A Retrospective Comparison of Abdominal Sacrocolpopexy with Burch Colposuspension versus Sacrospinous Fixation with Transvaginal Needle Suspension for the Management of Vaginal Vault Prolapse and Coexisting Stress Incontinence

The objective of this study was to compare the surgical outcome of abdominal sacrocolpopexy and Burch colposuspension with sacrospinous fixation and transvaginal needle suspension in the management of vaginal vault prolapse and coexisting stress incontinence. One hundred and seventeen women with vaginal vault prolapse and coexisting stress incontinence were surgically managed over a 7-year period. The first 61 consecutive women who underwent sacrospinous fixation and transvaginal needle suspension comprised the vaginal group, and the following 56 consecutive women who underwent abdominal sacrocolpopexy and Burch colposuspension comprised the abdominal group. Office records were reviewed to assess the presence of recurrent prolapse and urinary incontinence during postoperative follow-up. Objective follow-up was available for 101 women. Mean duration of follow-up was 24.0 ± 15 months for the vaginal group, and 23.1 ± 12.6 months for the abdominal group. The incidence of recurrent prolapse to or beyond the hymen (33% vs. 19%, P = 0.0505) and lower urinary tract symptoms (26% vs. 13%, P = 0.0506) were significantly higher in the vaginal group than in the abdominal group. Our data suggest that the combined abdominal approach has a lower incidence of recurrent prolapse and lower urinary tract symptoms than the combined vaginal approach in managing vaginal vault prolapse and coexisting stress incontinence.     

Colposuspension or Sling for Low Urethral Pressure Stress Incontinence?

The aim of this study was to compare Burch colposuspension with the pubovaginal sling in the management of low urethral pressure urinary stress incontinence. Forty-five women with low urethral pressure stress incontinence were retrospectively reviewed: 21 underwent colposuspension and 24 a pubovaginal sling. The subjective success rate of the Burch colposuspension and the pubovaginal sling was 90% and 71% (P= 0.12), respectively; the objective success rate was 67% and 50% (P= 0.26), respectively. The incidence of postoperative complications, including de novo detrusor instability and symptomatic voiding dysfunction following the colposuspension, was 5% compared to 25% following the pubovaginal sling (P= 0.06). Colposuspension should be considered in the management of women undergoing surgical correction of low urethral pressure stress incontinence. In a clinically similar group of women, the Burch colposuspension had a superior subjective and objective success rate with a lower incidence of complications than did the pubovaginal sling. Although these differences failed to reach statistical significance, colposuspension can be safely considered in the management of women with low urethral pressure GSI.     

An unusual complication of Burch colposuspension

Burch colposuspension remains one of the successful operations for genuine stress incontinence. We report a patient who developed an intravesical foreign body granuloma post-Burch colposuspension. Any patient developing unexplained lower urinary tract symptoms following bladder or pelvic surgery for incontinence must be evaluated endoscopically in order to exclude this complication.     

Burch against Stamey. Comparison of two competing operative procedure

Summary Stress incontinence is the most frequent form of incontinence found in females. The usual method of surgery for this is to lift the bladder neck towards cranial and ventral. Two competitive techniques – bladder neck suspension in accordance with Stamey and colposuspension in accordance with Burch – were retrospectively investigated. A total of 95 women underwent surgery and it was possible to evaluate the postoperative course in 46 and 30 (total 76) patients respectively. Initially, both surgical techniques demonstrated a very good success rate (91.3 % and 96.7 % resp.). However, the continence rate of the Stamey patients deteriorated after 6 weeks down to 78.3 % and after more than 2 years only 28.6 % of these patients were still completely continent (mean follow-up 40.4 mths), whereas deterioration in the Burch patients was only 87 % (mean follow-up 44.25 mths). The disappointing results with the Stamey technique did not correlate with the degree of initial continence. It was noted here that obese patients showed a greater tendency towards regression. The three cases of recurring incontinence after Burch colposuspension were already relapses at the time of surgery. With respect to long-term follow-up, our results with the Stamey method were distinctly poorer than with the Burch technique. Therefore, in our opinion, the Burch colposuspension procedure and fascioplasty should be the method of choice for the management of stress incontinence.      

