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Comparison of the laparoscopic and laparotomic retropubic colposuspension in the treatment of genuine urine stress incontinence: a retrospective study.

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(1)228. Comparison of the Laparoscopic and Laparotomic Retropubic Colposuspension in the Treatment of Genuine Urine Stress Incontinence: A Retrospective Study Wu-Chou Lin, Chin-Tao Tai, Yao-Yuan Hsieh, Huey-Yi Chen, Horng-Der Tsai, Tai-Yen Hsu Department of Obstetrics and Gynecology, China Medical College Hospital, Taichung, Taiwan, R.O.C.. Background. This study compared the differences between laparoscopic and laparotomic retropubic colposuspensions in the treatment of patients with genuine urine stress incontinence. Methods. Between January 1997 and December 1998, we studied 70 patients by dividing them into two groups: a laparoscopic colposuspension group and a laparotomic colposuspension group. The concomitant operations included hysterectomy, salpingectomy, salpingooophorectomy, ovarian cystectomy, utero-vaginal suspension with round ligament shortening, modified McCall-Moschowitz culdoplasty and colpopexy, and posterior colpoperineorrhaphy. Their perioperative courses and follow-ups were then compared for more than a year. The operation efficiencies were evaluated by subjective questionnaires , an estimated pad test and an objective urodynamic examination . Results. The patients in the laparoscopic group had longer operative times, less blood loss, less morbidity, shorter hospitalizations, and a similar successful rate when compared with patients in the laparotomic group. The subjective success rates between laparoscopic and laparotomic group were 94% and 91% respectively. Conclusions. Conclusions. With advanced operative laparoscopy technology, the laparoscopic approach to colposuspension had similar efficiencies and less morbidities in genuine stress incontinence when compared to the laparotomic approach. ( Mid Taiwan J Med 2000;5:228-34). Key words Burch colposuspension, genuine stress incontinence, laparoscopy. produce significant postoperative morbidity. INTRODUCTION. first. and prolonged hospitalization [5-6]. In an. described in 1961, has been considered as the ". effort to reduce morbidity associated with. golden standard " procedure in genuine stress. the abdominal retropubic urethropexy, a. incontinence [1]. The open Burch colposus-. minimally invasive technique known as. pension successfully restores continence in. transvaginal needle bladder neck suspension. 84% to 94% of patients within 1 to 2 years [2].. was developed by Pereyra in 1959 [3].. However, access to the retropubic space. Unfortunately, the needle bladder urethropexy. involves a large abdominal incision that can. and its many modifications have exhibited. The. Burch. colposuspension,. lower long-term cure rates and an increased Received : June 19, 2000.. Revised : August 17, 2000.. Accepted : October 11, 2000. Address reprint requests to : Wu-Chou Lin, Department of. incidence of postoperative voiding dysfunction compared with the traditional. Obstetrics and Gynecology, China Medical College Hospital,. retropubic approach [4]. Laparoscopy has. No 2, Yuh-Der Road, Taichung 404, Taiwan, R.O.C.. evolved into an alternative technique that.

