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Chapter 123 Laparoscopy in Urogynecology and Reconstructive Pelvic Surgery Jerome L. Buller and Geoffrey W. Cundiff Table Of Contents |
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| Jerome L. Buller, MD Assistant Professor, Division of Gynecologic Specialities, Johns Hopkins Hospital, Baltimore, Maryland (Vol 1, Chap 123) |
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INTRODUCTION OVERVIEW OF SURGICAL TECHNIQUES DESCRIPTION OF PROCEDURE REVIEW OF THE LITERATURE COMPLICATIONS ANALYSIS OF COST CONCLUSIONS REFERENCES |
| INTRODUCTION |
Laparoscopic surgery for the treatment of urinary incontinence and pelvic organ prolapse is evolving rapidly. There is a desire to achieve the long-term cure rates of traditional open repairs with a less invasive surgical approach. Reported benefits of laparoscopic surgery included shorter hospital stay, less patient discomfort, improved cosmesis, and shorter convalescence. Some surgeons suggest laparoscopy provides improved visualization due to laparoscopic magnification, insufflation effects, and improved hemostasis. This allows for more precise dissection and suture placement. The potential disadvantages of laparoscopy include the cost of laparoscopic equipment, increased operative times, and the technically more demanding nature of laparoscopic surgery, which results in a more prolonged learning curve. Genuine stress incontinence (GSI) is defined by the International Continence Society (ICS) as the involuntary loss of urine coincident with increased intra-abdominal pressure, in the absence of a detrusor contraction or an overdistended bladder,1 making the diagnosis of GSI a urodynamic-based diagnosis. The most common cause of GSI is urethral hypermobility where laxity of the pubocervical fascia compromises the normal backboard against which the urethra is compressed during increases in intra-abdominal pressure. GSI can be treated conservatively with medical therapy, pelvic muscle exercises, or a pessary, but many patients progress to surgical therapy. When considering the anatomy of the repair of pelvic organ support, a surgeon needs to keep in mind the three levels of support of the vagina.2 The upper fourth of the vagina (level 1) is suspended by the cardinal/uterosacral complex; the middle half (level 2) is attached bilaterally to the arcus tendineus fasciae pelvis and the medial aspects of the levator ani muscles; and the lower fourth (level 3) is fused to the pubic symphysis anteriorly and the perineal body posteriorly. The fibromuscular layer of the anterior vaginal wall (commonly referred to as pubocervical fascia) provides most of the structural integrity of the anterior vaginal wall. Posteriorly, the fibromuscular layer of the vaginal wall (commonly referred to as the rectovaginal fascia or fascia of Denonvilliers) similarly provides most of the structural integrity of the posterior vaginal wall. All pelvic support defects, whether anterior, apical or posterior, represent (at least in part) a break in the continuity of this fibromuscular layer of the vagina, or a loss of its suspension, attachment or fusion to adjacent structures. The goals of pelvic reconstructive surgery are to correct all defects, thus reestablishing vaginal support at all three levels, and to maintain and/or restore normal visceral and sexual function.3 At one time the most common surgical approach to GSI was anterior vaginal wall plication, but the vaginal plication techniques have been largely supplanted by retropubic techniques, or sling techniques based on prospective data demonstrating poor durability for the vaginal approach.4 The first retropubic technique for GSI was described by Marshall and co-workers in 1949, and fixed periurethral pubocervical fascia to the posterior aspect of the pubic bone. They reported a success rate of 82%.5 Burch6 modified the procedure by attaching the periurethral tissue to the iliopectineal line (Cooper's ligament). His reported success rate was 93%.7 Prospective studies have confirmed the early success rates8 and long-term series have demonstrated excellent durability. Numerous procedures have been described which have sought the success and durability of the retropubic procedure with a less invasive and shorter approach. The needle suspension procedure originally was described by Pereyra,9 but numerous modifications have followed.10–12 Initial high success rates were reported, but in later prospective reports fell to 50% to 70%.13,14 At five years they have been described as low as 40%, comparable to the long-term success rates for vaginal procedures.4 |