Biomechanics of Urinary Stress Incontinence Surgery – Theory of the Non-Permanently Acting Suburethral Supportive Structure

This biochemical study of the lower urinary tract as it relates to urinary continence and incontinence is based on the morphotopographic results of radiological, autopsy and surgical investigations in the period 1966–1968. The process of urinary continence is simply explained by the application of universal hydromechanical laws, which demonstrated that continence during straining results from compression of the urethra over a suburethral resistant structure. Compression occurs during dorsocaudal physiologic displacement of the urethrovesical complex in conditions of increased intra-abdominal pressure. The theory of a non-permanently acting suburethral support is based on these results and represents the essential principle of urinary stress incontinence surgery, namely, that surgery should create a suburethral resistance over which the proximal urethra is compressed during increased intra-abdominal pressure.  Such suburethral resistance may be created via the vaginal or the abdominal routes, using autogenous or heterogeneous tissue. A critical analysis of different surgical techniques and how they achieve the demands of this theory is presented. In this context two orginal surgical procedures incorporating the best biomechanical features are elaborated: slinglike colposuspension via the abdominal route, and suburethral duplication of the anterior vaginal wall by the vaginal route. The aim of this paper is to present the biomechanical study of urethrovesical phenomena playing a role in urinary continence and the pathogenesis and surgery of stress incontinence in light of our theory. Our personal experience with 1836 surgical procedures between 1968 and the end of 1997, encompassing 1056 slinglike colposuspensions and 780 suburethral duplications of the vagina, gives practical support to our concepts.     

Effects of the Menstrual Cycle on Urodynamic Work-up: Should We Change our Practice?

The aim of this study was to compare urinary symptoms and urodynamic parameters during follicular and luteal phases of the menstrual cycle of women with lower urinary tract symptoms. Fifteen women were eligible and agreed to participate in the study. The subjects underwent urodynamic work-up, including filling urethrocystometry, urethral pressure profile and Valsalva leak-point pressure, cough stress test and subjective assessment of severity of symptoms in the mid-follicular and mid-luteal phases of the menstrual cycle. Mean age was 37 years (range 18–43), mean parity 1 (range 0–3). Five women were found to have genuine stress urinary incontinence, 6 detrusor instability, 3 mixed incontinence and 1 urethral instability. Clinical diagnosis did not change and the urodynamic parameters were not statistically different in the two separate evaluations. A trend toward worsening of symptoms in the luteal phase in women with detrusor instability was identified. Our study suggests that the menstrual cycle does not significantly affect the work-up of women with lower urinary tract complaints.     

Irritative Symptoms after Colposuspension: Are they due to Distortion or Overelevation of the Anterior Vaginal Wall and Trigone?

Symptoms of bladder irritability are common after incontinence surgery but their cause is unknown. This study tests the hypothesis that irritative symptoms after colposuspension are due to distortion of the trigone. As part of longitudinal follow-up studies, 175 women were examined 6 months to 12 years after either an open or a laparoscopic Burch colposuspension. The main outcome measures were symptoms of bladder irritability (frequency, nocturia and urge incontinence) and ultrasound findings (bladder neck position at rest and on Valsalva, the presence of a colposuspension ridge, ridge depth and ridge distance, and trigonal angle). Two positive associations between ultrasound parameters and symptoms of bladder irritability were observed: urge incontinence was more likely in the presence of bladder neck funneling, and women with nocturia had a higher trigonal angle. Increased distortion of the trigone was associated with a reduced incidence of urge incontinence in the subgroup of patients after laparoscopic colposuspension. The data presented in this study do not support the hypothesis that symptoms of bladder irritability are due to trigonal distortion or overelevation.     

Assessment of the results of Stamey bladder neck suspension

A total of 48 patients with genuine stress incontinence underwent endoscopic bladder neck suspension; 36 patients (75%) were completely cured of their incontinence but 12 (25%) suffered recurrent leakage. In 2 cases this was due to infection and erosion of the vaginal sutures; in 4 cases failure was ascribed to a small capacity bladder and "pipe-stem" urethra. In the remaining 6 unsuccessful cases the Stamey sutures had cut through flimsy endopelvic fascia. It was concluded that endoscopic bladder neck suspension has advantages over colposuspension in terms of reduced dissection and hospital stay, but its success rate is lower than originally reported. Failures due to suture infection and buttress displacement may be avoided by not using Dacron and, instead, by picking up vaginal subdermis with nylon sutures--the same tissue used to provide support in a Burch colposuspension.     

