Laparoscopic Surgical Treatment for Stress Urinary
Urinary incontinence is the involuntary loss of urine to the degree
that is socially and hygienically unacceptable to the patient. The
amount of leakage, which varies from a few drops to a large gush,
usually increases with age. However, urinary incontinence is not
a normal consequence of aging. There are several different types
of urinary incontinence:
Genuine stress incontinence is leakage resulting from any type
of straining (coughing, laughing, sneezing, or lifting) that puts
pressure on the bladder.
Urge incontinence is leakage from an overactive bladder. which
cannot be suppressed and controlled.
Mixed incontinence is a combination of genuine stress and urge
Overflow incontinence is leakage occurring with overdistention
of the bladder, this usually results from partial obstruction of
the urethra, thereby causing a constant dripping of urine.
Treatment for urinary incontinence varies depending on the type
of incontinence. The first step in treatment is accurate diagnosis.
This consists of the patient's medical and urological history, physical
and pelvic examination, and some simple office tests, such as post
void residual urine (the amount of urine left in the bladder after
voiding), Q-tip test (this tells us how mobile the urethra is, and
if there is an anatomic component to the incontinence). Additional
tests may be necessary in more complicated cases. These may include
multichannel urodynamic studies, which test the dynamics of various
phases of bladder function, including bladder's filling, storage,
and empting phases, plus nerve conduction . A cystoscopic examination
may also be necessary if patient exhibit any bladder irritability
Conservative therapy may involve hormonal replacement, medication,
pelvic floor exercises, bladder retraining, and life style modification
such as weight reduction or avoidance of foods that irritate the
bladder. Other options include the use of a urethral plug or vaginal
pessary. Surgical treatment is only effective with genuine stress
urinary incontinence, in which the urethra becomes either hypermobile
and unstable or its intrinsic sphincter becomes incompetent, resulting
in urine leakage with physical stress. The goal of surgery is to
stabilize the hypermobile urethra and restore the competence of
urethral sphincter. Over 200 different anti-incontinence surgical
procedures have been reported in the literatures, the vast majority
of them have poor long term results. Recently there seems to be
a consensus, especially among gynecologists and urogynecologists,
that retropubic colposuspension (Burch procedure) is the surgical
choice for incontinent patients with hypermobile urethra and suburethral
sling procedure for patients with urethral sphincteric deficiency.
With advanced technologic development in laparoscopic and video
equipment and the improved skill in performing operative laparoscopy,
we have no difficulty in performing the Burch and suburethral sling
procedures laparoscopically for our patients suffering from genuine
stress urinary incontinence.
Advantages of Laparoscopic Surgery for Urinary Incontinence
The laparoscope is a small telescope-like instrument (one half
to one centimeter in diameter) inserted into the abdominal cavity
through a tiny incision inside the navel. A bright light directly
shines onto the operative field through the laparoscope, and with
a very sophisticated video camera , the operative field can be greatly
magnified onto the high resolution video monitor. This allows the
surgeon to view the operative field in superb detail. With such
visibility, the surgeon can then perform accurate tissue dissection
in their right planes, thus greatly reducing blood loss, place sutures
precisely, approximate tissues without undue tension, avoid damaging
the blood vessels and achieve perfect hemostasis. In minimally invasive
surgery with a laparoscope, a large abdominal incision can be avoided,
blood loss minimized, tissue handled very gently, and disruption
to the surrounding abdominal and pelvic organs greatly reduced.
The patient typically experiences much less discomfort and pain
postoperatively, has quicker recovery and shorter hospital stay.
I have been performing laparoscopic surgery for urinary incontinence
for the past 10 years, and more than 90% of my patients go home
within the first 23 hours of surgery (versus an average of 3-5 days
with traditional open surgery). All my patients are allowed to drive
in one week and return to work within 2 weeks after surgery, providing
their jobs do not require much physical exertion. Our long-term
outcome of the surgery (more than 5 years follow up) are equal to,
if not better than, the results of traditional open surgery.
Laparoscopic Burch Procedure (Retropubic Bladder Neck Suspension)
The first report for retropubic bladder suspension for the treatment
of urinary incontinence was in 1949 by Drs. Marshall, Marchetti,
and Krantz. In 1961, Dr. John Burch of Nashville, modified the Marshall
Marchetti-Krantz procedure to avoid complication, and to improve
the surgical outcomes. In 1976, Dr. Emil Tanago of San Francisco
proposed some modifications to the Burch procedure, which proved
to be very effective in correcting stress urinary incontinence caused
by hypermobility of the urethra. This surgical technique has become
the gold standard for surgeons performing the Burch procedure. In
1991, I performed the first laparoscopic Burch bladder neck suspension
by using Tanago technique. With a bright fiberoptic light directly
shining on the retropubic space and the magnification provided by
video laparoscopy, I was able to view the anatomy in great detail
and to perform delicate tissue dissection with minimal blood loss.