(2) Wu-Chou Lin, et al.. 229. permits placement of suspension sutures. criteria: 1) more than one-degree improvement. under direct vision while avoiding the. of continence compared to the pre-operation. morbidity associated with the open retropubic. condition 2) normal results of the urodynamic. colposuspension.. long-term. study and no need for an underpad even with. durability of the approach is controversial [7-. occasional incontinence. We defined the cure. 11]. The aim of this study was to evaluate the. rate as being the cumulative subjunctive and. clinical differences between laparoscopic and. objective evaluations showing normal results.. open Burch colposuspension in genuine stress. A p value of less than 0.05 was considered as. incontinence. Some authors compared the. significant.. effects of these two approaches with a. Operation Methods. However,. subjective evaluation [12]. In this report, we evaluated the clinical change prior to and after operative condition with objective and subjective evaluation.. We divided the patients into two groups, according to the two opporative approaches: the laparoscopic and the laparotomic groups. The same surgeon (WC Lin) performed all operative procedures. Both groups accepted. MATERIAL AND METHODS. Between January 1997 and December 1998, there were pre-menopausal patients with. the same retropubic urethropexy (modified Burch. method,. Hodgkinson's. method). genuine stress incontinence receiving the. procedures. Group 1: Laparoscopic Approach. All patients. operative retropubic colposuspension at China. were placed in the dorsal lithotomy position.. Medical College Hospital. All patients accepted. A no. 14 Foley catheter was inserted to decom-. the pelvic examination, urodynamic exam-. press the bladder. A pneumoperitoneum was. ination, and sonography preoperatively. The. obtained in standard fashion with a Veress. degree of uterovaginal prolapse, incontinence,. needle. A 10-mm trocar was placed in the. and other associated symptoms (bearing-down. inferior umbilical crease. Two 5-mm ancillary. sensation, frequency, and urgency of urination. trocars were placed at the level of the. etc) were recorded in detail. The other. umbilicus in the bilateral middle quadrant,. combined urogynecologic conditions included. lateral to the rectus muscle. A fourth 5-mm. uterine leiomyoma, adenomyosis, cervical. suprapubic trocar was then inserted medial to. carcinoma in situ, uterovaginal prolapse. the lateral umbilical ligament and 20 mm. (grade I), cystorectocele (grade I), enterocele. above the pubic symphysis. The dissection. (grade I), and ovarian cysts (endometrial cyst,. was initiated by transverse incision of the. cystadenoma, dermoid cyst, simple cyst etc).. peritoneum two-finger border above the. The cases of grade II or III uterine prolapse. symphysis pubis and medial to the inferior. were excluded.. epigastric vessels. The transveralis fascia and. The subjective self-estimation of each. Retzius space were incised and pushed. patient was recorded via telephone interview,. downward. The Retzius space was then. written questionnaire, and outpatient visits.. opened to identify the Cooper's ligament. The. The objective evaluation of the urinary. paravaginal space was developed from mid-. continence was done by a 60-minute. urethra to the ischial spine. Other anatomic. estimated pad test (EPT) and urodynamic. landmarks were identified, including the. studies. The pre- and post-operative results of. internal obturator muscle, arcus tendineus,. both groups were compared by using the t-. pubocervical fascia, urethra, bladder neck,. 2. tests with SAS software. The. obturator foramen and its bundle nerves and. established success rate consisted of improve-. vessels.The ischial spine, coccygeal, and. ment and the cure rate. Improvement was. piriformis muscles were also identified. Two. defined according to one of the following. interrupted. test and. paravaginal. repairs. were.

(3) Laparoscopic vs Laparotomic Colposuspension in GSI. 230. Table 1. Patient characteristics and degree of stress urinary incontinence Groups. Group 1 (laparoscopy). Group 2 (open). p value. 35 41.2 3.7 2.7 0.8 4 (11.4). 35 42.1 4.1 3.1 0.8 3 (8.6). NS 0.01 NS. 8 (22.9) 23 (65.7) 4 (11.4). 6 (17.1) 26 (74.3) 3 (8.6). NS NS NS. No. of patients Age (yr)* Parity* Vaginal delivery > 4000 gm Degree of stress urinary incontinence 1 2 3 *Data are expressed as mean. SD. Data in the parentheses represent percentages. NS = no significant difference. (p value > 0.05).. Table 2. Comparison of the operation results, combined operation and follow-up Groups. Group 1 (laparoscopy). Group 2 (open). p value. Operative time (min)* < 0.05 93.7 37.0 126.0 40.7 Blood loss (ml)* 0.0001 631.4 229.6 55.3 30.3 Combined operation 23 (65.7) Hysterectomy NS 20 (57.1) 8 (22.9) Ovarian cystectomy NS 10 (28.6) 4 (11.4) Oophorectomy NS 5 (14.3) 8 (23.0) 10 (28.6) Round ligament shortening NS 33 (94.3) 30 (85.7) Modified McCallNS Moschowitz culdoplasty and colpopexy 25 (71.4) 21 (60.0) Posterior colporrhaphy NS 6.2 2.4 3.9 1.3 Hospitalization (days)* 0.0001* 14.1 2.4 15.3 3.6 Follow-up (months)* NS Outcome NS 28 (80) 29 (82.9) Cured (no incontinence) 4 (11.4) 4 (11.4) Improved (occasional incontinence) 3 (8.6) 2 (5.7) Failure *Data are expressed as mean SD. Data in the parentheses represent percentages. NS = no significant difference (p value > 0.05).. performed with a no. 1, CT-2 needle and sawe. G r o u p 2 : L a p a r o t o m i c A p p r o a