Journal Of Laparoendoscopic Surgery
Volume 4, Number 5, 1994
Mary Ann Liebert, Inc., Publishers
A Laparoscopic-Assisted
Extraperitoneal Bladder Neck Suspension: An Initial Experience
E.D. RIZA, M.D.(1) and A.S. DESHMUKH, M.D.(2)
ABSTRACT
A new procedure
is described for the correction of stress urinary incontinence caused
by hypermobility of the urethrovesocal junction using an extraperitoneal
laparoscopic approach with the use of a new needle. There has been
no previous publication of this approach. The initial study show that
this procedure offers technical advantages over existing procedures
and requires short hospitalization, less use of postoperative pain
medication, and early recovery. We hope to report a long-term follow-up
in the future.
INTRODUCTION
THERE ARE
MANY ANTIINCONTINENCE PROCEDURES described in the literature. Some
procedures require an open suprapubic incision, as in the Marshall-Marchetti
suspension (1) or the Burch Procedure.(2) Some procedures are done
with a vaginal incision, (3,4) and one is done without such an incision.(5)
A laparoscopic extraperitoneal approach has been used to perform a
modification of an open Marshall-Marchetti procedure.(6,7)
Needle Suspensions of the bladder neck have been established as a
satisfactory way of dealing with female stress urinary incontinence
resulting from hypermobility of the urethrovesical junction. All of
these procedures involve blind passage of a needle from the suprapubic
area to the vagina. Cytoscopic monitoring excludes passage of the
needle through the bladder or the urethra and judges the proximity
of the needle pass to the area that needs the support.
A new method using a laparoscope by the extraperitoneal route to actually
visualize a needle pass made from the suprapubic area to the vagina
and the use of the Riza-Ribe needle (R-Med Inc., Oregon, Ohio) with
a loop to easily retrieve a suture is described (Fig. 1).
MATERIALS
AND METHODS
Any patient with
stress urinary incontinence caused by hypermobility of the urethrovesical
junction is a candidate for this procedure. Preoperative evaluation
consists of a history and physical examination, with demonstration
of stress urinary incontinence with hypermobility of the urethrovesical
junction and detection of medial or lateral defects because of cystocele
or prolapse. A cystometrogram is performed to rule out a neurogenic
or unstable bladder, and a cystoscopy is done to rule out any problems
that may contraindicate the procedure.
(1) Department
of Gynecology and (2) Department of Urology, St. Charles Hospital,
Oregon, Ohio.
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RIZA
AND DESHMUKH
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A
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B
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Cephalosporin
is given intravenously in the preoperative and the perioperative period.
Under a general anesthetic, the patient is placed in a modified lithotomy
position with the legs on the Allan stirrups, allowing access to the
perineum and the suprapubic area. A Foley catheter is inserted into
the bladder.
A 15-mm midline incision is made in the suprapubic area about 2 inches
above the pubic symphysis. Open laparoscopic technique is used. Through
the incision, a finger dissection is performed toward the pubic symphysis,
and a Hassan trocar is inserted and secured. At this time, over a
finger in the retropubic space, an incision is made on the right and/or
left for a 5-mm trocar 1 inch above the pubic symphsis and 2 inches
lateral to the midline. The retropubic space is insufflated with CO2
at a pressure of 10-13 mm Hg. In our experience, one port usually
is adequate. (Fig. 2).
RESULTS
Twenty-two
patients were evaluated clinically for urinary incontinence from September
1993 to February 1994. Of these pateints, 19 underwent urologic evaluation,
and 15 were judged to be suitable canidates for
Fig. 2. A.
A schematic illustration of abdominal trocar placement sites; suprapubic
incision; and positions of gynecologist, urologist, and assistant.
A. suprapubic incision. B1. 5-mm port for right-handed
surgeon. B2. 5-mm port for left-handed surgeon. C.
12-mm port. D. Umbilicus.
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EXTRAPERITONEAL
BLADDER NECK SUSPENSION
Fig.
3. Initail view of Space of Retzius.
surgery. Thirteen
of these underwent the suspension procedure by the method described.
The other 2 patients underwent an LAVH and so were not considered
suitable for this procedure. Of these patients who underwent this
procedure, 4 had previous TAH, 1 had alaparotomy. 1 had TAH and a
failed MMK procedure, 1 had LAVH, 3 had tubal ligation, and 1 had
a cardiac transplantation.
The initial operating time was 85-110 min. The last 8 procedures took
47-62 min, indicating a short learning curve. Five patients were treated
as outpatients, and the rest were treated on a 23 h observational
status.
The first office visit was 2-6 days postoperatively. At the initial
visit, 4 patients had less than 50 mL residual urine, 1 had 125 mL
residual urine, 6 had more than 125 mL residual urine when a catheter
was placed for 4 more days, and 2 had retention. The longest duration
for the residual urine to drop below 100 mL was 12 days.