I was able to place sutures in a precise manner and to resuspend
the bladder neck without undue tension. The patient's postoperative
recovery was beyond our expectations. (My first patient went home
within 24 hours of surgery!). Since 1991, I have performed more
than 600 cases of laparoscopic Burch bladder neck suspension with
excellent long-term results. In summary, laparoscopic Burch procedure
is quick, almost bloodless, and very effective. Compared to the
traditional open Burch procedure, the patient has no large abdominal
scar, has much less postoperative discomfort and pain, and shorter
hospitalization and recovery period.
Laparoscopic Suburethral Sling Procedure
The suburethral sling procedure is the surgical treatment of choice
for severe stress urinary incontinence caused by incompetence of
the internal sphincter of urethra. In such cases, the internal sphincter
of the urethra is incompetent, and is open, with small amounts of
urine retained in the proximal part of the urethra drives the entire
urethra open during physical stress, thereby causing leakage. The
Burch bladder neck suspension is ineffective in treating this type
of incontinence; however, the suburethral sling has more than 90%
cure rate for this type of incontinence. The suburethral sling procedure
places the center of the graft underneath the bladder neck and anchors
both ends of the sling to the anterior abdominal wall or to the
Cooper's ligament (a strong tissue located just above the pubic
bone in the pelvis). The sling graft works as a block to close the
bladder neck during increases in intraabdominal pressure caused
by physical stress. There are basically two types of graft materials
available for the sling; organic and synthetic materials. Because
synthetic graft materials have high a incidence of infection, erosion,
and rejection by the body, we prefer using organic graft either
obtained from the patient's own body(autologous graft) or from cadavera
source (heterologus graft). I perform the laparoscopic suburethral
sling procedure first by obtaining a strip of fascia (a very strong
and tough tissue just on top of the muscle) from patient's thigh
if the patient is not frail and has good fascia. This does not cause
much discomfort to the patient, but it does leave a small scar about
half inch long on the lateral side of thigh just above the knee.
If the patient is old and frail, I will use treated cadavera fascia
which is expensive but almost as good as patient's own fascia. The
fascia graft is placed into the retropubic space through the laparoscope
after the retropubic space is dissected out laparoscopically. A
small incision about an half inch then is made over the bladder
neck on the anterior vaginal wall. A long clamp with a sharp end
is then put into the retropubic space on one side of the bladder
neck through the vaginal incision. Grasping one end of the sling
graft and pulling it into the vagina by the clamp, and then with
the sling at the tip of the clamp, the clamp is again placed back
into the retropubic space vaginally on the other side of the bladder
neck. Both ends of the sling graft then are sutured to the Cooper's
ligament laparoscopically, and the vaginal incision is closed with
few stitches. Unlike the traditional suburethral sling procedure
which practically is performed blindly except by the tactile feelings
of the surgeon to guide the placement of the sling. The laparoscopic
suburethral sling procedure is carried out entirely under the direct
visualization of the operative field. The sling graft can be placed
with precision. Furthermore, a complete hemostasis can also be achieved
in laparoscopic approach to the suburethral sling. We have been
using laparoscopic suburethral sling procedures for our patients
who suffer from severe urinary incontinence due to incompetent urethral
sphincter for the past 6 years with very satisfactory results.
Dr. Liu is the pioneer who introduced the "Laparoscopic Burch Bladder
Neck Suspension" and "Laparoscopic Suburethral Sling Procedure".
The center has the largest series of laparoscopic Burch procedure
and laparoscopic suburethral sling procedure by a single surgeon
in the world.
Frequently Asked Questions
Can Surgery Be Used To Treat Urinary Incontinence?
Urinary incontinence never jeopardizes a woman's physical health,
but it does play havoc with a woman's ability to live and enjoy
her life. For those women who had tried medications and exercise
for relief of incontinence but still are plauged by bothersome symptoms
(socially embarrassing and hygienically unacceptable to her). For
those women, surgery may restore a sense of basic good health and
quality of life and free them of worry and wetness.
As we mentioned in our introductory section that there are basically
four different types of urinary incontinences: Stress Urinary Incontinence,
Urge Urinary Incontinence, Mixed Urinary Incontinence, and Overflow
Urinary Incontinence. Surgery is most effective when stress incontinence
is a major component of the incontinence, and it may help if some
urgency accompanies stress incontinence. It is not likely to be
effective for pure urgency or urge incontinence.
The goal of the surgery for the treatment of incontinence is to
restore the bladder and urethra to their normal position or provide
a sling compression of the bladder neck during stressful events.
What is the recovery like after a laparoscopic surgery for urinary
Most women can go home within 23 hours of the surgery. Since the
incisions are small, there is minimal pain, and you can be up and
walk the next day of surgery. Since the supporting tissue for the
bladder is involved during the surgery, a suprapubic urinary catheter
(a tiny catheter put into the bladder suprapubically) is routinely
used for draining the bladder for the first few days of surgery.