c h . In the. unabsorbable polybutylate-coated polyester. traditional group, the approach to the Retzius. material (Ethibond, Ethicon, UK) placed 1-2 cm. space and further colposuspension were. apart. Starting from the upper part of the. similar to the laparoscopic group. No drainage. iliococcygeal muscle to the lower part para-. was put in the Retzius and paravesicle space.. bladder level we sutured the pubocervical. After carefully checking the bleeder, the. fascia upward to the arcus tendineus of the. abdominal wound was closed in standard. levator ani. The Burch procedure was. fashion.. performed by suturing the pubocervical fascia RESULTS. to the Cooper's ligament with a no. 2, CT-2 needle, and Gore-Tex sutures (W.L. Gore &. There were 70 cases in this series, 35. Associates, Inc, Flagstaff, Arizona). Two. cases of group 1 (laparoscopy) and 35 cases of. rstitches were made over the levels of the mid-. group 2 (open). There were no significant. urethra and bladder neck, respectively. The. differences. reperitonized bladder flap was performed on. incontinence between the two groups (Table. all patients. The Foley catheter was removed. 1). The detailed personal characteristics of. postoperatively 48 hours later, and then the. both groups aer presented in table 1. The. residual urine was checked.. hospitalization for group 1 was shorter than. in. the. age,. or. degree. of.

(4) Wu-Chou Lin, et al.. 231. group 2. The concomitant operations,. The clear view of the surgical site also helps. operation results, and follow-up in both. the surgeon to place the sutures correctly on. groups are summarized in Table 2. The. the anterior vaginal wall and Cooper's. combined operations, follow-up period, and. ligament while avoiding blood vessels.. subjective cured rates in both groups were not. Although the operative time is longer, the. statistically significant. In the laparoscopic. laparoscopic approach offers more benefits. group, longer operative time, less blood loss,. compared to traditional open retropubic. and shorter hospitalization were observed. suspensions.. when compared with the laparotomic group.. The colposuspension technique used in. The period of recording urinary continence. both laparotomic and laparoscopic groups was. ranged from 1 to 2 years postoperatively. The. anatomically the same, so the continence rates. clinical success rates were 94% vs 91%. should be similar irrespective of the approach.. between laparoscopic and laparotomic groups,. We believe, the laparoscopic approach should. respectively.. result in a similar cure rate as well. In this. Operative complications were rare in. series, the subjective cure rates in both groups. both groups. Only two patients with wound. were similar and compatible with the results. infection were noted in the laparotomic group.. of other literature [21]. The failure rates of the. Two from the laparoscpic and three patients. laparoscopic and open groups were 6% and. from the laparotomic groups had transient. 9%, respectively, which was not statistically. postoperative voiding difficulty . All five. different. The patients after laparoscopic. patients were discharged after teaching self-. colposuspension experienced less discomfort,. catheterization within eight hospitalized days.. minimal blood loss, a shorter hospital stay, and faster recovery than the laparotomic group experienced.. DISCUSSION. a. The genuine stress incontinence often. pathologic condition usually accompanied. combined with pelvic prolapse. The combined. with poor support to the pelvic organs and. symptoms, including bearing-down sensation,. excessive mobility of the bladder base due to. back soreness, and pelvic pain , long-period. stress [13,14]. Numerous surgical approaches to. standing and anal incontinence were present. stabilize the bladder base have been designed.. in most patients. We felt that the simple. The three most popular surgical approaches. colposuspension would not satisfy the. for primary stress urinary incontinence are. patients' discomfort. Few authors [22] have. anterior colporrhaphy [15], vaginal and. recommended combined surgical cure. In this. abdominal retropubic procedures [16-18].. series, all patients in both groups accepted the. Among these methods, the Burch procedure. Burch retropubic colposuspension and. was suggested to be the golden standard. paravaginal repair for correcting genuine stress. repair for genuine stress incontinence [19]. The. incontinence and cystorectocele. Paravaginal. long-term follow-up revealed restorative of. repair and posterior colpoperineorrhaphy. Genuine. stress. incontinence. is. continence in approximately 80% in the. were performed on both groups of patients in. patients [1,20].. order to correct the combined cystorectocele.. With advanced laparoscopic techniques. Eriksen demonstrated that the colposus-. and equipment, the space of Retzius and the. pension procedure might aggravate posterior. surrounding anatomy can be easily dissected. vaginal wall weakness [23]. He also presented. and magnified on a TV monitor. Laparoscopic. that 7% of patients experienced uncomfort-. retropubic urethropexy also affords excellent. able enterocele within 5 years after Burch. vision within the space of Retzius and allows. colposuspension. Stanton also reported that. for easy mobilization of periurethral, paravesi-. the incidence of post-colposuspension ente-. cal tissue and placement of suspension suture.. rocele was as high as 17% [24]. In this series,.

