Operative Setup and General Entry into the Retropubic Space

In preparation of this technique, the patient is supine, with the legs supported in a slightly abducted position, allowing the surgeon to operate with one hand in the vagina and the other in the retropubic space. The vagina, perineum, and abdomen are sterilely prepped and draped in a fashion that permits easy access to the lower abdomen and vagina. A three-way 16- or 20-French Foley catheter with a 20- to 30-mL balloon is inserted sterilely into the bladder and kept in the sterile field. The drainage port of the catheter is left to gravity drainage, and the irrigation port is connected to sterile water, with or without blue dye. One perioperative intravenous dose of an appropriate antibiotic should be given as prophylaxis against infection.

A Pfannenstiel or Cherney incision is made. During intraperitoneal surgery, the peritoneum is opened, the surgery is completed, and the cul-de-sac is plicated, if necessary. The retropubic space is then exposed. Staying close to the back of the pubic bone, the surgeon’s hand is introduced into the retropubic space and the bladder and urethra gently moved downward. Sharp dissection is not usually necessary in primary cases. To aid visualization of the bladder, 100 mL sterile water with methylene blue or indigo carmine dye may be instilled into the bladder after the catheter drainage port is clamped.

If previous retropubic or other bladder neck suspension procedures have been performed, dense adhesions from the anterior bladder wall and urethra to the symphysis pubis are often present. These adhesions should be dissected sharply from the pubic bone until the anterior bladder wall, urethra, and vagina are free of adhesions and are mobile. If identification of the urethra or lower border of the bladder is difficult, one may perform a cystotomy, which, with a finger inside the bladder, helps define the bladder’s lower limits for easier dissection, mobilization, and elevation.

Burch Colposuspension

After the retropubic space is entered, the urethra and anterior vaginal wall are depressed. No dissection should be performed in the midline over the urethra or at the urethrovesical junction, thus protecting the delicate musculature of the urethra from surgical trauma. Attention is directed to the tissue on either side of the urethra. The surgeon’s nondominant hand is placed in the vagina, palm facing upward, with the index and middle fingers on each side of the proximal urethra. Most of the overlying fat should be cleared away, using a swab mounted on a curved forceps. This dissection is accomplished with forceful elevation of the surgeon’s vaginal finger until glistening white periurethral fascia and vaginal wall are seen (Fig. 15-1). This area is extremely vascular, with a rich, thin-walled venous plexus that should be avoided, if possible. The position of the urethra and the lower edge of the bladder is determined by palpating the Foley balloon and by partially distending the bladder to define the rounded lower margin of the bladder as it meets the anterior vaginal wall.

Figure 15-1 Dissection of the lateral retropubic space. After forceful elevation of the surgeon’s vaginal finger, the fat overlying the glistening white periurethral fascia is cleared in preparation for suture placement.

Once dissection lateral to the urethra is completed and vaginal mobility is judged to be adequate by using the vaginal fingers to lift the anterior vaginal wall upward and forward, sutures are placed. No. 0 or 1 delayed absorbable or nonabsorbable sutures are placed laterally as far in the anterior vaginal wall as is technically possible. We apply bilaterally two sutures of No. 0 braided polyester on an SH needle (Ethibond; Ethicon, Inc., Somerville, NJ), using double bites for each suture. The distal suture is placed approximately 2 cm lateral to the proximal third of the urethra. The proximal suture is placed approximately 2 cm lateral to the bladder wall at or slightly proximal to the level of the urethrovesical junction. In placing the sutures, one should take a full thickness of vaginal wall, excluding the epithelium, with the needle parallel to the urethra (Fig. 15-2, inset). This maneuver is best accomplished by suturing over the surgeon’s vaginal finger at the appropriate selected sites. On each side, after the two sutures are placed, they are passed through the pectineal (Cooper’s) ligament so that all four suture ends exit above the ligament (Fig. 15-2). Before the sutures are tied, a 1 × 4 cm strip of Gelfoam may be placed between the vagina and obturator fascia below Cooper’s ligament to aid adherence and hemostasis.

Figure 15-2 Technique of Burch colposuspension. After the two sutures are placed on each side, they are passed through the pectineal (Cooper’s) ligament, so that all four suture ends exit above the ligament to facilitate knot tying. In placing the sutures (inset), one should take a full thickness of vaginal wall, excluding the epithelium, with the needle parallel to the urethra. This maneuver is best achieved by suturing over the vaginal finger.

