Stress incontinence is defined as the involuntary loss of urine in the absence of detrusor contraction, when the intravesical pressure exceeds the maximum urethral closure pressure secondary to an increase in the intra-abdominal pressure 1. The goal of surgical treatment is to provide support to the hypermobile urethra and bladder neck 2. Colposuspension still, however, is the most effective operation currently available for treating genuine stress incontinence 2. In this work, cystoscopic control to the suspensory sutures was carried out to insure equal placement and adjustment of the sutures to the bladder neck.
Patients and methods
In all, 130 female patients complaining of stress urinary incontinence attending the Kasr Al Ainy outpatient clinic (urology or gynecology clinic), during the period between March 2010 and March 2013, were included in this study.
Informed consent was obtained from all patients after full explanation of the aim and procedures of the study; data were collected after informing the patients about the purpose of the study; the patients had the right to withdraw from the study without giving any reasons. Privacy and confidentiality of the obtained data were insured for all participants. The ethical committee of Kasr Al Ainy hospitals approved this study before starting.
Inclusion criteria consisted of being a female between 28 and 55 years of age, suffering from genuine stress urinary incontinence, which is proved by a urodynamic study (flowmetry, cystometry, and urethral pressure profile). We excluded patients with previous repair and fibrosis, those with detrusor instability or with mixed stress incontinence and patients unfit for surgery; all patients were subjected to careful history taking, general examination, local examination (cough stress test, Bonney’s test, examination for the presence of genital prolapsed, and the Q-tip test), and routine laboratory tests (complete blood count, kidney function tests, liver function tests, coagulation profile, fasting blood sugar); they also undergo midstream urine specimen analysis for culture and sensitivity (to exclude infection), postvoiding residual urine (PVR), and finally a urodynamic study (uroflowmetry, cystometry, urethral pressure profile) to confirm genuine stress incontinence.
Patients were then offered the Burch colposuspension operation as a repair; proper explanation of the procedure (possible complications, morbidity, mortality rates, recurrence, postoperative follow-up) was carried out for each patient.
Blunt finger dissection in the retropubic space of retzius between the symphysis pubis and the anterior surface of the urinary bladder and the urethra was performed. With the operator’s finger still in the vagina and elevating the vaginal fornix, we started the insertion of a nonabsorbable (0-0) polydioxanone suture on one side from the paravaginal tissues into the nearest point on the ipsilateral iliopectineal ligament, opposite the bladder neck identified by the inflated balloon of the folds catheter in the bladder. Then under cystoscopic control, using a 17-Fr sheath and 0° lens to visualize the proximal urethra, we start suturing the other side. After that and before suturing to the iliopectineal ligament, we raise the sutures on both sides to assure that both sutures are at the same level. Under cystoscopic control, we ensure that the sutures on either side are at the same level and there is no tilting of the urethra or the bladder neck. After assurance that the sutures on both sides are at the same level, the sutures are inserted to the ipsilateral iliopectineal ligament. After that, we start tightening the sutures under cystoscopic control. We start with one side, which is followed by the other side to have equal elevation of the vagina and avoid over tightness of one side over the other side. Then, we assure that there is no tilting of the bladder neck or overclosure of the bladder neck. The procedure ends by suprapubic catheter drainage of the bladder for 48 h, drain for 72 h (Fig. 1).
Ninety-nine patients were followed up for 24 months, 23 patients were followed up for 10–12 months, and eight patients were followed up for only 6 months.
During the follow-up period, all patients were subjected to the following: clinical examination (cough stress test, Bonney’s test, examination for the presence of genital prolapsed, and the Q-tip test) and provocation stress test every 3 months. Patients were asked about the presence of symptoms and signs of retention of urine every 3 months. Ultrasonographic measurement of the residual urine every 3 months (PVR) and flowmetry to measure the Qmax every 6 months were performed.
Urine analysis and, in case of presence of pus cells more than 25/HPF, a urine culture and sensitivity were performed. This is repeated every 2 weeks for the first 2 months, and then every 3 months after that.
