Laparoscopic Burch Urethropexy
2011 FDA warnings on transvaginal meshes have resulted
in resurgence in the old “gold standard” Burch procedure for the
treatment of stress urinary incontinence. (press release)
The Burch colposuspension for the treatment of stress urinary incontinence was first introduced in the U.S.A. by Dr. John Burch in 1961. The Burch procedure has remained one of the top 3 surgeries in the treatment of stress urine incontinence since the 1960s until 2011. However since the introduction of the TVT sling (1998), TOT sling (2002) and the mini sling (2006) the Burch has lost its influence because the slings have:
- Smaller incisions
- Less Blood loss
- Shorter operative time
- Less post-operative pain
- Less post-operative complications
- Equivalent cure rates to the Burch
However since the recent FDA warnings on the use of transvaginal meshes (which excludes TVT, TOT and mini slings) in 2008 and 2011, we have seen a resurgence (2011) in patients who request the Burch procedure. The patients who are asking for the Burch procedure are doing so specifically because they fear the potential complications associated with mesh slings such as the TVT, TOT, mini slings.
Laparoscopic Burch Urethropexy Indications
Once the patient has been diagnosed with stress urinary incontinence (urine leakage due to coughing, sneezing, or increased abdominal pressure) after urodynamic testing, surgical options, such as Burch laparoscopy, are discussed with the patient. Once diagnosed with stress urinary incontinence, the patient is usually a candidate for either a sling or laparoscopic Burch procedure. The urodynamic study, along with the physical examination, determines which operation the patient should receive. If a patient has a cystocele due to paravaginal defects and has stress urinary incontinence, Drs. Miklos and Moore are more likely to recommend Burch laparoscopy over the sling, because laparoscopic access during the Burch procedure allows for reconstruction of the bladder support system (see paravaginal repair).
Advantages of Laparoscopic Burch Urethropexy
We combine the advantages of laparoscopy with the proven, conventional Burch urethropexy. Patients that undergo the Laparoscopic Burch do not have to endure post-operative pain and discomfort that is associated with the abdominal incision. In addition, our patients spontaneously void sooner in comparison to the conventional Burch. We believe this is due to less tissue disruption with the laparoscopic approach.
Laparoscopic Burch Advantages
- Miniature Abdominal Incisions (< 1.2 cm)
- Decreased Post Operative Pain and Recovery
- Decreased Postoperative Voiding Dysfunction
- Reduced Blood Loss
- Shortened Hospitalization
- 90% Cure Rate of 5-10 Years After the Operation
- Access To Advanced Pelvic Reconstruction Procedures
- Less Chance of Ureter and Bladder Injury
Dr. Miklos published a review article in the Contemporary OBGYN describing his approach in great detail.
Review of the Surgical Literature – Laparoscopic Burch
Fig 1: Laparoscopic Burch
Scientific medical research suggest cure rates >90% at 1 year, 85% at 5 years, and 80% at 10 years. Most recent published literature describes the Burch urethropexy utilizing:
- Four permanent sutures
- Two sutures are placed at the level of the midurethra
- Two sutures are placed at the level of the bladder neck
- All sutures are passed through the Coopers ligament
- Higher cure rates utilizing four sutures instead of two sutures
Supporting the vagina (pubocervical fascia) beside the urethra is one of the two best cures for stress or activity related urine leakage.
Fig 2: Laparoscopic Burch
Laparoscopic Burch Results
Drs. Miklos and Moore have experienced a long-term cure rate of 90% with the laparoscopic Burch procedure. These results are similar to a study in Obstetrics and Gynecology revealing an equal cure rate for laparoscopic vs. laparotomy over 2 years. With these results, we believe the laparoscopic Burch is a superior procedure over the conventional Burch, especially since results are similar without the disadvantage associated with a large incision.
Many patients feel that they must live with incontinence once they have had a failed incontinence procedure. We demonstrate a 90% cure rate in patients undergoing a laparoscopic Burch in those patients who have undergone previous procedures for incontinence. Drs. Moore and Miklos's results were published in the Journal of the American Association of Gynecologic Laparoscopists. Conventional wisdom states that repeat incontinence surgery should have a lower chance of success than a patient receiving surgery for the first time. Drs. Moore and Miklos' article shows even higher cure rates for repeat procedure with Burch laparoscopy than most physicians have published for primary procedures.
Complications of Laparoscopic Burch Urethropexy
Because of Drs. Miklos and Moore 's vast experience in the laparoscopic Burch and/or paravaginal repair, their complication rate is lower than most physicians. A study by Drs. Harris and Cundiff from Duke University Medical Center revealed a 3.3% bladder and 6.7% ureter complication rate during the abdominal Burch procedure compared to our laparoscopic Burch complication rate of 2.3% bladder and 0% ureter.
