Philippe E. Zimmern and Elise J. B. De (eds.)Native Tissue Repair for Incontinence and Prolapse10.1007/978-3-319-45268-5_4

4. Burch Colposuspension

Ajay K. Singla¹ and Nirmish Singla²

(1)

Department of Urology, University of Toledo, Toledo, OH, USA

(2)

Urology, UT Southwestern, Dallas, TX, USA

Ajay K. Singla (Corresponding author)

Email: ajay.singla@utoledo.edu

Nirmish Singla

Email: nirmish@gmail.com

Abstract

The surgical management of stress urinary incontinence (SUI) in women has evolved over the last several decades, with bladder neck suspension procedures representing the oldest approach. The Burch colposuspension in particular was originally introduced in 1961 and has since undergone modification in technique, most recently with the introduction of robotic approaches. With the recent rise in litigation and concerns over vaginal mesh, there has been renewed interest in bladder suspension procedures. Outcomes remain promising for this technique, based on its long-term efficacy and durability. In this chapter, we present an index patient with SUI who experienced favorable outcomes following Burch colposuspension. We discuss surgical indications, patient counseling, intraoperative techniques, post-operative considerations, and contemporary outcomes using this approach. In the accompanying video supplements, we provide an open Burch colposuspension as well as an illustrative example demonstrating a robotic Burch colposuspension.

Electronic supplementary material

The online version of this chapter (doi:10.1007/978-3-319-45268-5_4) contains supplementary material, which is available to authorized users.

Keywords

Stress urinary incontinenceBladder suspensionBurch colposuspensionRetropubic suspensionSurgical techniqueOutcomes

Background

Urinary incontinence is estimated to affect between 15 and 50 % of adult women [1]. Of incontinent women, stress urinary incontinence (SUI) predominates in approximately 50–80 % [2]. Two mechanisms of SUI have been recognized: (1) hypermobility of the proximal urethra and bladder neck due to weakened urethral support with an otherwise normal sphincter muscle, and (2) intrinsic sphincter deficiency (ISD) resulting in poor urethral coaptation. The goal of surgery is to reposition the proximal urethra and urethrovesical junction in cases of hypermobility or to correct urethral coaptation in cases of ISD. It is not uncommon to exhibit some combination of both types of SUI. Hypermobility may be present on physical examination without SUI, as seen in many women following multiple vaginal deliveries, while some element of ISD may be evident if leakage is demonstrated with stress.

The mainstay of SUI treatment is surgery, though we continue to lack an ideal procedure for this problem. There has been an evolution in the surgical management of SUI over the last several years with the emergence of various slings. Open retropubic bladder suspension remains the oldest SUI procedure with robust longitudinal data available. Three variations of bladder neck suspension procedures have been described:

1.

Marshall Marchetti-Krantz (MMK) procedure
2.

Burch colposuspension
3.

Paravaginal repair or Obturator Shelf procedure

In the late 1990s mid-urethral slings were introduced as a less invasive alternative and became very popular because of short operative time, quick recovery and decreased morbidity relative to open abdominal procedures. Recent anti-mesh publicity and FDA warnings concerning potential mesh complications, however, have led to resurgence of the Burch procedure, as patients increasingly desire mesh-free surgery.

The Burch procedure was originally described in 1961 by attaching the paravaginal tissue to the arcus tendineus [3]. The point of fixation was later shifted to Cooper’s ligament, with additional modification described by Tanagho in 1976 [4]. More recently, minimally-invasive approaches including laparoscopic and robotic Burch colposuspension have been described, reducing the morbidity of the traditional open procedure.

Case Presentation

History and Physical Examination

Our patient is a 42-year-old G3P3A0 female (all vaginal deliveries) who presents with progressively worsening SUI over the last few years. She denies any urinary frequency, urgency, dysuria, or hematuria, and her history is not suggestive of voiding dysfunction. She denies any prior abdominal surgeries. Her urinary leakage is primarily prompted by abdominal straining including coughing, laughing, and sneezing. She uses 2–3 pads per day and maintains an active lifestyle. Her incontinence is very bothersome to her and negatively impacts her quality of life. She has tried pelvic floor (Kegel) exercises with no improvement.

Her pelvic examination reveals normal genitalia without pelvic organ prolapse. She is noted to have hypermobility of her proximal urethra and bladder neck on bimanual examination. A Q-tip test is positive with deflection of more than 30° during Valsalva.

A bladder diary shows frequency every 3 h during the day and nocturia twice over a 48-h period. Her urinalysis demonstrates no evidence of urinary tract infection.

Urodynamic study reveals a bladder capacity of 350 ml with normal bladder sensations and no evidence of detrusor overactivity. Abdominal Valsalva leak point pressure is measured at 96 cm H₂O, and SUI is demonstrated during the study. She is able to void to completion with both detrusor contraction and pelvic floor relaxation.

Surgical Indication

The ideal patient for the Burch colposuspension procedure is a young woman usually in her 20s, 30s and 40s preferably in pre-menopausal age group with pure hypermobility, high abdominal leak point pressures, and no prior anti-incontinence procedures. She should not have a history of postural incontinence, defined as urinary leakage with change in posture from the sitting position to standing position (this suggests poor sphincter function).

Surgical options were discussed with our patient, including mid-urethral sling using synthetic prolene mesh tape, periurethral bulking agents, pubovaginal fascial sling, needle suspension and retropubic bladder suspension (Burch).

Our patient declined procedures using synthetic mesh due to mesh concerns. Given her young age and pure hypermobility, Burch colposuspension was offered as an ideal alternative that would correct her hypermobility and restore the vesicourethral angle while avoiding the potential complications associated with synthetic mesh.

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