| OVERVIEW OF SURGICAL TECHNIQUES |
Vancaillie and Scheussler15 first reported on the laparoscopic retropubic urethropexy in 1991. This series of 9 patients with 2 conversions to laparotomy is representative of other early case series. Numbers were small, and follow-up was short and largely subjective. The surgeons were skilled laparoscopists who developed new procedures that sought to duplicate traditional procedures aside from the laparoscopic access. However, as less experienced laparoscopic surgeons sought to master the laparoscopic approach, the technical aspects became an obstacle. This led to the development of modifications to avoid or simplify suturing. Techniques were designed using staples and sutures,16 bone anchors,17,18 staples and mesh,19–25 fibrin sealants,25,26 and various new suturing devices.27,28 It is our opinion, as well as other authors,29 that laparoscopy is a surgical approach from which a variety of procedures may be performed, rather than a specific procedure for the treatment of urinary incontinence. These deviations from the original procedures are new procedures and should be evaluated on their own merit, rather than lumping them with traditional retropubic procedures performed laparoscopically. |
| DESCRIPTION OF PROCEDURE |
Retropubic Urethropexy The laparoscopic retropubic colposuspension may be performed by a transperitoneal approach or by an extraperitoneal approach. The transperitoneal approach begins with conventional laparoscopic entry into the peritoneal cavity, including creating a pneumoperitoneum and placement of trocars. We usually use four trocars, an umbilical port for the scope, two 5-mm lateral ports at one-third the distance from the anterior superior iliac crest to the umbilicus, and a 10-mm suprapubic port. Incising the peritoneum, approximately 2 to 4 cm cephalad to the bladder dome, between the medial umbilical folds, allows access to the space of Retzius. Dissection is continued within the loose areolar tissue toward the region of Cooper's ligament bilaterally. The dissection should avoid the midline close to the pubis, where the urethra and dorsal vein to the clitoris are vulnerable. Similarly, the dissection should not be carried too far laterally to avoid the obturator neurovascular bundle, which is located above the ischial spine. Sharp dissection, electrocoagulation, laser, and hydrodissection have all been described as adjuncts for dissection in the space of Retzius. Once the anatomy in the space of Retzius has been clearly defined, the bladder is retracted medially and the periurethral fat is bluntly dissected off the sidewall and bladder in a lateral to medial direction; whitish pubocervical fascia is then visualized. Dissection is usually limited to within 2 cm from the urethra as describe by Tanagho.30 One or two sutures of nonabsorbable material are placed bilaterally. Number and location of sutures and suture material have varied greatly in the literature. We use two sutures of 0-Prolene bilaterally, the first at the level of the midurethra, the second at the level of the urethrovesical junction. We begin by bringing the suture down through Cooper's ligament from the ipsilateral port, then performing a figure-of-eight in the periurethral tissue from the contralateral port, followed by a second pass through Cooper's ligament. Thus the knot, which is tied in an extracorporeal fashion, lies on top of the ligament. The primary advantages of the intraperitoneal approach are a larger operative field and the ability to do concurrent abdominopelvic surgery. The major disadvantages are associated with the risk of laparoscopy in general, such as intra-abdominal or intrapelvic visceral injury and diaphragmatic irritation. The extraperitoneal approach begins with transabdominal wall access into the preperitoneal space, usually with the aid of the Hassan trocar. Blunt dissection is then used to carry the dissection into the space of Retzius. This dissection may be accomplished under direct vision, although some surgeons use a balloon dilator or hydrodistention to develop the space of Retzius.. Once access to the space of Retzius is established, a pneumoretzius is obtained and the procedure is completed as described above for the open technique. Flax31 described a gasless laparoscopic Burch procedure utilizing an extraperitoneal balloon dissection of the space of Retzius followed by insertion of a mechanical retractor system. He reported a 90% subjective success rate, although only 32 of 44 patients (70%) undergoing the procedure were subjectively dry. He also reported five bladder injuries and three patients with