Burch retropubic urethropexy and paravaginal repair - Indications and Complications

Indications Burch retropubic cystourethropexy 1. Stress urinary incontinence A. Cough or valsalva and observed leak of urine from urethra B. urethrovesical neck descensus–greater than 45 deg at rest or change of >= 30 degrees change with strain Paravaginal repair 1. Symptoms of prolapse and: A.   Presence of a cystocele within 1 cm of the hymen or beyond (Stage 2 POPQ or greater) with unilateral or bilateral vaginal wall collapse B.	Presence of a paravaginal defect at time of surgery Criteria for successful procedure 1.   Intrinsic sphincter deficiency has been ruled out if previous surgery, trauma, radiation near urethra 2.	Switch or discontinue medicines that affect internal urethral sphincter (alpha one blockers) if possible 3.	Switch medicines that affect external urethral sphincter (benzodiazepines, skeletal muscle relaxants) if possible 4.	Diagnose and treat any associated urge incontinence prior to surgery 5.	Diagnose and treat any associated excessive bladder capacity (>800 ccs) or excessive residual urine (>300ccs)  prior to surgery 6.	Rule out or treat any urinary tract infection prior to surgery 7.	Set reasonable post op expectations (decreased leakage, not absolutely dry) 8.	Set reasonable post op expectations (decreased protrusion of tissue, not necessarily decreased vaginal pressure) 9.	Teach diaphragmatic cough, lift and strain Complications 1. Continued bothersome incontinence 2.  Urinary  urgency 3.  Obstructed voiding 4.  Ureter injury 5.  Bladder injury 6.  Bladder suture 7.  Bleeding 8.  Suture in vagina (suture erosion) 9.  Nerve injury 10. Dyspareunia 11. Pelvic Pain Complication Prevention 1. Continued stress incontinence A. Place stitches at least 1.5-2 cm lateral to urethrovesical neck B. Preoperative urethral pressure profile of Closure Pressure >20-30cm H20 or valsalva leak point pressure >60 cm H20 2. Irritative voiding and urgency A. Determine pre operative assessment of any urge component B. Retract bladder and bladder neck for adequate visualization C. Place stitches at least 1.5-2 cm lateral to urethrovesical neck 3. Obstructed voiding A.	Leave gap of 2-3 cm between vagina and Cooper’s ligament to ensure the hammock effect is not too tight. 4. Ureter injury A. Keep stitches lateral on paravaginal surgery to prevent injury or kinking of the ureter insertion to the trigone 5. Bladder Injury A.	Use gentle retropubic dissection B.	Retract bladder and bladder neck for adequate visualization C.	Cystoscopy to diagnose any immediate bladder injury or suture in bladder. D.	If laparoscopic procedure, retrograde fill the bladder with approximately 300-400 ml of sterile water or saline to define bladder margins prior to dissection of the retropubic space. 6. Bladder Suture A.	Retract bladder and bladder neck for adequate visualization B.  Place suture in white,  shiny pubovesicocervical fascia C.   Use upward digital pressure through the vagina pushing the bladder and urethra medially while feeling the suture being placed with the vaginal hand. D. Cystoscopy (consider 70 degree lens with cystoscope)

7. Bleeding A.	Discontinue ASA, Plavix and other anti-clotting meds prior to surgery. B. C.	Gentle retropubic dissection D.	Dissect in paramedian paraurethral area to expose pubovesical cervical fascia by moving tissue medially toward urethra and laterally toward paravaginal veins E.	Avoid dissection in the midline immediately above the urethra F.	Avoid stuttering and stammering with the needle G.   When 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 H.. Clearly identify and avoid any dissection or stretching of the obturator neurovascular bundle I.  Surgical clips are often helpful for bleeding close to the obturator neurovascular bundle J.  If laparoscopic procedure, use the inferior epigastric arteries as your lateral most landmarks for dissection 8. Suture in vagina -   Keep anterior pressure with hand in vagina when placing paravaginal or Burch sutures 9. Nerve injury -   Visualize and identify obturator vessels/nerve when placing paravaginal repair stitches