Complications of Female Incontinence and Pelvic Reconstructive Surgery (Current Clinical Urology) 2nd ed.

10. Retropubic Bladder Neck Suspensions

Elizabeth R. Mueller 

(1)

Division of Female Pelvic Medicine and Reconstructive Surgery, Departments of Urology and Obstetrics/Gynecology, Loyola University Chicago Stritch School of Medicine, 2160 South First Avenue, Building 103, Suite 1004, Maywood, IL 60153, USA

Elizabeth R. Mueller

Email: emuelle@lumc.edu

Abstract

Open abdominal retropubic procedures for urinary incontinence were widely performed in the United States starting in the 1950s till the turn of the century when the use of transvaginal synthetic slings gained in popularity [1]. That said, data regarding the success and complications of retropubic suspensions were mostly expert opinion, cases series, or underpowered randomized trials until the last decade when two large randomized trials comparing the Burch urethropexy to suburethral slings were published [2, 3]. This chapter will review the retropubic procedures for incontinence and the diagnosis and management of complications that arise from retropubic urethropexy procedures.

Introduction

Open abdominal retropubic procedures for ­urinary incontinence were widely performed in the United States starting in the 1950s till the turn of the century when the use of transvaginal synthetic slings gained in popularity [1]. That said, data regarding the success and complications of retropubic suspensions were mostly expert opinion, cases series, or underpowered randomized trials until the last decade when two large randomized trials comparing the Burch urethropexy to ­suburethral slings were published [23]. This chapter will review the retropubic procedures for incontinence and the diagnosis and management of complications that arise from retropubic ­urethropexy procedures.

Overview of Retropubic Procedures for Incontinence

Retropubic urethropexy procedures generally include the Marshall Marchetti Krantz (MMK), the Burch colposuspension and the paravaginal defect repair. First described by Marshall in 1949, the MMK procedure [4] suspends sutures placed on each side of the bladder neck to the posterior aspect of the pubic bone. This is thought to stabilize the bladder neck and allow abdominal pressures that are being transmitted to the bladder to be equally transmitted to the proximal bladder neck, maintaining continence during stress activities.

The Burch urethropexy was described by John Burch in 1961 as being born out of necessity when the sutures he was trying to place during a MMK kept pulling out of the pubic bone periosteum [5]. After utilizing the arcus tendonious and Cooper’s ligament as the point of fixation, he chose the latter based on its consistent presence and inherent strength.

First described by White in 1909 as a procedure for anterior vaginal prolapse repair, the paravaginal defect repair was based on White’s cadaveric dissections that demonstrated that the “bladder stays in place because it rests upon a firm fibrous shelf stretched across between the pubic bones” [6]. The procedure was popularized for female stress incontinence when the authors reported that reattaching the detached and retracted levator ani fascia to the arcus tendineus resulted in a greater than 90% cure rate [7] but it does not have acceptable success rates to justify its use as a stress incontinence procedure at this time.

Surgical Techniques

All of the abdominal retropubic procedures require the patient to be prepped and draped in dorsal lithotomy so that the primary surgeon can have their nondominant hand in the vagina for definition of anatomy and counter-traction. A Foley catheter is passed into the urethra and kept in the sterile field. A Pfannenstiel or Cherney incision is made and the space of Retzius is entered. The surgeon slides their dominant surgical hand (fingers first and palm faced up) behind the pubic bone and with gentle downward traction the retropubic and lateral pelvic sidewalls are exposed.

The nondominant hand is placed into the vagina and gentle tugging on the Foley catheter identifies the bladder neck. A finger on each side of the balloon allows the apt surgeon to use the remaining fingers and thumb to tug on the catheter when needed. Typically, the surgeon starts on the contralateral side and the surgical assistant uses a sponge stick to provide countertraction by directing the midline away from the sidewall of interest. A swab mounted on a curved forceps is used to sweep the overlying periurethral vessels and fat towards the midline and at the same time the vaginal fingers are elevated towards the ceiling so that the white, glistening tissue of the vagina is exposed. The venous plexus that can be seen in the vaginal wall should be avoided as much as possible since these vessels can be the source of a significant amount of blood loss when sheared during dissection or suture placement.

