Revisiting the Laparoscopic Burch
IUGA Academy. Gabriel I. Jun 30, 2018; 213255; 248
Iwona Gabriel
Iwona Gabriel

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Revisiting the laparoscopic burch

Barletta , K1; Cohen, S1;Gabriel, I1; Minassian, V1

1: Brigham and Women's Hospital Boston MA

Introduction: More than twenty million women suffer from urinary incontinence (UI) in the US. UI is a burdensome condition leading to emotional, social and physical discomfort. Stress urinary incontinence (SUI) is the most common subtype and is the predominant type in the middle-aged women. In the past, the open Burch procedure was offered to reconstruct the endopelvic fascia and lift bladder neck and urethra, with success rates up to 82%. More recently, the synthetic mid-urethral sling (MUS) has become the mainstay of treatment. However, with ongoing controversy regarding long-term mesh use, or for patients who fail MUS treatment, the Burch procedure has come back into favor. Advances in minimally invasive surgery have allowed this procedure to be increasingly performed via a laparoscopic approach.

Objective: We present the minimally invasive laparoscopic Burch procedure to address persistent, debilitating SUI in a woman who has failed previous alternative options.

Methods- Case presentation: 58-year-old woman with past medical history of Ehler-Danlos syndrome presenting after long-standing history of SUI despite multiple interventions. These include an anterior repair with bone anchor sling, several collagen bulking procedures, and repeat anterior repair with mesh placement. Notably, the surgery with bone anchor was complicated by surgical site bacterial and yeast infection requiring prolonged hospitalization with IV antibiotics. At the time of presentation to our clinic, she had mixed UI with predominant SUI with a significant impact on her quality of life. On clinical exam, no prolapse was appreciated. Her urodynamics testing confirmed SUI with small bladder capacity. Due to her complex surgical history, we opted for the laparoscopic Burch procedure.

Results: The procedure was performed using three laparoscopic port sites. The bladder was back-filled with sterile water to delineate its margins and identify the entry point into the retroperitoneal space. The peritoneum above the space of Retzius was entered using sharp and blunt dissection, and was continued down to the level of proximal urethra. The Cooper’s ligament was identified bilaterally. Using a vaginal finger, the assistant tents up the endopelvic fascia. Two 0-prolene sutures were placed in a figure-of-eight fashion around the urethrovesical junction and proximal urethra and brought to the Cooper’s ligament on the ipisilateral side to suspend the bladder neck. Cystoscopy was performed to ensure absence of any suture material in the bladder mucosa. The procedure was uncomplicated and patient went home on the same day with resolution of SUI symptoms at the 6 weeks post-op visit.

Conclusion: The laparoscopic Burch procedure can be offered to patients with long-standing history of SUI who fail other surgical treatment options. It could also be the treatment of choice in women who fail conservative SUI therapy and who are either concerned about permanent synthetic slings or in whom mid-urethral slings offer a high-risk procedure.


Work supported by industry: no.

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