(5) Laparoscopic vs Laparotomic Colposuspension in GSI. 232. the uterovaginal prolapse and as well as to. provides equivalent cure rates with less. prevent the future enterocele, we adopted the. morbidity when compared with laparotomic. modified McCall-Moschowitz culdoplasty and. retropubic colposuspension. However, the. colpopexy in most cases. We belived that the. operative time for laparoscopic Burch method. laparoscopic method also enables the further. was longer than that for the laparotomic. evaluation of the pelvic organs and con-. approach.. comitant operations, as traditional laparotomic approach does. We agreed with other investigators' reports [2,4,21,25-27], that current postoperative. REFERENCES 1.. Burch JC. Urethrovaginal fixation to Cooper's ligament for the correction of stress incontinence,. occurrence of detrusor instability and long-. cystocele, and prolapse. Am J Obstet Gynecol 1961;. term difficulties in voiding were low. In this. 88:281-90.. series, only one case in laparoscopic group. 2. van Geelen JM, Theeuwes AG, Eskes TK, et al. The. had persistent urine retention postoperatively. clinical and urodynamic effects of anterior vaginal repair and Burch colposuspension. Am J Obstet. and required urethral dilation. No patient in the open group had long-term voiding. Gynecol 1988;159:137-44. 3.. difficulty. However, Galloway [27] reported 6. correction of stress incontinence in women. West J Surg Obstet Gynecol 1959;67:223.. of 50 patients (12%) with Burch colposuspension had one or more urethral dilations.. 4. Bergman A, Ballard CA, Koonings PP. Comparison of three different surgical procedures for genuine stress. Colombo did the urethral dilation in only 4 of. incontinence: prospective randomized study. Am J. 457 patients operated with laparotomic retropubic Burch colposuspension.. Obstet Gynecol 1989;160:1102-6. 5.. pension in group 1. We emphasized the twobite bilateral attachment of the anterior. Gillon G, Stanton SL. Long-term follow-up of surgery for urinary incontinence in elderly women. Br J. In this series, we adopted the same procedure as the traditional Burch colposus-. Pereyra AJ. A simplified surgical procedure for the. Urol 1984;56:478-81. 6.. Grout D, O'Conor VJ Jr. Long-term results of suprapubic vesicourethropexy. J Urol 1972;107:610-2.. 7.. Bosman G, Vierhout ME, Huikeshoven FJ. A mod-. vaginal wall to the bilateral Cooper's ligament. ified Raz bladder neck suspension operation. Results. in the laparoscopic approach. The reason for. of a one to three years follow-up investigation. Acta. the poor outcome in other series may be due to inexperienced surgeons or to over. Obstet Gynecol Scand 1993;72:47-9. 8.. simplification of the procedure (only one side. for the treatment of stress incontinence. Br J Urol. colposuspension, or fewer bites when compared with the laparotomic approach). The unilateral suspension may result in poor efficacy of the fixation of the bladder neck.. Mundy AR. A trial comparing the Stamey bladder neck suspension procedure with colposuspension 1983;55:687-90.. 9.. Park GS, Miller EJ Jr. Surgical treatment of stress urinary incontinence: a comparison of the Kelly plication, Marshall-Marchetti-Krantz, and Pereyra procedures. Obstet Gynecol 1988;71:575-9.. Also, it may distort the urethral adapting. The. 10. Kil PJ, Hoekstra JW, van der Meijden AP, et al.. laparoscopic Burch procedure needs careful. Transvaginal ultrasonography and urodynamic. dissection, hemostasis, and suturing [28,29].. evaluation after suspension operation: comparison. Under the well-trained surgeon , a similar cure rate could be achieved. Our data compared contemporary. among the Gittes, Stamey, and Burch suspensions. J Urol 1991;146:132-6. 11. Walker GT, Texter JH Jr. Success and patient satisfaction following the Stamey procedure for. patients undergoing laparotomic and laparo-. genuine stress incontinence. J Urol 1992;147:1521-3.. scopic Burch colposuspension procedures at. 12. Polascik TJ, Moore RG, Rosenberg MT, et al.. one institution. Laparoscopy provided a better. Comparison of laparoscopic and open retropubic. visibility of the operative field, more precise placement of paraurethral sutures and satisfactory hemostatsis. The results also indicated that the laparoscopic approach. urethropexy for treatment of stress urinary incontinence. Urology 1995;45:647-52. 13. Hodgkinson CP. Stress incontinence in the female. Surg Gynecol Obstet 1965;102:595. 14. Zacharin RF. Abdominooerineal urethral suspension.