The MMK cystourethropexy places 2–3 permanent sutures on each side of the bladder neck and mid-urethra. Each suture consists of two bites encompassing full thickness of the vaginal wall but not the vaginal epithelium. The nondominant fingers in the vagina provide the necessary tactile feedback. The vaginal fingers elevate the urethra to the back of the pubic symphysis and suture ends are placed into the pubic bone and periosteum. The assistant ties the sutures as the surgeon positions the urethrovesical junction. The intent is to elevate the vagina and not to constrict the urethra.

The Burch procedure has undergone modifications and most contemporary studies including the two randomized trials by Ward and Albo [23] place 1–2 sutures of delayed ­absorbable or permanent suture 1–2 cm lateral on each side of the urethrovesical junction. A second pair of sutures is placed 1 cm distal and lateral at the level of the mid-urethra. Each suture placement consists of two bites through the full thickness of the vaginal wall excluding the vaginal epithelium. The sutures are attached to the ipsilateral Cooper’s ligament and tied to elevate the anterior vagina to a minimally retropubic position. A suture bridge of 2–3 cm is expected between the vaginal wall and Cooper’s ligament. Again, the aim of the surgical procedure is to elevate the vaginal wall, not to constrict the bladder neck.

Numerous authors have described laparoscopic approaches to the Burch colposuspension [810]. While the dissection of the retroperitoneal space is similar, various materials have been used to attach the vaginal wall to Cooper’s ligament including sutures, staples, spiral metal tacks, and mesh.

Surgical Success

In the fourth edition of the International Consultation on Incontinence published in 2009, Smith et al. reviewed all of the literature available on retropubic suspensions and the authors have concluded, based on level 1 evidence, that open retropubic Burch colposuspension can be recommended as an effective treatment for primary stress incontinence [11]. In contrast, the MMK cystourethropexy and the paravaginal defect repair are not recommended for the treatment of stress incontinence. The authors also state that laparoscopic Burch colposuspension is not recommended for routine treatment but may be considered in patients undergoing concurrent laparoscopic surgery for other reasons. In contrast, the American Urological Society 2009 Guidelines for Surgical Management of Stress Urinary Incontinence state that open retropubic and laparoscopic suspension along with injectables, mid-urethral slings and pubovaginal slings, although not equivalent, may be considered for the uncomplicated women with stress ­incontinence [12].

Complications

Burch Colposuspension

Two large randomized trials comparing the open Burch colposuspension to tension-free vaginal tape and to the fascial sling were published in 2002 and 2007, respectively [23]. The studies randomized 475 women to Burch colposuspension thus providing a solid basis for understanding complications that arise when a large number of surgeons are performing the procedure. Ward et al. [13] enrolled women from 14 urogynecology and urology centers in the United Kingdom. Women were randomized to the open Burch colposuspension or the tension-free mid-urethral sling. Exclusion criteria included current need for, or previous history of, surgery for pelvic organ prolapse (POP). One hundred and forty six women underwent the Burch urethropexy. Women in the Ward-Hilton study had the following intra-operative and postoperative complications reported at 6 months: urinary tract infection (32%), de novo detrusor overactivity on urodynamics (11%), wound infection (7%), voiding disorder (7%), bladder injury (2%), deep vein thrombosis (2%), and incisional hernia (2%). There were no reports of vascular injury or retropubic hematoma in this series. The need for patient catheterization decreased over time, but remained substantial with 8% of women requiring catheterization after 6 months. Interestingly, there was no statistically significant difference in rates of catheterization and voiding dysfunction compared to TVT.

In 2004, the authors reported the 2-year ­follow-up data. Of the 146 women randomized to Burch urethropexy, 5 (3.4%) underwent surgery for stress incontinence, 7 (4.8%) surgery for POP, and 5 (3.4%) had an incisional hernia repair. At 2 years, 4 (2.7%) women continued to catheterize and 3 (2.1%) continued to have symptoms of UTI. On physical exam, the number of women with vault/cervical prolapse increased from 21% preoperatively to 63% at 24 months; 18% of the women with POP were symptomatic. Over the same 2-year time period, vault/cervical prolapse rates increased from 16 to 29% in the TVT arm. In summary, when compared to TVT, Burch ­colposuspension at 24 months resulted in higher rates of enterocele, voiding dysfunction, and need for catheterization and a 4% lower rate of UTI.