prolonged periumbilical discomfort for up to 3 months postoperatively. The main advantage of the extraperitoneal approach is not violating the intra-abdominal cavity, potentially avoiding the complications associated with pneumoperitoneum. Most notably, the extraperitoneal approach eliminates the need for opening and closing the peritoneum and lowers the risk of injury of intraperitoneal organs. It may also reduce intraperitoneal adhesions and the symptoms associated with a pneumoperitoneum. The major disadvantage of this approach is the development of subcutaneous emphysema associated with this technique.32 Most of the laparoscopic modifications to the retropubic urethropexy are directed at facilitating or eliminating the need for suturing in the space of Retzius. Henley described a repair using a surgical stapler to attach a single Gore-Tex suture 2 to 3 cm lateral to the urethrovesical junction and to Cooper's ligament.16 Although he reports that he has performed more than 60 of these procedures, his report provided insufficient data to allow evaluation of its efficacy. The Nolan-Lyons modification of the laparoscopic retropubic urethropexy utilized a figure-of-eight suture through the pubocervical fascia with one arm of the suture material stapled to Cooper's ligament. The staple anchored the suture to Cooper's ligament, which was subsequently tied extracorporeally.33 When this modification was compared to the laparoscopic retropubic and open retropubic urethropexies in a small, unblinded case series with 10 patients in each group, results were similar. Several authors have eliminated sutures altogether, replacing them with surgical mesh and staples.19–24,34 In the laparoscopic mesh urethropexy, access into the space of Retzius is the same as that described above. Surgical mesh is then attached bilaterally to the periurethral pubocervical fascia using a hernia stapler. Support of the pubocervical fascia is achieved by stapling the mesh to Cooper's ligament. Reported short-term success rates vary from 70% to 100%. Recently, Ou and Rowbotham reported an 88% subjective success rate with 5-year follow-up data on 34 patients who underwent laparoscopic mesh urethropexy.24 Laparoscopy has also been used to modify or augment the transvaginal needle suspension procedures.35–39 Although long-term data are lacking, advocates of this technique assert that laparoscopic dissection of the space of Retzius improves surgical outcome by enhancing retropubic scarring and allows more precise suture placement in the pubocervical fascia. We do not utilize these modifications. View video of Laparoscopy in Urogynecology and Reconstructive Pelvic Surgery Paravaginal Repair The paravaginal repair can also be accomplished from a laparoscopic approach. The laparoscopic approach to the space of Retzius for laparoscopic paravaginal repair is identical to that of the transperitoneal approach for the retropubic urethropexy. Once the space of Retzius is entered and Cooper's ligament is identified, the dissection is continued posteriorly, along the pelvic sidewall, toward the lateral aspect of the vagina. A vaginal hand may be used to elevate the vagina and retract the bladder medially. The endopelvic fascia and vaginal wall attachment to the arcus tendineus fascia pelvis, or white line, is examined from the ischial spine to the pubic bone bilaterally for any paravaginal defects. Blunt dissection on both sides is carried dorsally until the ischial spines are visualized. The arcus tendineus fascia pelvis runs from the ischial spine to the posterior surface of the pubic bone. Vaginal palpation of the ischial spines may assist in localizing these landmarks. Starting at the level of the ischial spine, the lateral aspect of the pubocervical fascia is sutured to the arcus tendineus fascia pelvis in a simple interrupted fashion using permanent suture. We find a 36- to 48-inch suture with the 5/8 round needle, from a contralateral port, facilitates suturing. The lateral vaginal vessels can identify the lateral margin of the pubocervical fascia. We generally try to encircle these vessels with our stitches. Sutures are placed 1 cm apart as needed to close the defect. When the paravaginal defect has occurred leaving the arcus on the lateral wall of the vagina, the vagina is reattached to the fascia of the obturator internus muscle along a line from the ischial spine toward the posterior aspect of the pubic symphysis. If this procedure is done in conjunction with a laparoscopic retropubic urethropexy, the paravaginal defect repair should be performed first, as exposure of the lateral defects becomes more difficult