Botulinum Toxin Urethral Sphincter Injection Resolves Urinary Retention after Pubovaginal Sling Operation

The management of prolonged urinary retention following pubovaginal sling surgery typically involves transvaginal urethrolysis for anatomical urethral obstruction. Brubaker [1] recently reported on urethral sphincter abnormalities as a cause of postoperative urinary retention following either Burch suspension or pubovaginal sling procedure. We report a case of functional urethral obstruction and detrusor acontractility following pubovaginal sling surgery that was successfully treated by botulinum A toxin urethral sphincter injection.     

Botulinum Toxin Urethral Sphincter Injection Resolves Urinary Retention after Pubovaginal Sling Operation

The management of prolonged urinary retention following pubovaginal sling surgery typically involves transvaginal urethrolysis for anatomical urethral obstruction. Brubaker [1] recently reported on urethral sphincter abnormalities as a cause of postoperative urinary retention following either Burch suspension or a pubovaginal sling procedure. We report a case of functional urethral obstruction and detrusor acontractility following pubovaginal sling surgery that was successfully treated by botulinum A toxin urethral sphincter injection.     

Transvaginal ultrasonography and urodynamic evaluation after suspension operations: comparison among the Gittes, Stamey and Burch suspensions

Radiological and ultrasonographic imaging enables the objective determination of bladder neck position and movement in stress urinary incontinence. Postoperative results were evaluated in 60 patients after Burch colposuspension (29) or bladder neck suspension according to the Gittes (18) or Stamey (13) method. No differences in continence rates were noted 3 months postoperatively (Gittes 83%, Stamey 85% and Burch 93% of the patients). Late results were assessed by urodynamic evaluation and transvaginal ultrasonography. The largest decrease in continence rate was observed after the Gittes procedure (44% of the patients continent, mean followup 14.7 months), in comparison with the Stamey (69% continent after 34.6 months) and Burch (86% continent after 30.5 months) procedures. Urodynamic parameters showed no significant differences for the 3 groups. Transvaginal ultrasonography did not indicate a correlation between absolute resting or stress position of the bladder neck and continence. The main factor concerning continence was the rotation angle and descent of the bladder neck during stress. Our data indicate that transvaginal ultrasonography is a safe and reliable method to evaluate the postoperative outcome for stress urinary incontinence.     

Long-term chronic complications from Stamey endoscopic bladder neck suspension: a case series

Purpose/objective Long-term complications from anti-incontinence surgical procedures are rarely reported. We report on delayed presentation of complications relating to the synthetic bolster placed for the Stamey bladder neck suspension. Materials and methods: Patients undergoing re-operative surgery following prior Stamey endoscopic bladder neck suspension were selected from a surgical database. Four women with lower urinary tract and/or vaginal symptoms following prior Stamey endoscopic bladder neck suspension were identified. All patients had undergone removal of the bolster material by a single surgeon (ESR) at re-operation. Preoperative, operative, and postoperative inpatient and outpatient records were reviewed. Results: Patients presented with a variety of symptoms including urinary incontinence, recurrent cystitis, vaginitis, and urinary frequency at 9, 11, 11, and 12 years after Stamey bladder neck suspension. In addition, two patients presented with recurrent, intermittent bloody vaginal discharge and two patients complained of recurrent urinary tract infections and irritative voiding symptoms. All patients underwent transvaginal excision of the Dacron bolster. Three patients also underwent placement of an autologous pubovaginal sling for symptomatic recurrent stress urinary incontinence. At a mean follow-up of 30 months all four patients were improved. There was no recurrence of vaginal discharge or urinary tract infections. Irritative voiding symptoms resolved. Conclusions: Delayed complications from surgically implanted synthetic materials can present many years after initial implantation. The clinical findings are often subtle and require a high degree of suspicion. Vaginal discharge and irritative urinary symptoms in patients with even a remote history of Stamey bladder neck suspension should prompt a thorough vaginal exam and cystoscopy. Excision of the bolsters can be performed and is usually followed by symptomatic improvement.     