The suprapubic catheter usually removed within the first 2-3 days
after the laparoscopic Burch procedure and 5-6 days for laparoscopic
suburethral sling procedure. You can be back to most normal activities
within 7-10 days. However, as with all bladder operations, you will
need to allow the sutures to heal and fibrosis (scarring) to firm
up so that the repair work will hold. This healing process in our
body takes about 3 months to complete, so no strenuous physical
activities during that time.
What is TVT? What is PVT?
The Tension Free Vaginal Tape or TVT is a new procedure first developed
in Sweden in 1995. This procedure is similar to the sling in principle
it forms a hammock under the middle portion of urethra that bolsters
it and stop the urine leakage when patient is under physical stress.
Percutaneous Vaginal Tape is recently approved by FDA for the treatment
of stress urinary incontinence. TVT and PVT are two new procedural
choices for placement of synthetic sling material at the mid-urethra
for the treatment of stress urinary incontinence. Both procedures
use sling material composed of polypropylene mesh, a nonabsorbable
synthetic material, placed at the level of the mid-urethra via an
ategrade (PVT, using a percutaneous ligature carrier) suprapubic
approach or retrograde (TVT, using vainal trocars) vaginal approach.
TVT has been performed widely over the Europe and United States
with good results. The success rate is about 85 to 90% after 3 years
which is comparable to Burch procedure. Surgery takes average about
45 minutes to one hour and may be performed under local or epidural
anesthesia. Most women can leave the hospital within 23 hours of
the surgery. Patient can usually urinate without problems immediately
A thin strip of Prolene (a synthetic material) tape is used to
form a hammock under the middle portion of urethra. Like the sling,
the procedure is performed through a small (2 cm) incision in the
vagina at the level of mid-urethra. A loose hammock is made beneath
the urethra, and the ends of the hammock are pulled up through two
very small incisions made side by side in the skin just above the
pubic bone. The tape is carried up to the abdominal wall with an
instrument that avoids the need for surgeon to make a tunnel. The
tape is placed properly below the mid-urethra, the extra material
is trimmed, and the incisions on the skin 's surface are closed.
PVT reverse the procedure of TVT by putting ligature carriers from
suprapubic region down toward the mid-urethra.
The synthetic material ( polypropylene or Prolene) for the tape
is well known to produce extensive scarring and fibrosis in human
body, what kind of adverse effect will be on the neurovascular system
around the urethra is yet to be determined. The TVT procedure is
new, long-term outcomes and risks are still unknown. The major complications
of TVT includes bowel and large vessel injury, bladder perforation,
retropubic hematomas. TVT should not be performed on patients who
have previous low abdominal or pelvic surgery due to higher rate
of complication among those patients.
What is an anterior vaginal repair?
An anterior vaginal repair, or cystocele repair, is one of the
older surgery developed to support the bladder and urethra to prevent
incontinence. The anterior vaginal repair is performed through a
vaginal incision just under the bladder and urethra and uses absorbable
sutures to plicate the strong vaginal tissue for support. This pushes
and elevate the bladder and urethra back closer to their original
positions. Unfortunately, this operation does not work very well
for incontinence, with only37% of women having long-term cures (5
years). Many gynecologists in the United States are still suing
this operation for correct the cystocele and incontinence even though
it is no longer considered as an effective treatment for cystocele
What is a Needle Bladder Neck Suspension?
There are various techniques of Needle suspensions described for
the treatment of stress Urinary incontinence that include Pereyra,
Stamey, Raz, and Gettis procedures. However, the basic surgical
techniques are the same except some minor modifications. Essentially,
a small vaginal incision is made around the urethra exposing the
supporting tissues of the urethra. Through this vaginal incision,
non-absorbable stitches are placed in the supporting tissue next
to the bladder neck and proximal part of urethra. The end of these
long sutures are then threaded through the end of a long, narrow
instrument and pulled back through a small (2 cm) incision over
the pubic bone. The sutures are then tied to the layer of strong
fascia on top of the abdominal muscles.
Where the Burch procedure attaches the urethra to an immovable
pubic ligament, the vaginal needle suspension operation attach the
urethra to connective tissue and muscles that move when you move
and, therefore, can stretch or break the sutures. This stretching
and breaking sutures probably account for the high failure rate
of these operations (with cure rates in less than 45% after 5 years).
Can surgery be used to treat Mixed Urinary Incontinence?
Mixed urinary incontinence means the patient has both stress and
urge incontinence. There are several issues patient needs to understand
before agreeing to surgery. Surgery can put the urethra and bladder
back where they belong, but this may only cure the stress component
of the incontinence. However, the symptoms of urgency may continue
and causes incontinence and wetness. To completely address mixed
incontinence, surgery can be combined with proper diet, pelvic muscle
exercise, and medications.
Some women with prolapse have both stress and urge incontinence.
Fixing the prolapse will cure both in 2/3 of these women. This is
especially likely if the urge incontinence only developed after
the prolapse developed. The other 1/3 will still require medication
to quiet down the urinary urgency.