Laparoscopic Management of Stress Incontinence

Genuine stress incontinence is the involuntary loss of urine which occurs when the intravesical pressure exceeds the maximum urethral pressure in the absence of a detrusor contraction. The preferred therapy for genuine stress incontinence is surgery.

 Urinary incontinence is becoming more prevalent as the population ages. A significant improvement in the psychological status of these patients after the successful surgical cure of stress incontinence has been demonstrated.

 In genuine stress incontinence the proximal urethra is displaced outside the abdominal cavity. Stress incontinence then results from inadequate transmission of increases in intra-abdominal pressure to the proximal urethra. The urethra has in fact lost its retro pubic position due to attenuated support.  As a result, coughing will produce an immediate increase in intravesical pressure but not a concomitant increase in intraurethral pressure, and a dribble of urine results. More than 160 types of operations are available to correct stress uri­nary incontinence, an optimal approach has not been developed. The Burch procedure is considered by many to be the gold standard for surgical treatment of genuine stress incontinence.

Figure: Laparoscopic Burch suspension

The Burch procedure requires the elevation of the anterior wall of the vagina to the level of the origin of the paravaginal fascia by suspension from Cooper’s ligaments (iliopectineal ligaments). A properly performed Burch procedure cures 93 percent.

Laparoscopic Anatomy

            The space of Retzius lies between the vesicoumbilical fascia posteriorly and the posterior rectus sheath and pubic bone, anteriorly. This is the space first entered in Burch suspension.

Preoperative Evaluation

Postmenopausal women should receive at least 3 months of estrogen replacement therapy. Preoperative evaluation includes history, physical, gynecologic, and neurologic examinations. The routine tests include stress test, Q-tip test, urinalysis, urine culture and sensi­tivity. All women should undergo an urody­namic evaluation, with emphasis on voiding time, voiding volume, and post void residual urine volume. Stress incontinence is diagnosed by a pos­itive stress test in the absence of simultaneous detrusor contractions or pressure equalization on the stress urethral closure pressure profile.

Operative Technique

Following the induction of general endotracheal anesthesia, a Foley catheter should be applied in the bladder. A 10mm operative video laparoscope is inserted infraumbilical and three 5-mm acces­sory trocars are inserted according to baseball diamond concept.

300 cc of methylene blue solution is placed into the bladder to keep the bladder weighted down and to allow the clear delineation of the dome of the bladder. Three port techniques is used one in umbilicus and two 5cm lateral and slightly below the umbilicus

The anterior abdominal wall peritoneum 3 to 5 cm above the symphysis pubis is cut and pulled down. To enter the space of Retzius intra-abdominally, the umbilical ligaments are identified laterally.

Figure: Peritoneal incision in midline

The space of Retzius is developed using blunt and CO2 dissection of fibro fatty tissue. Care is taken to avoid obturator nerve and aberrant obturator vessel injury.

The midline trocar entry and anatomic landmarks, including the round ligament from the internal ring, are used to avoid bladder entry. Blunt dissection, hydro dissection, and the CO2 laser for sharp dissection are used to expose the retro pubic space. Surgeon should stay close to the back of the pubic bone, dropping the anterior bladder wall, vaginal wall, and urethra downward. Dissection is limited over the urethra in the mid­line, to approximately 2 cm lateral to the urethra to protect its delicate musculature. An assistant should introduce one finger on each side of the catheterized urethra, elevating the lateral vaginal fornix. The overlying fibro fatty tis­sue is cleared laparoscopically from the anterior vaginal wall. The bladder is dissected medially from the paravaginal fascia from lateral to medial. Blunt dissection with atraumatic grasper is continued until the urethrovesical junc­tion becomes apparent and the white glistening tissue of the paravaginal fascia appears.

