians because of the easeof performing the procedure, short
operative time, excellent efficacy, and low complication rate, we
feel laparoscopic Burch still has a role in the treatment of female
stress incontinence. In particular, laparoscopic Burch colposuspension may be the procedure of choice in patients who are allergic to or donot desire polypropylene mesh,those in whomsuprapubic bowel adhesions are suspected, those who have femoral–
femoral bypass grafts, or those who are undergoing other laparoscopic procedures, especially paravaginal defect repair, in which
placement of the colposuspension sutures would add relatively
little time to the procedure.
376 — Jim W. Ross and Mark R. Preston
https://t.me/med1917
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