Urethropexy Case File

Urethropexy Case File

Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG

Case 20

A 46-year-old G3P3 woman is coming into the office for follow-up for menorrhagia. She originally presented to her gynecologist 2 months previously with complaints of heavy vaginal bleeding for several years, and the loss of a moderate amount of urine with Valsalva and cough; the loss of urine was reported as bothersome to her and limited her activities. She denied dysuria and urgency symptoms. She required the use of a sanitary pad to protect her clothing from her incontinence. On examination, she was found to have an enlarged uterus (18 cm in size) with multiple fibroids. A cotton tip applicator in the urethra moved 70 degrees with Valsalva, and the patient was noted to have a small cystocele and loss of urine with Valsalva. An endometrial biopsy was performed and revealed benign secretory endometrium; aa urine culture was negative for growth. Medical therapy with oral contraceptive pills had been initiated for her menorrhagia, and she was instructed on pelvic floor exercises. The patient reported that she complied with both the OCP’s and pelvic floor exercises, which provided no relief of symptoms. She is mildly anemic (hemoglobin 11.5 g/dL) requiring oral iron supplements. A urodynamic study is performed and reveals genuine stress incontinence. Because of the size of her uterus, a total abdominal hysterectomy is planned for definitive therapy. The patient is also counseled about a surgery for treatment of her urinary stress incontinence.

➤ What are two urethropexy surgical therapies that could be performed for her urinary incontinence at the time of her abdominal hysterectomy?

➤ What is the main difference between the two most common urethropexy surgeries?

ANSWERS TO CASE 20:

Urethropexy

Summary: This is a 46-year-old woman with symptomatic uterine fibroids not responsive to medical therapy desiring definitive therapy with a total abdominal hysterectomy. She also has stress urinary incontinence, for which she desires surgical therapy at the same time as the hysterectomy.

➤ Urethropexy procedures: Marshall-Marchetti-Krantz (MMK) and Burch procedures. Additionally, midurethral sling procedures could also be done.

➤ Difference between MMK and Burch: The primary difference between the MMK and Burch procedure is the points of attachment of the periurethral endopelvic fascia. The MMK was the first retropubic urethropexy procedure described and involves attachment of endopelvic fascia to the periosteum of the pubic symphysis. The Burch procedure attaches the endopelvic fascia to Cooper ligament.

ANALYSIS

Objectives

1. Describe the surgical principles of both the MMK and Burch procedures.
2. Become familiar with the important anatomical landmarks for both procedures.
3. Describe the strategies to prevent and recognize intraoperative complications.

Considerations

This is a 46-year-old woman with problems of urinary stress incontinence and symptomatic uterine fibroids. There are multiple surgical procedures to address stress urinary incontinence, which can be performed via an abdominal or vaginal approach. Recently, midurethral sling procedures have gained

popularity, either via the transobturator route or transvaginal route. The gold standard surgical treatment of stress urinary incontinence in patient with a hypermobile bladder neck is via a retropubic approach with MMK or Burch procedures. In this patient, because an abdominal hysterectomy is being planned, a retropubic urethropexy can be easily performed through an abdominal incision. Given the small cystocele, a Burch procedure would likely be the ideal surgery as it may help correct the small cystocele.

APPROACH TO

Urinary Incontinence

DEFINITIONS

OSTEITIS PUBIS: Inflammation of the pubic bone’s periosteum which can occur after suprapubic suspension procedures like the MMK.

URODYAMIC STRESS INCONTINENCE: Involuntary loss of urine when the intravesicular pressure exceeds the urethral closure pressure.

SPACE OF RETZIUS: Retropubic space where a retropubic urethropexy is performed.