after the urethropexy sutures are tied down. As with the open paravaginal repair, some surgeons add GSI to the usual indications of cystocele for this procedure, although we consider a cystocele due to lateral detachment as the only indication. Ostrzenski published a series of 28 patients who underwent laparoscopic repair of paravaginal defects for the treatment of urinary incontinence.40 He reported a 93% cure rate based on subjective and objective data with a minimum follow-up of 24 months. The “Paravaginal Plus” procedure, described by Miklos and Kohli, combines a laparoscopic paravaginal repair for restoration of normal lateral vaginal support combined with a single periurethral suture to the iliopectineal line on each side.41 This procedure adheres to the basic reconstructive pelvic surgery principle of repairing all fascial defects present, but thus far no outcome data have been reported. Uterosacral Ligament Suspension Suspension of the vaginal apex to the uterosacral ligaments can be accomplished via the abdominal, vaginal, or laparoscopic approaches. It can also be performed with the uterus in place. After transperitoneal placement of the trocars, the apex of the vagina is identified. The use of an end-to-end anastomosis (EEA) sizer is helpful in manipulating the vaginal apex and provides a backboard on which to dissect. The superior aspect of the anterior pubocervical fascia and posterior rectovaginal fascia are identified and the superior integrity between the two is verified. If there is a discontinuity between the anterior and posterior endopelvic fascial layers of the vagina, as may be seen with apical enteroceles, the layers are reapproximated using permanent suture in an interrupted fashion. Identification of the uterosacral ligaments may be done in several ways. If the uterosacral ligaments were incorporated into the closure of the apex of the vagina at hysterectomy, simply displacing the EEA sizer anteriorly and toward the contralateral side will generally outline the course of the uterosacral ligament. The identification of the uterosacral ligaments becomes more difficult if they were not incorporated into the closure of the vaginal cuff or if they are markedly attenuated or broken. In these situations, it is imperative to find a safe, intact portion of the ligament; doing a rectal exam facilitates this. The rectal finger can palpate the uterosacral ligament when it is under tension. When placed on tension, the anterior border of the ligament is visible, while the body of the ligament is posterior to the anterior border. Because of the proximity of the ureter to the anterior border, the suspending suture can compromise the ureteral patency if placed in the anterior border. A preferable location is 1 cm posterior to the anterior-most border.42 The optimum site of fixation is at the level of the ischial spine where the uterosacral ligament has excellent strength and there are fewer vital adjacent structures, which may be injured during reconstructive surgery.42 At this level, a nonabsorbable suture is placed through full-thickness uterosacral ligament. The suture is then passed through both the anterior and posterior endopelvic fascia, excluding vaginal epithelium, at the lateral aspects of the vaginal apex. Sutures are then tied extracorporeally. One or two additional sutures may be placed if higher elevation is desired. Plication of the uterosacral ligaments is not necessary, although this has not been evaluated in a comparative study. The goal of the uterosacral suspension is to re-establish the support of the vaginal apex by the uterosacral ligaments. This is accomplished by suturing the lateral aspects of the vaginal vault to the midportion of the ligament bilaterally. |
| REVIEW OF THE LITERATURE | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
The literature on laparoscopic treatment of urinary incontinence has followed the usual developmental stages. Initial numerous case reports and case series were followed by retrospective and prospective cohort studies; finally, prospective randomized clinical trials are now available.. For data comparison between procedures to be meaningful, common terminology, preoperative diagnoses, preoperative and postoperative testing, and, most important, objective outcome measures must be clearly defined. Caution is advisable when interpreting the data on the laparoscopic surgeries for urinary incontinence, as this information is frequently missing in much of the published literature. The literature for laparoscopic repair of pelvic organ prolapse is even sparser. Our review of the literature included a