As noted previously, this area is extremely vascular, and visible vessels should be avoided if possible. When excessive bleeding occurs, it can be controlled by direct pressure, sutures, or vascular clips. Less severe bleeding usually stops with direct pressure and after tying the fixation sutures.

After all four sutures are placed in the vagina and through the Cooper’s ligaments, the assistant first ties the distal sutures and then the proximal ones, while the surgeon elevates the vagina with the vaginal hand. In tying the sutures, one does not have to be concerned about whether the vaginal wall meets Cooper’s ligament, so one should not place too much tension on the vaginal wall. A suture bridge is usually found between the two points. After the sutures are tied, one can easily insert two fingers between the pubic bone and the urethra, thus preventing compression of the urethra against the pubic bone. Vaginal fixation and urethral support depend more on fibrosis and scarring of periurethral and vaginal tissues over the obturator internus and levator fascia than on the suture material itself.

Paravaginal Defect Repair

The object of the paravaginal defect repair is to reattach, bilaterally, the anterolateral vaginal sulcus with its overlying endopelvic fascia to the pubococcygeus and obturator internus muscles and fascia at the level of the arcus tendineus fasciae pelvis. The retropubic space is entered, and the bladder and vagina are depressed and pulled medially to allow visualization of the lateral retropubic space, including the obturator internus and levator muscles and the fossa containing the obturator neurovascular bundle. Blunt dissection can be carried dorsally from this point until the ischial spine is palpated. The arcus tendineus fasciae pelvis is often visualized as a white band of tissue running over the pubococcygeus and obturator internus muscles from the back of the lower edge of the symphysis pubis toward the ischial spine. A lateral paravaginal defect representing avulsion of the vagina off the arcus tendineus fasciae pelvis or of the arcus tendineus fasciae pelvis off the obturator internus muscle may be visualized (Fig. 15-3).

Figure 15-3 Lateral paravaginal defect and technique of paravaginal defect repair. Five or six sutures are placed (inset), first through the full thickness of the vagina (excluding the vaginal epithelium), and then into the obturator internus fascia or arcus tendineus fasciae pelvis, 3 to 4 cm below the obturator fossa.

The surgeon’s nondominant hand is inserted into the vagina. While gently retracting medially the vagina and bladder, the surgeon elevates the anterolateral vaginal sulcus. Starting near the vaginal apex, a suture is placed, first through the full thickness of the vagina (excluding the vaginal epithelium) and then deep into the obturator internus fascia or arcus tendineus fasciae pelvis, 1 to 2 cm anterior to its origin at the ischial spine. After this first stitch is tied, additional (four or five) sutures are placed through the vaginal wall and overlying fascia and then into the obturator internus at about 1-cm intervals toward the pubic ramus (Fig. 15-3, inset). The most distal sutures should be placed as close as possible to the pubic ramus, into the pubourethral ligament; alternatively, Burch colposuspension sutures can be placed bilaterally at the level of the bladder neck and urethra if the patient has SUI. No. 2-0 or 0 nonabsorbable suture on a medium-sized, tapered needle is usually used for the paravaginal repair.

This procedure leaves free space between the symphysis pubis and the proximal urethra but secures support so that rotational descent of the proximal urethra and bladder base is prevented with sudden increases in intra-abdominal pressure. According to Turner-Warwick (1986), the procedure avoids overcorrection and fixation of the periurethral fascia, which might compromise the functional movements of the urethra and bladder base and lead to obstruction and voiding difficulty. This principle may explain why the paravaginal defect repair usually results in spontaneous voiding on the first or second postoperative day. In fact, the vaginal obturator shelf repair has been used to correct patients with dysfunctional voiding symptoms after previous retropubic surgery.

General Intraoperative and Postoperative Procedures

If the surgeon is concerned that intravesical suture placement or ureteral obstruction may have occurred, cystoscopy—either transurethrally or through the dome of the bladder—or cystotomy may be performed to document ureteral patency and absence of intravesical sutures after retropubic procedures.

Closed suction drains in the retropubic space are used only as necessary when hemostasis is incomplete and there is concern about postoperative hematoma. The bladder is routinely drained with a suprapubic or transurethral catheter for 1 to 2 days. After that time, the patient is allowed to begin voiding trials, and postvoid residual urine volumes are checked, either with the suprapubic catheter or by intermittent self-catheterization.