Checklist for Burch retropubic urethropexy and paravaginal repair

Paravaginal defect repair & Burch retropubic cystourethropexy Pt. Name: _________________________

Birthdate: _________________________

Preoperative Checklist    (Please indicate    - Done,   X - Not done,   NA – Not applicable)

1. ___Preoperative urethral pressure profile of closure pressure >20cm H2O or leak point >60cm H2O (prevent continued SUI) if a history of previous radiation rx, surgery or trauma near urethra/bladder 2. ___Diagnose and treat urge component of mixed incontinence prior to surgery (prevent continued UI) 3. ___Diagnose and treat overflow incontinence or excessive bladder capacity prior to surgery (prevent continued UI or voiding dysfunction) 4. ___Discontinue/change medicines that affect internal sphincter (alpha one blockers) (prevent continued SUI) 5. ___Discontinue/change medicines that affect external urethral sphincter (benzodiazepines, smooth muscle relaxants) (prevent continued SUI) 6. ___Rule out or treat any urinary tract infection prior to surgery (prevent continued UI) (prevent post op irritative voiding) 7. ___Set reasonable post op expectations (decreased leakage, not absolutely dry) (prevent unrealistic expectations) 8. ___Set reasonable post op expectations (decreased bulge of tissue, not necessarily vaginal pressure) (prevent unrealistic expectations) 9. ___Teach Valsalva avoidance using diaphragmatic cough, lift and strain with exhale prior to surgery (prevent continued SUI or suture tear out) 10.___Sign consent for above complications including continuing stress incontinence, irritative voiding and urgency, obstructive voiding, ureter injury, bladder injury, bladder                                                                                                suture, bleeding  requiring transfusion, suture in vagina (stitch erosion), nerve injury, further surgery to repair any of above (prevent unrealistic expectations) 11.___ Discontinue ASA, Plavix and other anti-clotting meds prior to surgery Intraoperative Checklist 12.___Use Allen (Yellow fin) stirrups with weight resting on heel and toe, heel, knee, opposite shoulder if using lithotomy position (prevent nerve injury) 13.___Use gentle, blunt retropubic  dissection if no history of previous surgery (avoid excessive bleeding) 14.___Dissect in paramedian paraurethral area to expose pubovesicocervical fascia by moving tissue          medially toward urethra and laterally toward paravaginal veins (avoid excessive bleeding) 15.___Avoid stuttering and stammering with the needle (avoid excessive bleeding) 16.___If bleeding occurs, increase anterior pressure with vaginal hand or hold untied suture  tight. Initially don’t place more suture; place retropubic packing against veins/vagina 5 minutes via clock (avoid excessive bleeding) 17.___Avoid any dissection over obturator bundle (avoid excessive bleeding) (prevent nerve injury) 18.___Retract bladder and bladder neck (use 30cc foley bulb for adequate visualization (prevent bladder injury) (prevent sutures in bladder) 19.___Visualize and identify obturator vessels/nerve prior to placing paravaginal repair stitches (prevent nerve injury) 20.___Place suture in white, shiny pubovesicocervical fascia (prevent sutures in bladder) 21.___Keep anterior pressure with hand in vagina when placing paravaginal or Burch sutures (prevent suture erosion into vagina) 22.___Keep stitches lateral (>=4cm from midline) on paravaginal surgery (prevent injury or kinking of the ureter insertion to the trigone) 23.___Place Burch stitches at least 1.5-2 cm lateral to urethrovesical neck (prevent urethral obstruction) 24.___Leave gap of 2-3 cm between vagina and Cooper’s ligament on Burch stitches to ensure the hammock effect is not too tight 25.___Perform cystoscopy (consider 70 degree scope to evaluate for bladder sutures and to evaluate for ureteral patency after a Burch procedure) (prevent undiagnosed bladder injury or undiagnosed ureteral injury) Signature: ___________________¬¬¬¬______ Attending:_____________________ Date:______ Global Evaluation: |Initial learning|       |Needs work|       |Progressing|      |Good for level|        |OK on own|