In the Stress Incontinence Surgical Efficacy Trial (SISTEr) involving nine surgical centers in the United States, women were randomized to an open Burch colposuspension or autologous rectus fascial sling. A total of 329 women received a Burch colposuspension; however, 48% of the women had concomitant procedures for POP. The following adverse events were reported in women who underwent the Burch colposuspension: cystitis (50%), new-onset urge incontinence (3%), incidental cystotomy (3%), surgical wound complications requiring surgery (2.4%), voiding dysfunction >6 weeks (2%), recurrent cystitis leading to diagnostic cystoscopy (1.5%), bleeding (1%), ureteral injury (1%), incidental vaginotomy (0.5%), ureteral vaginal fistula (0.5%), erosion of suture into the bladder (0.5%), and pyelonephritis (0.5%). In summary, compared to a rectus fascial sling, a Burch colposuspension resulted in lower rates of success for stress incontinence and lower rates of cystitis, urge incontinence, and voiding dysfunction. In this study, women often received a concomitant POP procedure.

Marshall-Marchetti-Kranz Procedure

Complications related to the MMK procedure are similar to those mentioned for the Burch colposuspension. In a 1988 review of the literature, Mainprize and Drutz summarized the occurrence of postoperative complications in 2,712 patients as follows: wound complications (5.5%), urinary tract infection (3.9%), osteitis pubis (2.5%), direct injury to the urinary tract (1.6%), ureteral injury (0.1%). Of course, this data is limited and, with the exception of osteitis pubis, direct comparisons to the Burch data obtained in a randomized trial would not be advised [14].

Approach to Specific Complications

Urinary Tract Infections

Women who undergo surgical treatment for stress incontinence will most often develop symptoms that are consistent with or mistaken for a urinary tract infection. The rates are highest in the first 6 months but do remain between 2 and 9% 24 months after surgery [313]. As a result, it is sensible to require that women with a history of urinary tract infections be free of infection prior to undergoing surgery. Women with symptoms of urinary tract infection (urgency, frequency, burning with urination) would benefit by having urine cultures obtained prior to antibiotic treatment to allow for more specific antibiotic treatment but also to document when the symptoms occur with negative cultures. Nonbacterial etiologies include lower urinary tract inflammation, urethral irritation, and irritative voiding symptoms associated with urethral obstruction.

Possible etiologies or recurrent or persistent UTI included incomplete emptying, bacterial colonization from instrumentation, and a foreign body in the urinary tract (Fig. 10.1). Women who require catheterization (intermittent or indwelling) should be placed on “treatment” doses of antibiotics once they have stopped using catheters since bacterial colonization occurs often within days of catheter use. Data from the SISTEr trial demonstrate that cystitis rates are highest in the first 6 weeks after surgery [15]. When compared to self-voiders with a cystitis rate of 6%, women who have intermittent or indwelling catheters have higher (23% and 13%, respectively) rates of cystitis. In addition, women who undergo voiding trials with postvoid residual measurements are often catheterized 2–3 times prior to being discharged thus increasing their risk of colonizing the urinary tract.

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Fig. 10.1

(a) Cystoscopic view of a stone at the bladder neck in a patient with pelvic pain and UTIs following a Burch procedure. (b) Prolene suture and stone following surgical removal (photographs courtesy of Howard Goldman, MD, Cleveland Clinic, OH)

When UTIs also present with systemic signs such as fever, chills, and flank pain, upper tract imaging is warranted. The specific imaging depends on the question that needs to be answered. For example, in women presenting with febrile UTI and flank pain following an isolated retropubic urethropexy the imaging question may be “does this patient have ureteral reflux or obstruction” and a voiding cystourethrogram and renal ultrasound can be ordered. For patients with concomitant prolapse repair, upper tract imaging to assess ureteral patency and cystoscopy to rule-out bladder foreign body or cystotomy would be indicated.