Fig 3: Laparoscopic Burch
Dr. Miklos published his complication rate in a series of 171 patients in the Journal of Urology. Of the 171 patients, 4 (2.3%) had injury to the lower urinary tract during laparoscopic Burch urethropexy and/or paravaginal repair. All 4 injuries were cystotomies (unavoidable entry into the bladder) in which 2 were in patients with previous abdominal retropubic urethropexies. Previous surgery in this area dramatically increases scar tissue making dissection difficult thus increasing the incidence of bladder injury. No ureteral ligation or placement of suture into the bladder was diagnosed. Other surgical parameters for our laparoscopic Burch urethropexy and paravaginal repair include an estimated blood loss of 50 mL, average hospital stay of less than 23 hours, and an average operative time of 50 minutes. All patients had their surgery completed via laparoscopy.
The literature review and our personal experience suggest that the laparoscopic Burch urethropexy and paravaginal repair procedure is safer and has fewer complications than the traditional open laparotomy for the treatment of stress urinary incontinence and cystourethrocele resulting from lateral vaginal wall defects.
Drs. Buller and Cundiff at The Johns Hopkins University Medical Center wrote a comprehensive review on laparoscopic surgeries for urinary incontinence. These physicians state, "The majority of the data for laparoscopic surgeries for the treatment of urinary incontinence suggest that the success rates are similar and complication rates are lower than those for the open procedure." Buller and Cundiff also discuss the doubt about long-term results. The conclusion was that long-term results are determined by the physician's experience and if the physician modifies the procedure. To date, Dr. Miklos and Moore have performed more than 700 laparoscopic Burch and/or paravaginal repairs with no modifications of the Burch procedure.
General Complications of Laparoscopic Burch
- Bladder or Ureter Injury
- Voiding Dysfunction
- Incomplete Bladder Emptying
- Urinary Retention
Atlanta Urogynecology Associates Experience
Drs. Miklos and Moore have per anti incontinence surgery. Because of this vast experience with Burch laparoscopy, they are able to achieve high cure rates and low complications from the laparoscopic Burch procedure with a successful long-term outcome. By performing the Burch in the original manner in which it was designed, we have taken a proven open surgery and applied our advanced laparoscopic skills to allow for smaller incisions and a shorter recuperation time. Dr. Miklos and Moore have performed just as many, if not more, laparoscopic Burch and or paravaginal repairs than most surgeons in the country. Their published series of 171 patients as noted above constitutes the largest known published series in the English literature. These 171 patients account for less than 2.5 years of their total surgical series. They also have the largest series in the English literature of complicated laparoscopic Burch procedures which are performed in patients that have had previous surgeries. Today's surgeons rarely achieve these results.
Laparoscopic Paravaginal Repair w/ Burch Urethropexy
Dr. Miklos' and Dr. Moore's recent study review of the more than 200 patients who had received a laparoscopic Burch urethropexy revealed more than 90% of these patients also required a paravaginal repair. Dr. Miklos previously described combining these two surgical techniques in an attempt at restoring anterior vaginal wall anatomy and correcting the stress urinary incontinence. This surgical procedure is recommended for patients with cystocele (due to paravaginal defects) and stress urinary incontinence. The paravaginal repair is performed between the apex (highest point) of the anterior vaginal wall and the "bladder neck" (urethra meets the bladder) this part of the surgery corrects the cystocele (bladder drop). The Burch urethropexy is performed to stabilize and support the urethra. The combined surgical procedure routinely utilizes:
- Total of ten sutures
- Six sutures for the paravaginal repair (cystocele repair)
- Four sutures for the Burch urethropexy (incontinence repair)
- All permanent sutures
Paravaginal Plus Burch Urethroplexy
Not only addresses the incontinence (Burch) but also the cystocele (paravaginal repair). Dr. Miklos and Dr. Moore have found 95% of patients receiving a Burch procedure also have paravaginal defects. Therefore, most patients should have both the Burch and paravaginal repair procedures.
Burch Urethroplexy without Paravaginal repair
Note the paravaginal defects are present. The Burch procedure will address the urine leakage, but the paravaginal defects are not addressed therefore the patient will continue with a cystocele in this area.
Side View of Anterior Vaginal Wall Prolapse and Repair
Cystourethrocele – A lack of support of the whole anterior vaginal wall
Burch Urethropexy without Paravaginal Repair
The patient continues to have a cystocele, even though she had a Laparoscopic Burch procedure for her urine incontinence. If this patient would have also had a paravaginal repair, the cystocele would have been cured and her support would look like the normal support pictured above.