MEDLINE search and a review of the references listed in the articles. Articles on all types of laparoscopic surgeries for incontinence were reviewed. Papers were subsequently grouped by study design, including randomized controlled trials, nonrandomized comparative trials, prospective cohorts, retrospective reviews and observational case reports or case series. Fifty papers were evaluated: 5 were prospective, randomized clinical trials, 1 was a prospective cohort, 5 were retrospective cohorts, 5 were case-control studies, and 34 were observational case series. Collectively, 1867 patients underwent laparoscopic surgery for the treatment of GSI. At a mean follow-up of 17 months, a cure rate of 89% was observed with only 30.8% of studies reporting objective outcome data (Table 1). Overall complication rates for all laparoscopic surgeries evaluated varied between 0% and 25% and total operative times varied from 35 to 330 minutes with means ranging from 90 to 196 minutes. The patient populations described in these 50 manuscripts represent a heterogeneous group. There was little consistency in how the initial diagnosis of stress urinary incontinence was made, the severity and duration of the disease, or how the procedure was performed, and there were few objective outcome measures. Although most authors excluded patients with intrinsic sphincter deficiency and detrusor instability, some did include these high-risk groups20,43 and many did not clearly state how they were treated. Table 1. Combined Data for Laparoscopic Surgeries for Urinary Incontinence
*One study did not report outcome data. The literature includes five prospective, randomized clinical trials. Two present the same study sample at 1-year and at 3-year intervals (Table 2). To date, there are only three such studies comparing the laparoscopic and open retropubic urethropexies. Burton randomized 60 women with urodynamically proven genuine stress urinary incontinence to either open or laparoscopic Burch colposuspension. Laparoscopically, a transperitoneal approach was utilized and both techniques used four Polyglycolic sutures, two on each side. Follow-up at 6, 12, and 36 months included videourethrography, urethral pressure profilometry, 1-hour ICS pad testing, urinary diary, and visual analog symptoms analysis. The cure rates, based on subjective and objective data, for laparoscopic colposuspension were considerably worse than for open colposuspension and decreased significantly from 1 year (73% versus 97%) to 3 years (60% versus 93%) of follow-up.44,45 No data were provided from this study with regard to complication rates. Although this was a well-designed study, it is not without flaws. Perhaps most importantly, the primary surgeon had done only 10 laparoscopic retropubic urethropexies before starting the study. Many authors comment on the long learning curve associated with this procedure and the need for a larger series to become proficient.29,46,47 Some have also questioned the use of absorbable sutures for the retropubic urethropexies in this series, although this should impact the control group to the same degree as the intervention group. Table 2. Randomized Clinical Trials
Tp, Transperitoneal; CL, Cooper's ligament;RPU, Retropubic urethropexy; Lsc, Laparoscopic Su and co-workers48 randomly assigned 92 patients to either open (N = 46) or laparoscopic (N = 46) Burch colposuspension and reported 1-year follow-up data. All patients underwent multichannel urodynamics preoperatively and 1-hour pad test and stress test at maximum cystometric capacity in the standing position, postoperatively. Objective cure rates at 1 year were lower in the laparoscopic group (80.4%) than in the open group (95.6%). Complication rates, however, were higher in the open group (17.2%) than in the laparoscopic group (10.8%). Operative times were also higher in the open group than in the laparoscopic group, but not significantly. The author used permanent suture for both open and laparoscopic retropubic urethropexies. However, two or three sutures were placed bilaterally for the open procedures versus only one suture bilaterally for the laparoscopic procedures. This represents a significant technical variation or deviation that precludes comparison of the laparoscopic to the abdominal approach as the actual procedures are different. This is born out by a study reported by Persson and co-workers,49 who compared 1-year cure rates of laparoscopic Burch colposuspensions between one and two sutures on each side of the urethra. In this study, 161 patients with genuine stress urinary incontinence were randomly assigned to laparoscopic Burch