Laparoscopic Mesh and Staple Burch Colposuspension

Our objective was to describe our experience with laparoscopic Burch colposuspension and to relate our results to traditional open Burch procedures for the treatment of genuine stress incontinence. Retrospective case series were compared to historical controls. Forty-six women found to have only genuine stress incontinence by history, examination and clinical urodynamics, underwent a mesh and staple laparoscopic Burch procedure. Follow-up ranged from 3 to 50 months. Thirty-seven women were dry, 6 were improved and 3 showed no improvement. This compared to between 75% and 90% of women cured of stress incontinence by the traditional open Burch procedure. We concluded that the results of a mesh and staple laparoscopic Burch procedure in a carefully selected population of women with genuine stress incontinence appears comparable to that reported in the literature for an open Burch procedure.     

Clinical Outcome or Abdominal Urethropexy–Colposuspension: A Long-Term Follow-up

The aim of this study was to investigate the long-term results of abdominal urethropexy–colposuspension in terms of cure rate of stress urinary incontinence, complications and side effects. Between 1985 and 1992, 169 women between 27 and 79 years old underwent abdominal urethropexy–colposuspension at Stockholm So¨der Hospital. In 1997 they were invited to participate in a long-term follow-up study, 5–11 years after the operation. One hundred and thirty-one women (78%) were willing to attend for a clinical review; 38 were lost to follow-up. At the follow-up visit all women were assessed with medical history, symptoms of incontinence, and their satisfaction and problems after the operation, following a predefined protocol. Peri- and postoperative data were retrieved from the files. The patients underwent a gynecological examination, measurement of residual urine volume and a provocative leakage test. One hundred and nine women (83%) were satisfied with the results of the operation and 22 (17%) were not. Seventy-one (54%) were subjectively completely dry, 48 (35%) had a little leakage and 14 (11%) had frequent leakage; 122 women were continent in the provocation test, and only 9 (7%) demonstrated leakage. The cure rate for stress incontinence was 93%. According to their medical histories 63 (48%) women had mixed incontinence before their operation. At the follow-up examination 43 of these 63 women still had symptoms of urgency. Twenty-six women with genuine stress incontinence before the operation had developed urgency or urge incontinence during the follow-up period. Urge symptoms before operation was a negative prognostic factor for a good outcome in terms of subjective cure of incontinence, but had no impact on objective cure rate or satisfaction of the operation. The cure rate for stress incontinence was high but still there were women who were not satisfied with the operation. Most of these complained of urge incontinence. There were few serious complications. The objective cure rate was better than the subjective cure rate.     

Abdominal Urethrocystopexy Using Fibrin Sealant. A Prospective Study of Long-Term Efficacy

Over the past decade efforts have been made to develop less invasive surgical treatment for female stress urinary incontinence (SUI). Abdominal urethrocystopexy with fibrin sealant combined with a couple of absorbable sutures has previously been reported as a promising method. This prospective observational study was aimed at evaluating the efficacy and safety of abdominal urethrocystopexy through a minilaparotomy using solely fibrin sealant (Tisseel) as the fixation glue. Forty-three women with objectively proven SUI were operated upon with this method. The subjective cure rates at 1 and 3 years’ follow-up were 72% and 55%, respectively. The corresponding objective cure rates were 64% and 60%. No serious major operative complications occurred. One patient had transient urinary retention for 3 months. Otherwise, micturition was established within a median 1 day (range 1–3 days) after the operation. The result of this pilot study indicates a cure rate lower than that obtained with the conventional abdominal Burch colposuspension. Thus the method cannot be recommended as a standard procedure for treatment of SUI.     

Laparoscopic Burch colposuspension after failed sub-urethral tape procedures: a retrospective audit

Our objective was to evaluate the outcome of laparoscopic Burch colposuspension in women with recurrent stress urinary incontinence after failed primary sub-urethral tape procedures. A total of 16 patients were identified, and their data from symptom-specific questionnaires, urodynamic studies and urogynaecological assessment were collected. At a median follow-up of 24.5 months, objective and subjective cure rates were 54.5% and 92.9%, respectively. Average satisfaction score regarding outcome after surgery was 9.3 on a rating scale from 0 to 10. All but one patient had symptoms of urge incontinence pre-operatively with 64.3% experiencing cure or improvement post-operatively. Voiding difficulties were observed in one patient, and post-operative urodynamics revealed a significant decrease in urinary flow rate (p < 0.05) but with no difference in urinary residuals or maximum urethral closure pressure. Severe peri-urethral fibrosis was identified in 62.5% of the patients. Laparoscopic Burch colposuspension is an effective and safe surgical option.     

