Laparoscopic mesh and staple Burch colposuspension

Laparoscopic colposuspension using sutures or prolene meshes: a 3-year follow-up

OBJECTIVE(S)

To compare the long-term effectiveness of two different laparoscopic colposuspension procedures.

STUDY DESIGN

Sixty women affected by genuine stress incontinence (GSI) were enrolled in a prospective randomized controlled trial (RCT) and treated by transperitoneal laparoscopic colposuspension using nonabsorbable sutures (group A) or prolene mesh fixed with tackers or staplers (group B). In each group the subjective and objective failure rates were evaluated at 12, 24, and 36 months after surgery. For the subjective evaluation patients were asked whether they had experienced urine leakage and any urine loss they reported was recorded on a visual analogue scale (VAS). The objective evaluation was performed by means of a clinical examination and multichannel urodynamic studies. The data were analyzed by the intention-to-treat method.

RESULTS

The subjective failure rate was significantly (P < 0.05) lower in group A than in group B at 12 months (3.3% versus 13.3%, respectively), 24 months (20.0% versus 36.7%, respectively), and 36 months (33.3% versus 53.3%, respectively) after surgery. The objective failure rate also differed significantly (P < 0.05) between the two groups after 12 (10.7% versus 25.0% for group A and group B, respectively), 24 (29.6% versus 57.7%, respectively), and 36 (42.3% versus 61.5%, respectively) months of follow-up.

CONCLUSION(S)

Laparoscopic colposuspension performed with sutures is more effective than laparoscopic colposuspension accomplished with the use of prolene meshes in the long term, and the use of prolene meshes should be avoided in treatment of GSI.

Laparoscopic treatment of urinary incontinence

The optimal surgical management of stress incontinence in women remains a contentious issue. Retropubic urethropexies such as the Burch procedure are regarded as having excellent long-term success rates. The learning curve for transvaginal tape procedures is by far shorter and easier than for the laparoscopic Burch procedure. Data from the few randomized trials published thus far show that both procedures are associated with high success rates and patient satisfaction.

Pelvic floor reconstruction: state-of-the-art and beyond

Reconstructive surgery for pelvic-floor dysfunction is challenging and complex. It requires an extensive familiarity with pelvic anatomy and a wide armamentarium of surgical procedures to offer patients with various structural defects. Not every patient is suited for every procedure and the surgeon must be able to individualize the approach. Each technique has indications and benefits: vaginal repairs are relatively simple and cause less morbidity than abdominal repairs, which are generally more durable. Laparoscopic repairs provide excellent visualization with decreased morbidity, but operative times are longer, there is greater cost, and learning curves are steep. Techniques and principles described for vaginal and abdominal approaches can be applied to laparoscopic and robotic surgery, but comparative outcomes are not available. Robotic assistance with the laparoscopic approach may bring this method to the mainstream by helping surgeons who are not trained formally in laparoscopy to perform advanced skills. Advances in technology and surgical skills will support the application of laparoscopic and robotic approaches, and the development of better synthetic and biologic materials likely will improve vaginal repairs. Future studies will determine the utility of the approach.

A randomised trial comparing open Burch colposuspension using sutures with laparoscopic colposuspension using mesh and staples in women with stress urinary incontinence

OBJECTIVE

To compare open Burch colposuspension using sutures with laparoscopic colposuspension using mesh and staples in women with stress urinary incontinence.

DESIGN

Multicentre, prospective randomised trial.

SETTING

Departments of Obstetrics and Gynaecology, Sahlgrenska University Hospital, Göteborg, Borås County Hospital and Orebro University Hospital, Sweden.

POPULATION

Women with genuine stress urinary incontinence or mixed incontinence with a predominantly stress component were included, and were randomised to either open colposuspension (n= 120) or laparoscopic colposuspension (n= 120).

METHODS

Women were randomised to open colposuspension with sutures or laparoscopic colposuspension with polypropylene mesh and staples. Anaesthesia/operation time, blood loss, complications and other related surgical parameters were compared.

MAIN OUTCOME MEASURES

Objective and subjective cure rates from 48-hour frequency-volume chart, a 48-hour pad test and a subjective assessment of the woman's incontinence and quality of life performed one year after surgery.

RESULTS

Objective and subjective cure rates were higher after open compared with laparoscopic colposuspension (P < 0.001). Quality of life was improved following surgery in both groups (P < 0.0001) and the improvement was significantly greater in the open colposuspension group (P < 0.05) with regard to physical activity. Performing an open colposuspension was less time consuming (P < 0.0001), resulted in more blood loss (P < 0.0001), longer catheterisation time (P < 0.01), greater risk of urinary retention (P < 0.01) and a longer hospital stay (P < 0.0001) compared with performing a laparoscopic colposuspension. The rate of serious complications was low in both groups.

CONCLUSION

Open colposuspension had a higher objective and subjective cure rate one year after surgery but with a greater blood loss, greater risk of urinary retention and a longer hospital stay than laparoscopic colposuspension.

Anatomic comparison between laparoscopic and open Burch colposuspension for primary stress urinary incontinence

OBJECTIVES

To examine the anatomic results after laparoscopic and open Burch colposuspension for primary stress urinary incontinence.

METHODS

A cohort study was conducted of patients treated during a 7-year period, predominantly with an open Burch procedure for the first 2.5 years and laparoscopy thereafter. The actual suspension technique, including placement of sutures and the degree of tension for suspension of the bladder neck, was the same in both the laparoscopic and the open Burch colposuspension procedures. Ultrasound cystourethrography was used to assess the preoperative and postoperative bladder neck positions.

RESULTS

A total of 157 patients were identified and constituted the study groups: 75 who had undergone laparotomy (open group) and 82 who had undergone laparoscopy (laparoscopic group). No statistically significant differences were present in demographics, preoperative anatomic position, or urodynamic findings between the two groups. The laparoscopic group required significantly more posterior colporrhaphy procedures than did the open group (P <0.001). The subjective success rate at 1 year of follow-up for the laparoscopic and open groups was 89% and 84%, respectively. No statistically significant differences were found between the two groups in the resting and straining bladder neck positions or in urethral mobility at 1, 3, 6, and 12 months after the Burch operation. In both groups, a trend was noted that the urethrovesical support decreased with time.

CONCLUSIONS

The results of our study showed that, as long as an identical technique is used for suspension of the urethrovesical junction in Burch colposuspension, the clinical results with either an open or a laparoscopic approach are essentially the same.