Monday-October 20, 2014 
    
      Home | Procedures | Pre-Surgery Form | Registration | Search | About Us  
 
FORBES magazine names YourSurgery.Com as one of it's "Best of the Web"
 
Bladder Suspension
Surgery for loss of urine in women

Retropubic urethropexy or Burch procedure is a procedure performed to suspend the bladder in females with urinary incontinence. Loss (incontinence) of urine is one of the most unpleasant complications of childbirth. The woman may leak urine from early morning to late at night- whenever she is on her feet and particularly with the stress of coughing or sneezing (therefore, sometimes called stress incontinence). She is dependent on wearing pads or diapers and there may be a constant odor of urine. Correction of this condition produces a very grateful patient.

Anatomy and Physiology

  • The urinary bladder lies behind the pubic bone and in front of the vagina (Figure1)
Figure 1 - Anatomy of the pelvis as seen in a section cut through the center of the body from front to back (sagittal section). Note that the bladder is directly behind the pubic bone and in front of the vagina and uterus. The potential 'space' between the bone and bladder is called the 'space of Retzius'. During surgery these structures separate from each other like the pages in a book thus laying open the space of Retzius. © N. Gordon
  • Urine in the bladder exits the bladder through the urethra, a short tube like structure that leads from the bladder to a small opening positioned just in front of the opening of the vagina
  • The junction of the bladder and urethra (vesical neck) is positioned just behind the pubic bone
  • The wall of the bladder contains the detrusor muscle, which relaxes as the bladder distends and contracts during urination (also called micturition). The wall of the urethra contains the internal sphincter, a muscle that surrounds the urethra that contracts to contain urine in the bladder and relaxes during urination
  • Urination is normally an automatic function. As the urinary bladder fills with urine, the detrusor muscle is stretched until the pressure in the bladder causes the detrusor muscle to contract and the internal sphincter of the urethra to relax. Urine then flows from the bladder through the urethra to the outside
  • Pressure within the abdomen by bearing down or coughing may press on the bladder and initiate urination
  • Normally urination can be voluntarily started, stopped or interrupted at the will of the woman
  • The muscles and fascia of the pelvic floor help maintain the position of the bladder (and uterus) and aid in the control of urination

Pathology

  • Incontinence of urine occurs when the pressure within the abdomen and pressure within the bladder overcomes closure of the urethral sphincter and the support of the pelvic muscles that help close the urethra
  • Lack of support of the urethra occurs when there is relaxation of the surrounding fascia and the musculature after particularly after childbearing but, also, after trauma, and the natural aging process. This loss of support causes the vesical neck to drop back and downward. The upper part of the urethra near the bladder tends to become wider and no longer able to contract to control urine flow. (Figure 2A)
  • Leakage of urine may occur when a woman sneezes, coughs, bears down, or even when laughing
  • There may be a downward movement of the bladder towards the vagina producing a cystocele
  • There is frequently an associated loss of tone of the walls of the vagina and prolapse (dropping down) of the uterus (Figure 2A)

Examination

  • Examination of the vagina may show a laxity of the vaginal wall and a cystocele
  • The uterus may also show prolapse (see Hysterectomy)
  • Cystoscope- a lighted tube with fiber optics is passed into the bladder through the urethra to view the inside of the bladder
  • Cystogram- the bladder is filled with a fluid (contrast dye) that shows up on X-ray so that the position of the bladder can be evaluated
  • Cystometrogram- a test that injects fluid into the bladder and measures the pressure that is produced
  • Examination of bladder position when lying flat on the back and when standing. This may demonstrate that the bladder has dropped back away from the pubic bone

Indications and Contraindications for Surgery

  • The indication for this procedure is genuine urinary stress incontinence with leakage of urine when a women has an increase in pressure within the abdomen. Examples are sneezing, coughing, laughing, or bearing down
  • Failure of non-surgical therapy such as
    1. Voluntary emptying of the bladder on a regular schedule
    2. Absorbent pads
  • This procedure may be contraindicated in any woman having
    1. Significant heart disease
    2. Significant disease of the lungs
    3. Bleeding tendency or on anticoagulation (blood thinner) medication