colposuspension utilizing one double-bite (N = 78) and two single-bite (N = 83) sutures into the vaginal fascia bilaterally. A transperitoneal approach was used for the repair. Patients were interviewed and underwent pad testing at median follow-up of 12 months (range 9 to 24 months). Cure was defined objectively as no leaking at pad testing and subjectively as the women's description as cured, improved, or unimproved. Objective cure rate with one suture placed bilaterally was 58% compared to 83% with two sutures (p< 0.001). Also, the mean surgical time was 17 minutes longer on average for those two-suture group compared to the one bilateral suture (77 minutes, range 45 to 110 versus 60 minutes, range 35 to 121; p < 0.001) In 1996, Ross50 compared the laparoscopic Burch repair with a colposuspension utilizing polypropylene mesh and staples in 65 patients who were randomly assigned. Objective cure was defined as negative Q-tip, ultrasound, cough stress test, and cystometrogram. Overall cure rates of 91% for the laparoscopic Burch group and 94% for the mesh and staples group were not significantly different. A major complication rate of 6.2% was reported. There have been no prospective or retrospective cohort studies or randomized clinical trials of laparoscopic surgeries for the repair of pelvic organ prolapse. There are limited data available primarily from case reports or case series with short-term follow-up. There are no reports evaluating the laparoscopic paravaginal repair for the treatment of anterior wall prolapse. Ross51 reported concomitant paravaginal defect repairs with other reconstructive procedures but did not report on objective measures of anterior vaginal wall prolapse. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| COMPLICATIONS |
Considering all published reports that addressed complications, the overall complication rate was 10.3 ± 8.2% (range 0.0 to 25.0%, median 10.0%) The most commonly reported injury is to the bladder, usually at the dome, and typically is repaired laparoscopically. Injury to the urinary bladder may be detected by direct vision of the cystotomy, by visualizing urine in the operative field, hematuria, or by observing gaseous distention of the urinary bag.52 Differentiation between minor and major complications was poorly defined in the literature. Major perioperative complications include injury to the urinary tract,53 bowel injury, major vascular injury including inferior epigastric vessel, hemorrhage requiring blood transfusion, and abscess formation in the space of Retzius. Long-term problems include failure of the procedure requiring resuspension, new-onset urethral intrinsic sphincter deficiency, de novo detrusor instability requiring long-term medical management, urinary retention requiring permanent catheterization, voiding pain with or without suture material in the bladder, ureteral obstruction requiring re-operation, vesicovaginal fistula, vesicocutaneous fistula, posterior compartment compensatory defects requiring surgery, and incisional hernias.29 To date, no deaths have been reported. Ou and colleagues54 retrospectively reviewed 250 laparoscopic bladder neck suspensions that utilized mesh and staples and reported complications such as infection, trocar injuries, urinary retention, bleeding, enterocele formation, and de novo detrusor instability and found no cases of mesh rejection. Speights and co-workers55 reported a 2.3% incidence of injury to the lower urinary tract during laparoscopic Burch urethropexies and/or paravaginal repairs. They reviewed the medical records of 171 consecutive women of which 130 women underwent a laparoscopic Burch and paravaginal repair, 23 had a Burch procedure alone, and 18 had a paravaginal repair alone. All patients underwent intraoperative videocystoscopy. Four cystotomies were identified and all were repaired laparoscopically. |
| ANALYSIS OF COST |
The major cost of laparoscopic surgery arises from the expense of disposable laparoscopic equipment and cost of increased operative times. Capital cost of nondisposable equipment and video equipment must also be considered. Some surgeons believe these increased costs associated with laparoscopic surgery are offset by the decreased hospital cost associated with shorter lengths of stay and indirect cost benefits associated with shorter recovery times and faster return to work. Currently, there are three articles comparing the cost of laparoscopic versus open Burch colposuspension.56–58 No articles have been published evaluating the cost of other laparoscopic reconstructive procedures. Kung and colleagues56 evaluated cost-effectiveness