All the patients showed: a negative stress test, no retention of urine, residual urine less than 10 ml (as measured ultrasonographically), and a Qmax. in the range of 25–35 ml/s in all the patients.
Only 35 patients (26.9%) suffered from urinary infections in the early postoperative period (first month) associated with urgency. All the cases were treated medically till complete cure and improvement was detected by improved symptoms and repeated urine analysis.
Only 11 cases showed urge incontinence, and were treated by bladder retraining exercises and medically by anticholinergic drugs (8.4%).
Regarding urine retention, residual urine, and flowmetry, the success rate was 100%.
Till now, the Burch colposuspension has been considered as the gold standard surgical procedure to correct genuine stress incontinence by stabilizing the bladder neck and the proximal urethra behind the symphysis pubis 3.
Cystoscopy was used in combination with the Burch procedure for early detection, and hence immediate repair of any urinary tract injury occurring with the Burch procedure 4,5, during this study. Cystoscopy was used for the evaluation of the adequacy of the sutures placed during the Burch procedure, and hence decrease postoperative complications that may result from the Burch procedure.
In this study, we used cystoscopic control to the posterior urethra during placement of the four sutures to assure that they were at the same level at the bladder neck to avoid tilting of the bladder neck due to unequal tightening of the sutures.
In this work, with regard to urine retention, residual urine, and flowmetry, the success rate was 100% compared with results where the cystoscopic control was not used as in the study by Andersen et al.6 who reported an incidence of retention and voiding dysfunction in 6% of patients, and O’Kelly et al.7 who found an incidence of retention of 2%.
Development of complications in women undergoing Burch colposuspensions was associated with surgical factors and not patient-related factors. Concomitant surgeries increased complication rates in women undergoing continence surgery, specifically wound and gastrointestinal events. The most frequent complication after continence surgery was cystitis. These data can assist the clinician during preoperative counseling in the discussion of these risks in women undergoing continence surgery with or without concomitant surgery 8.
Also, intraoperative introital ultrasound standardizes Burch colposuspension, and thus, might help avoid overelevation and associated postoperative complications such as voiding difficulties and de-novo urge incontinence without compromising the success of the operation 9. Hence, it may be recommended as a simple add procedure that decreases complications without increasing the risks on the patients or increasing the cost.
In a 10-year follow-up study conducted by Alcalay et al. 10, the postoperative complications included de-novo detrusor instability (14.7%), voiding difficulty with objective recovery at the final follow-up (22%), and recurrent urinary tract infection (4.6%).
However, in our 2-year follow-up study, the complications detected were urinary tract infection in 26.9% of the cases, urge incontinence in 8.4%, urine retention in 0%, and residual urine in 0% of the cases.
Cure of incontinence after Burch colposuspension is time dependent, with a decline for 10–12 years when a plateau of 69% is reached 10.
Another 1–6 years (mean 4.5 years) of follow-up of 50 patients with stress urinary incontinence and treatment by Burch colposuspension, the cure rate was 84% immediately postoperatively, but decreased to 63% after 1 year and 56% after 6 years 11.
The definition of ‘cure’ accepted in this study is the same as in the study of Jarvis 12: ‘a patient who is totally continent of urine; any patient who has been described as “much improved” has not been accepted as cure’.
Proper follow-up needs a long time (5–10 years); a drawback of this study is the short follow-up (2 years); with regard to the culture and circumstances in our country, a longer follow-up was not feasible, and so we suggest further studies with a longer follow-up period for proper assessment of the sequelae of this procedure.
Cystoscopic control of the proximal urethra and the bladder neck in Burch colposuspension is of significant value and is important as it revealed no postoperative complications with regard to retention of urine or infravesical obstructive symptoms. It is a simple procedure, with no increase in the operative time or morbidity, and so it is recommended to be added whenever the Burch procedure is performed.
Conflicts of interest
There are no conflicts of interest.
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