Bladder muscle fibers of the urethrovesical junction should not be damaged at the time of dissection. Bleeding if happens in this area is controlled only with bipolar electrocoagulation because; monopolar current can cause perforation of bladder of stricture of urethra. Retro pubic dissection is continued until Cooper's ligament is clearly exposed. Dissection in the space of Retzius is difficult in pa­tients who have undergone previous laparotomy. Pneumoperitoneum pressure provides exposure of the space and its contents out to the obturator nerve.

Figure: Extraperitoneal approach

The space of Retzius also can be entered with a pre­peritoneal approach just like transabdominal preperitoneal hernia surgery. The balloon dissector consists of a cannula, balloon system. The dissector is inserted through a 10mm infraumbilical incision. It is advanced between the rectus muscle and the anterior surface of the posterior rectus sheath to the symphysis pubis. The dissector's ex­ternal sheath is removed, and the balloon is in­flated with approximately 500 ml of saline solu­tion. During inflation, the balloon unrolls sideways and exerts a perpendicular force that separates tissue layers. A blunt dissection of the connective tissues is propagated as the balloon expands. Full dissection takes about one minute but surgeon should keep the balloon inflated for 5 minute to achieve proper haemostasis. Lateral pressure of balloon will stop capillary bleeding if kept for 5 minutes. When maximal volume is reached, the balloon is deflated and re­moved through the incision.

Figure: Balloon Dilatation

The dissected space is insufflated with CO2 at a pressure of 8-10 mm Hg. The predefined shape of the balloon, its none­lastomeric material, and the incompressible char­acter of the saline assure a large, relatively blood­less working space of predictable size and shape. The space is adequate for identification of perti­nent landmarks and unencumbered manipulation of endoscopic surgical instruments.

Figure: Suturing of paravaginal fascia

After complete dissection, the paravaginal fas­cia is identified as glistening fascia over the finger of assistant. Using a needle holder a suture placed over the paravaginal fascia at the level of the urethrovesical junction, approximately 1 to 1.5 cm from the urethra. The urethrovesical junction can be identified easily because of the Foley bulb with the catheter under gentle traction. This suture is placed perpendicular to the vaginal axis to include approximately 0.5 to 1 cm of tissue.

The complete vaginal fascia should be taken so that it will not cut through, Precaution should be taken that suture should not to penetrate the vaginal mucosa. Once the suture is placed over the paravaginal fascia the suture is fixed to Cooper's ligament or the midline of the symphysis pubis.

The suture is tied either intracorporeal or extra corporeally with help from an assistant who lifts the vagina upward and forward. The urethra is observed carefully to prevent it from being compressed against the pubic bone. This same suturing technique is repeated on the opposite side, the aim is to create a platform on which the bladder neck can rest. If the suspension is not enough with one suture, a second and rarely, a third set of sutures can be placed along the base of the bladder proximally.

After taking suture on both sides, cystoscopy should be performed to en­sure that there is no suture pieced in the bladder, cystoscopy also help to assess the urethrovesical junction angle, and to check ureteral patency.

Proline mesh can be used instead of direct suture far bladder neck suspension. Medially over paravaginal fascia, mesh is fixed by sutures and laterally over cooper’s ligament it should be fixed with the help of Protak or Anchor. One of the advantages of mesh is that after some time it gives very good platform for bladder neck due to fibrosis developed through the mesh.

Figure: Mesh fixed with coopers ligament

Once the procedure is finished the pneumoperitoneum pres­sure is decreased and the retro pubic space is eval­uated. If there is any bleeding, it is controlled with bipolar electro­coagulation. The peritoneal defect may be left open to heal spontaneously, or, if it is large, it should be closed laparoscopically with three to four inter­rupted or purse string sutures. The laparoscope is withdrawn from the abdomen and the procedure concluded. The Foley catheter should left in place for 2 to 3 days. If there is any fear of detrusor instability or bladder injury the Foleys should be in place for one week or more.

Intercourse should not be allowed for 6 to 8 weeks postoperatively and the patients are advised to avoid heavy lifting or strenuous exercise for at least 2 months.