CLINICAL APPROACH

Proper patient selection and surgeon expertise determine the success of any surgical procedure. In general, there are two primary surgical treatments for stress urinary incontinence: retropubic urethropexy and sling procedures. In order to select the proper surgery, many factors need to be weighed. Some factors to consider are the age/health of the patient, presence of other pelvic disease, degree of pelvic organ prolapse, physician expertise, and patient preferences. In this

case, the patient has uterine pathology requiring a laparotomy with no evidence of significant pelvic organ prolapse. A retropubic urethropexy after the hysterectomy through the abdominal incision makes the most sense. Tension-free vaginal sling procedures would be best suited for patients desiring or requiring shorter operative and postoperative recovery times, having evidence of intrinsic sphincter deficiency, or undergoing concurrent vaginal surgery.

Published studies indicate that the 5- to 10-year cure rate is as high as 82% for both MMK and Burch procedures when properly performed.1 This is comparable to success rates published for most sling procedures. Long-term (10-20 years) cure rate after a Burch procedure is reported as 69%. Most studies that have compared laparoscopic Burch procedures to the open procedure have shown similar cure rates (one study in 2004 demonstrated improved cure rates with open technique). Removal of the uterus, in the absence of uterine pathology or prolapse, does not improve the efficacy of the urethropexy procedure. Hysterectomy may increase operative blood loss, operative/postoperative time, and the possibility of vaginal prolapse in the future.2-5

A large multicenter randomized trial compared the Burch procedure with tension- free vaginal tape (TVT) procedures and demonstrated no significant difference in objective short-term (< 10 years) cure rates.6 Bladder injuries were seen more often in TVT procedures, but Burch procedures had a higher incidence of delayed voiding and longer operative and postoperative recovery times.7

APPROACH TO

Retropubic Urethropexy

The two most common abdominal retropubic urethropexy procedures are the MMK and Burch procedures. Both procedures elevate and stabilize the anterior vaginal wall which, in turn, elevates the urethrovesical angle and proximal urethra into more of an intra-abdominal position. Either procedure can be performed by itself or in conjunction with another intra-abdominal procedure (abdominal hysterectomy). With the bladder neck in the intra-abdominal position, increased intra-abdominal pressure is equally distributed to both the urethra and bladder favoring continence.3

In the operating room, the patient is placed in dorsal supine position with legs in stirrups (Allen Universal Stirrups for example). A 16- to 18-Fr sterile Foley catheter is placed in the bladder with 30 cc of fluid in Foley bulb. A low transverse or low vertical incision is then made and carried down to the retropubic space.

The retropubic space, also known as “the space of Retzius,” is a potential space lying outside the peritoneal cavity (Figure 20–1). It must be entered and dissected prior to proceeding with either an MMK or Burch procedure. The retropubic space is bounded by the anterior pubic bones and symphysis pubis anteriorly and bladder, urethra, and vagina posteriorly. The space is filled with loose areolar connective tissue, fat, and many blood vessels. If the patient has not had previous surgery in this space, the area can be opened with careful and gentle blunt dissection. Patients with previous surgery in the retropubic space, usually require sharp dissection due to dense adhesion formation. The urethra is palpated easily with the aid of the Foley catheter, and the inferior edge of the bladder is identified with the aid of the large Foley bulb and is seen as a rounded midline structure. If the bladder anatomy is not easily seen, a cystotomy can be performed in the dome of the bladder to aid in identifying the limits of the bladder.

Once the limits of the bladder have been determined, the endopelvic fascia is identified. Permanent (or at least delayed absorbable) sutures are then placed through the endopelvic fascia while a finger in the vagina elevates the endopelvic fascia. The use of a sterile thimble can be used on finger elevating the endopelvic fascia to minimize risk of needle stick injuries. The suture should be placed so that the needle is directed upward and toward the midline to avoid vessel injury. Two endopelvic fascia sutures are placed on each side of the urethra and tied. If an MMK is performed, the endopelvic fascia is suspended to the periosteum of the pubic symphysis. In contrast, the endopelvic fascia is suspended to Cooper ligament during the Burch procedure (see Figure 20–2). The suspension should be without significant tension