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Fig.
4. Space of Retzius after complete dissection.
+, points of suture passes.
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RIZA
AND DESHMUKH
Three weeks
after surgery, all patients were continent and had less than 5 mL
of residual urine, except 1 pateint who needed to take urecholine
for 3 weeks. All the patients returned to work after 3 weeks.
DISCUSSION
The ability
of the surgeon to visualize the needle pass on the videomonitor enables
hom or her to judge the effectiveness of the suspending suture. the
new needle is smaller than the needles available in the market. The
retractable loop makes it easy to grasp the suture. The suture makes
a good loop, suspending the urethra rather than making it adhere to
the pubic periosteum, which avoids scarring around the urethra. Also,
the technical difficulty of anchoring sutures to the periosteum or
cooper's ligament is avoided.
Previous incisions in the area do not contrindicate the procedure.
If the peritoneum is opened inadvertently, a pursestring suture or
an endoloop can be used to close it, and the procedure can continue.
A needle holder or a bipolar cautery forceps through the 5-mm port
is used to complete the dissection around the bladder neck and the
urethra to define the area for passage of a needle. The bleeding points
can be secured with a bipolar cautery (Figs. 3, 4).
A weighted speculum is inserted into the vagina, and the labia are
sutured laterally. A zero Prolene suture is passed through the vaginal
mucosa in a helical manner starting well above the bladder neck and
going toward the midurethra (Fig. 5). At this stage, a small suprpubic
incision is made just above the pubic crest, and dissection is performed
down the fascia. A newly constructed RR needle is used. It is a small-bore
needle with a plunger. Pushing the plunger makes a retractable loop
of wire appear in the vagina to help grasp a suture. The first pass
of the needle is made 0.5 cm lateral to the bladder neck. The second
pass is made 1 cm lateral and caudal to the first pass. (Fig. 6).
The loop of the needle in the vagina grasps the suture ends that were
used previously to plicate the vaginal mucosa and pull it into the
suprapubic wound (Fig. 7).
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Fig.
5. Placement of helical sutures with 0
Prolene.
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EXTRAPERITONEAL
BLADDER NECK SUSPENSION
Fig.
6.View after two proximal and one caudal
sutures were retrieved. Left caudal suture retrieved with Riza-Ribe
Needle.
The adequacy
and accuracy of placement of the sutures are provided by visualization
of the passage of the needle on the screen and endoscopic evaluation.
When the placement of the sutures is deemed to be satisfactory, they
are tied suprapubically. Simultaneously, the bladder neck is evaluated
by cystoscopy for satisfactory occlusion.
The vagina and the retropubic space are thoroughly irrigated with
an antibiotic solution throughout the procedure. The fascia in the
large trocar wound is closed with one suture of 0 PDS. The rest of
the wounds are
Fig.
7. Sutures retrieved with Riza-Ribe Needle.
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RIZA
AND DESHMUKH
closed with
subcutaneous and subcuticular sutures. The use of a drain through
the 5-mm incision is an option in case of excess bleeding in the retropubic
space.
The patient is discharged the same evening or the next morning with
an indwelling catheter. She is kept on an oral cephalosporin and is
examined on the fourth postoperative day after removal of the catheter.
A follow-up examination consists of wound inspection and a determination
of residual urine. A urine culture is obtained id deemed necessary.
A pelvic examination is performed to check for any bleeding and to
check for an enterocle.
ACKNOWLEDGEMENT
The authors would like
to thank Ms. Ann Smolenski for her art work.
REFERENCES
- Marshall
V, Marchetti A, Krantz K: Correction of stress incontinence by
simple vesicourethral suspension. Surg Gynecol Obstet 1949:88:509-513.
- Burch C:
Urethrovaginal fixation to Cooper's ligament for correction of
stress incontinence, cystocele, and prolapse. Am J Obstet Gynecol
1961:81:281-290.
- Pereyra
AJ: A simplified surgical procedure for the correction of stress
incontinence in women. West J Surg Obstet Gynecol 1959:67:223-228.
- Stamey TA:
Endoscopic suspension of the vesical neck for urinary incontinence.
Surg Gynecol Obstet 1973:136:547-554.
- Gittes RF,
Loughlin KR: No incision pubovaginal suspension for stress incontinence.
J Urol 1987;138:568-570.
- Vancaille
T: Laparoscopic bladder neck suspension. J Laparo Endos Surg 1991;1:169.
- Raboy A,
Albert P: Extraperitoneal endoscopic vesicourethral suspension.
Curr Surg Tech Urol. 1993;6:227.
ADDENDUM
Since acceptance
of this manuscript for publication, the authors has performed seven
more laparoscopy-assisted extraperitoneal bladder neck suspensions
without a complication.
Address
reprint requests to:
Erol D. Riza, M.D.
3465 Navarre Ave.
Oregon, OH 43616 |
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