(6) Wu-Chou Lin, et al.. in the management of recurrent stress incontinence of urine: a 15-year experience. [Review] Obstet Gynecol 1983;62:644-54. 15. Bech PR, McCormick S. Treatment of urinary stress incontinence with anterior colporrhaphy. Obstet Gynecol 1982:59:269-74.. 233. Gynecol 1994;171:647-52. 22. Su TH, Wang KG, Hsu CY, et al. Prospective comparison of laparoscopic and traditional colposuspension in the treatment of genuine stress incontinence. [Review] Acta Obstet Gynecol Scand 1997;76:576-82. 23. Eriksen BC, Hagen B, Eik-Nes SH, et al. Long-term. 16. Pereyra AJ, Lebherz TB, Growdon WA, et al.. effectiveness of the Burch colposuspension in. Pubourethral support in prospective: modified. female urinary stress incontinence. Acta Obstet. Pereyra procedure for urinary incontinence. Obstet Gynecol 1982;59:643-8. 17. Stamey TA. Endoscopic suspension of the vesical neck for urinary incontinence. Surg Gynecol Obstet 1973;136:547-54. 18. Marshall V, Vaughan ED, Parnell JP. Suprapubic vesicourethral suspension (Marshall-Marchetti-. Gynecol Scand 1990;69:45-50. 24. Stanton SL, Williams JE, Ritchie D. The colposuspension operation for urinary incontinence. Br J Obstet Gynaecol 1976;83:890-5. 25. Bhatia NN, Bergman A. Modified Burch versus Pereyra retropubic urethropexy for stress urinary incontinence. Obstet Gynecol 1985;66:255-61.. Krantz) for stress incontinence. In: Walsh PC, Gittes. 26. Colombo M, Milani R, Vitobello D, et al. A. RF, Perlmutter AD, et al, eds. Campell's Urology.. randomized comparison of Burch colposuspension. Philadelphia: WB Saunders 1986:2711-7.. and abdominal paravaginal defect for female stress. 19. Bergman A, Elia G. Three surgical procedures for genuine stress incontinence: five-year follow-up of a prospective randomized study. Am J Obstet Gynecol 1995;173:66-71. 20. National Institutes of Health Consensus Development. urinary incontinence. Am J Obstet Gynecol 1996;175: 78-84. 27. Galloway NT, Davies N, Stephenson TP. The complications of colposuspension. Br J Urol 1987:60: 122-4.. Conference on Urinary Incontinence in Adults.. 28. Ou CS, Presthus J, Beadle E. Laparoscopic bladder. Bethesda, Maryland, October 3-5, 1988. Proceedings. J. neck suspension using hernia mesh and surgical. Am Geriatr Soc 1990;38:263-386. 21. Feyereisl J, Dreher E, Haenggi W, et al. Long-term results after Burch colposuspension. Am J Obstet. staples. J Laparoendosc Surg 1993;3:563-6. 29. Vancaillie TG, Schuessler W. Laparoscopic bladder neck suspension. J Laparoendosc Surg 1991;1:169-73..

(7) 234. 1997. 1998. 70. 35. 35 1 2. 94%. 91%. 2000;5:228-34. Burch. 404 6/19/2000 10/11/2000. 2 8/17/2000.

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