of the open versus laparoscopic Burch procedure by reviewing the associated professional fees, investigational cost, capital equipment cost, disposable equipment, length of hospital stay, and indirect cost of the two procedures. Total charges for the laparoscopic Burch ($2398) were significantly less than the open procedure ($5692). The cost difference was primarily related to length of stay, which was significantly higher for the open Burch (11.2 days) than for the laparoscopic Burch (3.6 days). These lengths of stay are greater than those routinely seen in the United States. Adjusted to 1 day ($666.11) and 2 to 3 days ($1016.42 to $1524.64), total charges for the laparoscopic retropubic urethropexy are still less than that of the open procedure. Loveridge and co-workers57 retrospectively reviewed 49 consecutive patients undergoing laparoscopic (26) or open (23) Burch colposuspensions and noted no significant difference in overall costs. The costs of increased operative times in the laparoscopic group were offset by the costs of longer lengths of stays in the open group. Costs for medication, investigation, and consultation did not differ significantly. Kohli and colleagues58 compared laparoscopic (17) and open (21) Burch colposuspension and found higher total hospital charges for the laparoscopic group ($4960) versus the open group ($4079). Though the mean length of stay was significantly shorter in the laparoscopic group, the savings associated with the shorter stay was insufficient to offset the cost of the longer operative times. They hypothesized that replacing their disposable laparoscopic equipment with reusable equipment might have closed this cost difference. |
| CONCLUSIONS |
Most of the data for laparoscopic surgeries for the treatment of urinary incontinence and pelvic organ prolapse suggest that the success rates are similar and complication rates are lower than the open procedures. Most authors reported less blood loss, shorter hospitalization, less frequent postoperative voiding dysfunction, and less de novo detrusor instability compared to the abdominal route. These data are largely retrospective in nature and are primarily from case series. The follow-up is generally short and most studies reported only subjective outcome measures. The two prospective, randomized clinical trials comparing the laparoscopic and open retropubic urethropexy procedures cast doubt on the long-term success of the laparoscopic approach for the treatment of GSI. However, both studies possessed design flaws: one experience based, the other technical in nature. The surgeon's lack of experience with the laparoscopic approach and use of absorbable suture material44,45 and the use of different numbers of suspension sutures48 may explain the poorer outcomes observed in the laparoscopic groups. Many laparoscopic procedures have been described as laparoscopic Burch procedures and report similar success rates and complication rates. However, many of the procedures described in the literature are quite different from the traditional Burch retropubic urethropexy. In situations where deviations from the classic procedures have occurred, the assumption of similar outcomes between different techniques is inappropriate. These new techniques for the treatment of urinary incontinence should be evaluated individually on their own merits, and should not be misleadingly called Burch retropubic urethropexies. Laparoscopic surgery for incontinence is feasible and possesses the usual advantages of minimally invasive surgery. However, the advantages of less postoperative pain, improved cosmesis, shorter hospitalization, shorter recovery period, and earlier return to work are offset by increased operative times and possibly increased cost. As the laparoscopic skills of urogynecologic and urologic surgeons improve, shorter operative times can be expected. Also, the use of reusable laparoscopic equipment may help to decrease the cost of laparoscopic surgery. Efforts at cost-containment should continue to be made, as cost remains a major hurdle. Although long-term data are lacking, patients will continue to seek out minimally invasive surgical procedures with reliable and durable outcomes. This will perpetuate the need for the laparoscopic approach. Also, the continued use of minimally invasive outpatient procedures is promoted by ongoing changes in health care allocation and reimbursement policies due to shorter hospital stays and shorter periods of convalescence. Therefore, we anticipate a continued need to evaluate and refine laparoscopic approaches for the treatment of genuine stress incontinence. |