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Urethral Sling & Artificial Urinary Sphincter

Urethropexy is a general term for the surgical procedures done to correct urinary incontinence by both supporting and stabilizing the urethra and bladder. There are various types of retropubic suspension surgeries available to manage stress incontinence.

The two primary surgical treatment methods to treat stress incontinence include:

• The Burch Procedure also called Burch colposuspension or retropubic urethropexy
• Marshall-Marchetti-Krantz (MMK) Procedure

These two procedures differ in the type of structures used to support the urethra and the bladder.

In the Burch procedure, the urethra and bladder are attached to muscle tissue in the pelvic area using sutures, whereas, in MMK, the urethra is sutured to the pelvic cartilage.

In both procedures, the parts of the pelvic region (pubic bone or ligaments) act as an anchor to attach the urethra for stability.

This surgery is known as suspension surgery as it suspends the urethra against a part of the pelvic region in order to stabilize it. Retropubic suspension surgery may also be performed using the laparoscopic technique with smaller incisions made in the lower abdomen.

The main indication for these procedures is the correction of stress urinary incontinence. Normally, a person is able to control the discharge of urine from the urethra through sphincter muscle activity. These are two sets of muscles that act in coordination to keep the bladder opening closed until you decide to pass urine. The intrinsic sphincter (urethral sphincter) muscles keep the bladder closed, and the extrinsic sphincter muscles surround the urethra and thus prevent leakage of urine. Urinary incontinence results when the urethra lacks its stability and tonicity (stress urinary incontinence), and if the sphincter muscles fail to keep the bladder closed (intrinsic sphincter deficiency, ISD).

A person eligible for this procedure may be a patient who also needs abdominal surgery that cannot be performed vaginally such as hysterectomy or sigmoid surgery, and the patients with stress urinary incontinence without ISD. The Burch procedure is commonly performed when another surgery is required such as repair of the urethra for cystoceles and urethral reconstruction.

The Burch procedure is done either through open abdominal surgery for which a longer incision is required or a vaginal approach. The surgery is performed under general anesthesia. In the retropubic area, the surgeon separates the anterior vaginal wall from the bladder. The bladder neck is isolated and its adhesions or fatty tissues are removed. Then, the bladder neck is sutured to the pubic ligaments to form new adhesions and gain stability. A catheter will be placed to facilitate postoperative voiding and to reduce the risks of infection.

The laparoscopic technique has been used in recent years to perform retropubic suspension surgery. This requires only 3 to 4 tiny, about 0.6 cm long incisions to be made on the abdomen, pubic hairline, or groin area. Through these keyhole incisions, small instruments and a camera is passed into the abdomen without the need to open the abdominal cavity. The surgeon then suspends the urethra to strong ligaments of the pubic bone. However, the laparoscopic Burch procedure demands highly skilled surgeons.

In recent years, robotic surgery has been extensively employed due to its improved precision and the surgeon's comfort as compared to laparoscopy.

With more experience and comfort using robotic surgery, the robot has been used for even complex surgical procedures including urogynecology procedures such as the retropubic urethropexies (Burch colposuspensions).

Minimally invasive surgeries have gained immense popularity over recent years.

Benefits include:

• Improved magnification resulting in better visualization
• Decreased blood loss
• Shorter hospital stays, usually not more than 24 hours
• Decreased postoperative pain
• Decreased risk of infections

As with any major abdominal or pelvic surgical procedures, complications may occur after this procedure, and include the following:

• Bleeding
• Bladder injury
• Injury of the urethra and ureters
• Wound infection
• Blood clot formation

The specific complications of the Burch procedure include:

• Urethral obstruction as a result of urethral kinking due to elevation of the vagina or bladder base
• Postoperative voiding difficulties
• Vaginal prolapse

Corrective surgery can be performed to release the urethra to a more anatomic position, and resolve voiding difficulties with a very high rate of success.

Patients who have undergone open retropubic surgery are prescribed postoperative pain medications that are gradually decreased in a couple of days. A suprapubic catheter may be placed for about five days after the surgery as most patients complain of voiding difficulties initially.

Patients who have undergone laparoscopic surgery incur less blood loss during surgery, and require fewer postoperative narcotic medications. They are usually discharged earlier from the hospital with post-operative instructions that include:

• Avoid strenuous activities for 3 months
• Schedule a follow-up visit after 3 weeks of surgery