Feasibility of and interest in laparoscopic assessment in recurrent urinary stress incontinence after Burch procedure performed by laparotomy

Background: The Burch colposuspension, performed by laparotomy or laparoscopy, remains one of the most popular operations for the treatment of genuine stress incontinence. The average failure rate is 10% in patients followed up for 5 years or more in the literature. The etiology of the failure is difficult to assess by clinical or urodynamic investigations; the failure may be due to weak sutures on the Cooper's ligaments or on the vagina, to excessive or insufficient elevation of the cervical neck, or to an incompetent urethral sphincter. Methods: The authors performed five preperitoneal laparoscopies for recurrent urinary stress incontinence in women after a colposuspension performed by laparotomy in order to determine the etiology of the recurrence (between 1992 and 1995 at the Department of Gynecology of the University Hospital of Caen, France). Results: Laparoscopic preperitoneal access was possible in all patients. No laparotomy had to be performed. One small bladder injury occurred during the dissection. It was sutured by laparoscopy. There were no postoperative complications. In one patient, both of the sutures had escaped. In two other patients both sutures were found in place, but urodynamics showed a decrease in closure pressure. In two other patients, complaining of dysuria (painful voiding and acute bladder distension) associated with urinary leakage, only the colposuspension on one side had failed, involving a lateral torsion of the bladder neck. Conclusion: Preperitoneal laparoscopy is feasible after a laparotomic colposuspension and gives a very interesting etiologic contribution to the recurrence of incontinence. It helps to choose the most appropriate procedure to treat these recurrent incontinent patients: a new colposuspension if the previous one has failed anatomically and a sling operation if it hasn't and if the sphincter is incompetent. Received: 8 March 1996/Accepted: 8 July 1996     

Long-Term (10–15 years) Follow-up after Burch Colposuspension for Urinary Stress Incontinence

The study group comprised 127 patients who underwent a Burch colposuspension for urinary incontinence. All had undergone urodynamic investigation both pre- and postoperatively. All patients had a mean follow-up of 12.4 years (range 10–15); 109 patients had an additional urodynamic investigation at least 10 years after the operation. Following surgery there was an improvement in symptoms of frequency (P<0.001), urgency (P<0.01) and urge incontinence (P<0.001). The cure rate was 93.7%. The only significant changes found on urodynamics were the measurements of the pressure transmission ratio, which were higher postoperatively (P<0.001) and remained so after 10 years. The most frequent postoperative complications were de novo detrusor instability (16.6%) and anatomical defects (18.7%). All failed cases were found during the first postoperative year. De novo detrusor instability appeared in 12/17 patients during the first year of follow-up. Postoperative anatomical defects were found only in 4/24 patients after 5 years. Ten years postoperatively most of the anatomical defects had been detected (20/24), stressing the need for long-term follow-up.     

Pharmacologic Causes of Female Incontinence

The etiology of female urinary incontinence is complex and multifactorial. Many medications have adverse effects on the lower urinary tract, including the promotion of incontinence in certain women. Medications may cause incontinence through three main mechanisms: decreased intraurethral pressure, increased intravesical pressure, and indirect effects on the lower urinary tract. Careful adjustments of a patient’s medications based on a knowledge of pharmacologic mechanisms of action may restore continence in some women.     

Colposuspension Success and Failure: A Long-term Objective Follow-up Study

The Burch colposuspension is regarded as one of the most successful procedures for the operative treatment of genuine stress incontinence. In this study the authors have attempted to define long-term subjective and objective success rates. Of 121 patients operated on between 1985 and 1995, 83 were fully assessed: 77% (64/83) had no stress leakage, but 41% (34/83) were suffering from urge incontinence. On clinical assessment 6 cases of uterine prolapse or vault descent, 21 cystoceles (25%) and 47 rectoceles or rectoenteroceles (57%) were detected, all but 8 being asymptomatic. On ultrasound 64/83 patients (77%) had a normal result. Ten patients demonstrated bladder neck hypermobility and in 9 there was urethral funneling without hypermobility. Survival analysis showed that the likelihood of all types of failure and of abnormal ultrasound findings increased over time. It is proposed that long-term results after incontinence surgery be presented as survival analysis.