Urge Incontinence

In the Ward study, 91% of women reported ­symptoms of bothersome urge incontinence prior to Burch urethropexy which decreased postprocedure to 34% at 6 months and 2 years. On ­urodynamic testing, the number of women who developed unstable detrusor contractions increased from 1% pre-op to 10% 6-months following a Burch colposuspension. Similarly, persistent urge incontinence was found in 18% of women enrolled in the Burch arm of the SISTEr trial and new-onset urge incontinence remained low at 3%.

Possible etiologies of de novo urge incontinence include UTI, obstructive voiding, and the presence of a foreign body in the lower urinary tract. In women whose symptoms persist after 6 weeks and post-void residuals are normal, conservative treatment for urge incontinence can be considered including anticholinergics and behavior modifications. A woman who is not responsive or whose symptoms appear severe might benefit from a cystoscopic examination to rule-out the presence of a foreign body in the lower urinary tract. Women, who have undergone a laparoscopic Burch procedure and have evidence of a foreign body in the bladder, may have undergone the procedure using metal helical “tackers” to suspend the bladder neck (Fig. 10.2). These are often placed or migrate into the bladder causing symptoms. If operative notes are not available, then an anterior/posterior and lateral plain X-ray will allow visualization of the offending material.

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Fig. 10.2

Cystoscopic view of a metal tacker placed during a laparoscopic Burch colposuspension (photograph courtesy of Howard Goldman, MD, Cleveland Clinic, OH)

Uterine or Vaginal Vault Prolapse

In his initial description of the surgical procedure, Burch reported the surgical complication of uterine or vaginal vault prolapse. As described previously, 18% of women developed symptomatic prolapse and 4.8% underwent surgical correction over the 24 months of the Ward–Hilton study [13]. This is believed to be due to the anterior orientation of the vaginal apex. As a result, all women undergoing surgical correction of stress incontinence should have a complete physical exam including the evaluation of vaginal topography ideally in the standing-straining position. Women, who demonstrate apical or uterine descent of greater than 3 cm from optimal ­position with Valsalva effort, would more likely benefit from a synthetic or autologous suburethral sling since they have not been shown to increase the risk of POP. When a patient is undergoing treatment of POP following an incontinence procedure, care should be taken to not “over-correct” the apical support since this may result in incontinence.

Voiding Dysfunction

Rates of voiding dysfunction following retropubic suspensions vary based on the definitions used, duration of the studies and whether women with preexisting voiding dysfunction were excluded from enrollment. The Ward–Hilton study [13] defined a woman as having voiding dysfunction when two of these three measurements were found on 6-month postoperative urodynamic studies (UDS): peak flow <15 mL/s, maximum voiding pressure >50 cm H2O, and residual volume >100 mL. Of the women who underwent postoperative UDS, 7% were diagnosed with a voiding dysfunction. Thirty-three percent of women required catheterization (suprapubic, urethral, or intermittent) a week after surgery and this continued to diminish over time to 13% at 1 month, 8% at 6 months, and 2.7% at 24 months. There were no reports of surgical intervention for voiding dysfunction.

The SISTEr trial also had a gradual return to self-voiding in women undergoing the Burch procedure. While only 56% of women passed their first voiding trial the authors reported low rates (2%) of voiding dysfunction >6 weeks after surgery and no surgical revisions for voiding dysfunction in the 329 women who had undergone Burch procedure. As the series above demonstrate, most voiding dysfunction resolves by 6 weeks and can be treated conservatively with intermittent or indwelling catheterization. In addition, many patients may benefit by undergoing pelvic therapy specifically aimed at pelvic floor relaxation techniques [16].

When obstructive voiding symptoms persist, patients may benefit by filling cystometry and pressure-flow studies to determine if the etiology is obstructive or due to decreased detrusor ­function. In centers with fluoroscopy, imaging can be helpful. A cystoscopy at the same time would rule-out suture placement in the urethra (although this is a rare phenomena). The etiology is typically obstructive from sutures pulling the bladder neck; sutures placed distally resulting in urethral kinking or scarring of the bladder neck to the back of the pubic bone.