Figure 20–1. Dissecting the space of Retzius. (Reproduced, with permission, from

Schorge JO,Schaffer JI,Halvorson LM,et al. Williams Gynecology. New York:McGraw-Hill,

2008:978.)

and that allows a finger between the endopelvic fascia and permanent attachment.8-14

Advantages of the Burch over the MMK include its ability to correct for a cystocele, firmer point of fixation, and the absence of osteitis pubis risk. The potential complication of hemorrhage exists for both procedures. Hemorrhage can occur from the vascular network of the rich thin-walled vessels located in the retropubic space or the longitudinal venous plexus that courses outside each anterior lateral vaginal fornix. Bleeding can be prevented by careful dissection and cauterization of blood vessels. If hemorrhage ensues, the gloved finger in the vagina, used for elevation of the endopelvic fascia, can be elevated to diminish bleeding until the source of the bleeding is identified and ligated. A surgical drain may be needed if excessive bleeding is noted in the retropubic space.12

Figure 20–2. Placement of sutures in the pubovesical fascia to the Cooper ligament. (Reproduced, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al. Williams Gynecology. New York: McGraw-Hill, 2008:979.)

Postsurgical voiding dysfunction can be seen with either procedure. The development of detrusor instability occurs in 10% to 15% of patients15,16 and once infection has been ruled out, should be addressed. Some degree of urinary retention is seen in 15% to 20% of patients. This often can be managed with prolonged bladder drainage and rarely with removal of suspension sutures. The incidence of urinary retention can be reduced intraoperatively by allowing a space (1-2 cm) between the suspended endopelvic fascia and fixation point.2

Osteitis pubis is a rare complication of the MMK procedure occurring in 1% to 2% of all patients.15 This painful condition is caused by an inflammatory reaction (noninfectious) in the periosteum of the pubic bone, resulting in pain (osteomyelitis is the infectious form). When supportive care is not sufficient, the suspension sutures may need removal.

Comprehension Questions

20.1 A third-year resident is being instructed in the surgical management of a patient with urinary incontinence. How many total sutures (both sides added together) should be placed in the endopelvic fascia during a Burch or MMK procedure?

A. One

B. Two

C. Four

D. As many as possible

20.2 A 35-year-old woman underwent an MMK urethropexy procedure and developed symptoms consistent with osteitis pubis. Which of the following about osteitis pubis is most accurate?

A. Often occurs after a Burch Procedure.

B. Occurs in the immediate postoperative period.

C. Is a delayed complication (> 2 months).

D. Pain symptoms are constant with no aggravating or alleviating factors.

20.3 While performing a Burch procedure, a significant amount of bleeding is encountered in the space of Retzius. The area has blood pooling and it is difficult to detect the origin of the bleeding. What is your first course of action?

A. Place a surgical drain.

B. Elevate the endopelvic fascia with your finger in the vagina.

C. Place a suture in the general area of the bleeding.

D. Obtain vascular surgeon intraoperative consultation.

ANSWERS

20.1 C. Two to three sutures are recommended through the endopelvic fascia on each side of the urethra (total of four). A higher failure rate has been observed with one suture compared to two sutures. The placement of too many sutures can lead to urinary retention.

20.2 C. A patient with osteitis pubis usually presents with pubic pain and a “waddling” gate 2 months after an MMK. The pain is usually abrupt in nature, may radiate down the inner aspect of the thigh, and is aggravated by activity. In the absence of an infection, the patient is treated with bedrest, steroids, and analgesics. If symptomatic treatment is insufficient, the suspension sutures may need removal.

20.3 B. When entering the space of Retzius, careful meticulous dissection is required to avoid substantial bleeding. However, if hemorrhage ensues after stitch is placed in the endopelvic fascia or with dissection, the endopelvic fascia with finger in the vagina should be gently elevated. This maneuver usually decreases the bleeding and allows for better visibility. Once the vessel is identified, it can be suture-ligated or cauterized under direct visualization. Blindly placing sutures in the space of Retzius can lead to injury to the bladder or urethra.