Surgical Procedure

  • The Burch Procedure is usually performed through a lower abdominal incision, however, some surgeons may perform the procedure laparoscopically. Preoperatively, the patient is kept without anything to eat for at least six hours before surgery. An intravenous catheter (IV) is placed and the patient is given fluids. Antibiotics may also be given IV. After the anesthetic has been given, a catheter is placed in the bladder to empty it
  • Abdominal Approach
    1. An incision is made in the skin of the abdomen just above the pubic bone (bikini incision). The incision is made through the muscles in the midline (rectus abdominus muscles). Below the muscles lies the peritoneum, the strong thin sheet of tissue that lines the abdominal cavity (Figure 2A)
    2. Between the muscle layer and the peritoneum just above the pubic bone lies the space of Retzius (not a true space but rather a plane in which the peritoneum can be separated from the muscles). The space of Retzius extends downward behind the pubic bone and gives the surgeon access to the area necessary to carry out the bladder suspension (Figure 2B)
    3. Dissection into this space also exposes Cooper's ligaments. The ligaments are tough bands of tissue that are attached to the upper back side of the pubic bone. These ligaments are used to suspend the bladder (Figure 2C,D,E)
    4. The surgeon places fingers in the vagina pushing the vaginal wall up to help identify the paravaginal fascia, which lies on the side of the bladder and the urethra. Sutures are placed in this fascia on either side of the bladder and then through the Cooper's ligaments above. The sutures are then tied which elevates the vesical neck (the junction of the bladder and urethra) in the direction of the Cooper's ligament
    5. The incision is closed with sutures and a sterile dressing placed
  • Lapraroscopic Approach
    1. The laparoscopic procedure and the procedure performed through an abdominal incision are essentially done the same manner. The main difference is the method of entry into the abdomen
    2. The laparoscopic procedure is performed by making three to four, 5-10 millimeter skin incisions. A laparoscope is a long tubular instrument containing fiber optics with a lens at one end and a camera at the other. It is passed into the abdomen though one of the incisions. The other incisions are used to pass other instruments such as graspers, needle drivers, scissors, and instruments that can stop bleeding by cauterizing the tissue
    3. Once the abdomen is entered, the space of Retzius is entered from the peritoneal side. The dissection of the bladder, urethra, Cooper's ligaments and paravaginal fascia is performed in a manner similar to that described above for the abdominal approach
    4. Sutures are placed in the paravaginal fascia and Cooper's ligaments to elevate the vesical neck. The instruments are removed and the small incisions closed with sutures

     

Figure 2a - Sagittal section similar to that in figure 1 in a woman with urinary incontinence. Note that both the bladder and uterus have dropped. The arrow shows the direction the surgeon takes through the rectus muscles towards the space of Retzius. © N. Gordon
Figure 2b - Surgical view of the space of Retzius showing in front the pubic bone with Cooper's ligaments to each side and on the back side of the space the bladder, upper urethra and, on each side, the paravaginal fascia. © N. Gordon
Figure 2c - Sutures are placed in the paravaginal fascia on each side of the urethra and tented to each Cooper's ligament. This lifts the junction of the urethra and bladder and once again straightens the urethra. © N. Gordon
Figure 2d - View of the space of Retzius as in C as seen through the laproscope. Courtesy O. Kadry, M.D
Figure 2e - Same as in C but as seen from above and to the right side with parts of the bladder and urethra cut away. The lifting action of the sutures are better appreciated in this view. © N. Gordon

Complications

There is no surgical procedure that is free of the possibility of complications.

  • As with any surgical procedure there may be a complication of the anesthetic
  • Injury to the bowel or rectum
  • Injury to the bladder or urethra
  • Hemorrhage that may require a blood transfusion
  • Wound Infection
  • Urinary tract infection
  • Failure to correct the incontinence
  • Urinary retention requiring use of a catheter
  • Bowel obstruction
  • Vaginal pain

When the procedure is performed laparoscopically, there is always the possibility that it must be converted to a an abdominal approach.

Care after surgery

  • The catheter is left in the bladder until the day of discharge. On the day of discharge the catheter is taken out and the woman attempts to urinate. The amount of urine remaining in the bladder is measured either with an ultrasound or by catheterizing the bladder. If the amount remaining is small, the woman will go home without a catheter. If the amount is large it may be necessary for the patient to be sent home with the catheter in place for 2-3 weeks
  • Pain management may be given through an IV, into the muscle or by mouth
  • Hospital stay after surgery is usually three days. For women undergoing the procedure laparoscopically, the hospital stay after surgery is one to two days.
  • Some advantages of the laparoscopic procedure are: shorter hospital stay, reduced recovery time at home, minimal discomfort, active lifestyle quickly resumed and proven cost effectiveness