Women who clearly demonstrate obstruction on UDS should be considered for an urethrolysis. In women who have physical exam findings of an indentation of the anterior vaginal wall where sutures have been placed, we consider a transvaginal urethrolysis. A midline vaginal incision is made near mid-urethra and carried to the level of the bladder neck. The dissection continues using sharp and blunt dissection as if making the sling tunnels for a rectus fascial sling. Tissue that is adherent to pubic bone is swept lateral to medial using the surgeon’s index finger. Since it is customary in our practice to use a permanent suture, we can palpate the suture as it travels from the proximal urethra and bladder neck to its attachment on the pubic bone (MMK) or Cooper’s ligament (Burch). A scissors is then guided to the level of the sutures behind the pubic bone by the surgeon’s index finger and the sutures are transected on each side.

In woman who are clearly obstructed and have failed a transvaginal urethrolysis or who do not have a palpable indentation at the level of the bladder neck, a retropubic urethrolysis can be performed. A Pfannenstiel incision is made and carried to the level of the fascia which is incised 2 cm proximal to the back of the pubic bone. As when placing the sutures, the surgeon’s nondominant hand is placed into the vagina to assist in locating the sutures which are transected. If the anterior bladder remains fixed to the back of the pubic bone then this is carefully dissected until the bladder neck and urethra are sufficiently freed to restore a normal degree of mobility.

Anger et al. reported on a retrospective review of 16 women who had symptoms of overactive bladder and/or obstruction following a Burch urethropexy [17]. The study consisted of 7 women who had a vaginal approach and 9 who underwent the retropubic approach. The groups were not equivalent since 43% in the vaginal group and 55% of the women in the retropubic group performed self-catheterization. Success rates for a return to normal voiding were 66% with the vaginal approach and 100% with retropubic. The authors also reported that overactive symptoms were improved in the retropubic group compared to the transvaginal. They hypothesize that the inability to transect the most proximal sutures through the transvaginal route might result in the lower rates of symptom improvement. That said, most surgeons would agree that the transvaginal approach is less morbid and worth attempting as first-line treatment.

Intraoperative Hemorrhage

One of the most anticipated intraoperative complications during a retropubic urethropexy is intraoperative hemorrhage. There are numerous vessels that run alongside the bladder and within the vaginal wall. Vaginal wall vessels that are visible can usually be avoided when placing the sutures and if punctured will often stop bleeding once they are tied in place. When brisk bleeding does occur, direct pressure held for 5 min (by the clock) is often sufficient. Attempts to use metal clips often result in additional shearing of vaginal wall ­vessels. When packing is insufficient, agents such as gelfoam/thrombin or fibrin glue may be necessary. Of course, bleeding can be minimized by assuring that exposure to the retroperitoneal space is adequate and reviewing the simple steps of checking patient and surgeon positioning, light and retractor placement along with incision length.

Osteitis Pubis

Osteitis pubis is an inflammatory disease of the pubic symphysis and its surrounding attachments. It occurs in 1–2.5% of MMK procedures but can also occur in any procedure that is in the retropubic space (Fig. 10.3). Symptoms include pubic pain that may be localized to the pubis or radiate to the lower abdomen and thigh. Often patients adopt a limp and wide-based gait. The diagnosis can be aided by the use of MRI which can distinguish between osteitis pubis and pelvic osteomyelitis [18]. Medical management includes rest, ice, nonsteroidal anti-inflammatory drugs, physical therapy, and the use of steroids. Patients who are refractory to medical management may benefit by surgical removal of the offending sutures (Fig. 10.3).

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Fig. 10.3

(a) Cystoscopic view of suture in the right lateral wall of the bladder placed during open Burch colposuspension 3 years prior. Early postoperative course complicated by osteitis pubis requiring removal of the left sided suspension sutures. (b) Removal of the right bladder wall suture resulted in resolution of suprapubic pain at rest and ambulation (photographs courtesy of Howard Goldman, MD, Cleveland Clinic, OH)

Summary

With the advent of synthetic mid-urethral slings, the retropubic suspensions are often referred to as a procedure of historical interest. However as we continue to deal with the complications from surgical mesh placed in a transvaginal route, there remains a role for this procedure in the armamentarium of the well-versed pelvic surgeon.

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