Abdominal Retropubic Approaches for Female Incontinence

Abdominal Retropubic Approaches for Female Incontinence


Urinary incontinence (UI) is common, with approximately 30% of women reporting any incontinence; about 25% to 50% of these cases are estimated to be stress urinary incontinence (SUI) (1,2,3). In addition, the number of women seeking care for UI is increasing. Office visits for UI more than doubled from 815,832 visits in 1992 to 1,932,768 visits in 2000 (4). A recent analysis of population growth and future demand for care concluded that consults for pelvic floor disorders will increase by 45% from 2000 to 2030 (5). In terms of surgical management, one out of nine women will have surgery for a pelvic floor disorder in their lifetime, and this number represents only a subset of women who have the condition (6). About one-third of the surgeries were for SUI alone, and another 20% of surgeries were performed for combined SUI and pelvic organ prolapse (POP).

Although the exact mechanism that leads to SUI is not known, proposed theories include loss of proximal urethral support, or the “hammock” theory, and intrinsic deficiency of the external urethral sphincter. Surgical procedures are directed toward correction of the deficiency, either reestablishing support of the proximal urethral or improving urethral closure. The suburethral sling procedure can be performed using autologous fascia (rectus fascia or fascia lata) or synthetic material. The sling procedures are covered in other chapters.

Urethral position depends on anterior vaginal wall support. Retropubic colposuspension, or urethropexy, aims to improve the support of the vesicourethral junction by elevating the periurethral tissue toward the pubic bone, thus restoring the proper anatomy. The procedure is believed to treat incontinence by providing improved resistance to increases in intra-abdominal pressure, resulting in more effective urethral compression. The Marshall-Marchetti-Krantz (MMK) procedure involves suturing the periurethral tissue at the level of the bladder neck directly to the periosteum of the pubic symphysis. Burch, a gynecologist, modified this technique by altering the suspension laterally to the iliopectineal line or Cooper’s ligament. The Burch technique was further modified by Tanagho, a urologist, to include a suture bridge instead of direct apposition of the anterior vaginal wall to Cooper’s ligament. The Burch urethropexy has traditionally been performed via a small Pfannenstiel incision, but the laparoscopic approach has been used as well.

The MMK is largely a historical procedure as the Burch appears to be slightly more efficacious. In addition, the complication of osteitis pubis is specific to the MMK approach due to the placement of suture directly into the periosteum. Although the Burch urethropexy may be regarded as an outdated procedure as well, it is still a reasonable option for a
woman desiring an incontinence procedure, particularly if she is undergoing a concomitant abdominal surgery. In addition, as will be discussed later in the chapter, it is indicated for an asymptomatic, stress-continent woman undergoing an abdominal sacrocolpopexy for prolapse.


The main indication for an incontinence procedure is the presence of symptomatic SUI that adversely affects the woman’s quality of life. The patient should also have the sign of transurethral loss of urine with a cough stress test or during formal urodynamic testing. Additionally, the patient must be sufficiently healthy to undergo regional or general anesthesia, be able to be placed in dorsal lithotomy position, and have a habitus that allows a suprapubic incision. There appears to be a risk of worsening POP after a Burch procedure (13,14,15); therefore, a Burch urethropexy probably should not be performed as a solitary procedure if there is significant apical descent. Lack of urethral hypermobility and a previously failed retropubic approach would be considered indications for a suburethral sling by most pelvic surgeons.

A Burch urethropexy is also appropriate for an asymptomatic woman (without SUI) undergoing a sacrocolpopexy for POP. A randomized controlled trial showed that performing a concomitant Burch urethropexy at the time of abdominal sacrocolpopexy resulted in a decrease of new-onset postoperative SUI from 40% to 20% in stress-continent women (16).


Conservative therapies for SUI may involve use of pessaries or physical therapy for pelvic floor muscle (PFM) rehabilitation. In women successfully fitted with a pessary for UI, rates of continued use and satisfaction range from 16% to 59% at 1 year (17,18). PFM physical therapy includes both strengthening and instruction on timing of activation of PFMs to avoid leakage. A Cochrane review in 2007 supported that PFM training should be included in first-line conservative management for women with UI (19). In women with SUI who participated in a course of PFM exercise, 44% to 56% of patients were satisfied with symptom improvement and desired no further treatment (20,21).

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Apr 24, 2020 | Posted by in UROLOGY | Comments Off on Abdominal Retropubic Approaches for Female Incontinence

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