Clinical Pearls

See Table 1-2 for definition of level of evidence and strength of recommendation

➤ Short-term outcomes of midurethral slings are similar to the traditional retropubic approach (Level A).

➤ The development of de novo detrusor instability occurs in about 15% of patients after a retropubic urethropexy (Level B).

➤ The placement of two to three permanent sutures in the endopelvic fascia during a Burch procedure has been shown to be superior to the placement of just one (Level B).

➤ In the event of hemorrhage in space of Retzius, elevation of the endopelvic fascia decreases the amount of bleeding so that the injured vessels can be visualized and ligated (Level C).

REFERENCES

1. Feyereisl J, Dreher E, Haenggi W, et al. Long-term results after Burch colposuspension. AM J Obstet Gynecol. 1994;171:647. 

2. American College of Obstetricians and Gynecologists. Urinary Incontinence in Women. ACOG Practice Bulletin No. 63. Washington DC; 2005. 

3. Katz VL, Lentz GM, Lobo RA, Gershenson DM. Urogynecology. In: Comprehensive Gynecology. 5th ed. Philadelphia, PA: Mosby; 2007:537-563. 

4. Langer R, Ron-El R, Neuman N, Herman A, Bukovsky I, Caspi E. The value of simultaneous hysterectomy during Burch colposuspension for urinary incontinence. Obstet Gynecol. 1988;72:866-869. 

5. Lapitan MC, Cody DJ, Grant AM. Open retropubic colposuspension for urinary incontinence in women. Cochrane Database Syst Rev. 2003;(1):CD009212. [DOI: 10.1002/14651858. CD002912]. 

6. Ward K, Hilton P. Prospective multicentre randomized trial of tension-free vaginal tape and colposuspension as primary treatment for stress incontinence. United Kingdom and Ireland Tension-Free Vaginal Tape Trial Group. BMJ. 2002;325:67-70. 

7. Alcaly M, Monga A, Stanton SL. Burch colposuspension: a 10-20 year follow up [published erratum appears in Br J Obstet Gynaecol. 1996;103:290]. Br J Obstet Gynaecol. 1995;102:740-745. 

8. Ankardal M, Ekerydh A, Crafoord K, Milsom I, Stjerndahl JH, Engh ME. A randomized trial comparing open Burch colposuspension using sutures with laparoscopic colposuspension using mesh and staples in women with stress urinary incontinence. BJOG. 2004;111:974-981. 

9. Baggish M, Karram M. Operative setup and entry into the retropubic space and retropubic urethropexy for stress incontinence. In: Atlas of Pelvic Anatomy and Gynecologic Surgery. 2nd ed. Philadelphia, PA: Elsevier Mosby; 2006:333-338. 

10. Hurt G. Retropubic urethropexy or colposuspension. In: Urogynecologic Surgery. 2nd ed. Baltimore: Lippincott Williams & Wilkins; 2000:80-92. 

11. Moehrer B, Carey M, Wilson D. Laparoscopic colposuspension: a systematic review. BJOG. 2003;110:230-235. 

12. Ostergard DR, Bent AE, Cundiff GW, Swift SE. Surgical correction of stress urinary incontinence. In: Ostergard’s Urogynecology and Pelvic Floor Dysfunction. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:455-467. 

13. Rock J, Jones H. Urinary stress incontinence. In: Te Linde’s Operative Gynecology. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:936-955. 

14. Wheeless CR. Retropubic urethropexy: Marshall-Marchetti-Krantz and Burch operations. In: Atlas of Pelvic Surgery. 3rd ed. Baltimore, MD: Williams & Wilkins; 1997:139-143. 

15. Mainprize T, Drutz H. The Marshall-Marchetti-Krantz procedure: a critical review. Obstet Gynecol Surv. 1988;43:724-729. 

16. Jarvis GJ. Surgery for genuine stress incontinence. Br J Obstet Gynaecol. 1994;101:371-374.

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