Retropubic Therapy for Stress Incontinence

Mark D.Walters

Since 1949, when Marshall et al.1 first described retropubic urethrovesical suspension for the treatment of stress urinary incontinence, and since Burch's landmark article in 1961,2 retropubic procedures have emerged as consistently curative. Although numerous terminologies and variations of retropubic repairs have been described, the basic goal remains the same: to suspend and stabilize the anterior vaginal wall, and thus the bladder neck and proximal urethra, in a retropubic position. This prevents their descent and allows for urethral compression against a stable suburethral layer. We select a retropubic approach (versus a vaginal approach) depending on many factors, including the need for laparotomy for other pelvic disease, the amount of pelvic organ relaxation, and whether a vaginal or abdominal procedure will be used to suspend the vagina. Additionally, the age and health status of the patient, and the preferences of the patient and surgeon are also determining factors. We generally do not perform a retropubic procedure for intrinsic sphincter deficiency.

Few data differentiate one retropubic procedure from another, although all have advantages and disadvantages. The three most studied and popular retropubic procedures are the Burch colposuspension, the Marshall-Marchetti-Krantz (MMK) procedure, and the paravaginal defect repair. At the Cleveland Clinic, we prefer the Burch colpo-suspension for urodynamic stress incontinence with bladder neck hypermobility and adequate resting urethral sphincter function, and we combine it with a paravaginal defect repair when the patient has stage II anterior vaginal prolapse or when a concurrent sacral colpopexy is to be done. We do both open and laparoscopic retropubic repairs; laparoscopic techniques will be discussed elsewhere. We no longer perform MMK procedures, so this operation will not be described. The surgical techniques described herein are contemporary modifications of the original operations: Tanagho in 19763 described the modified Burch colposuspension; the paravaginal defect repair has been described by Richardson et al.4 and Shull and Baden.5 Although less critically studied, the paravaginal defect repair is regionally popular and widely performed in the United States.

This chapter describes only retropubic suspension procedures that utilize an abdominal wall incision for direct access into the space of Retzius. The use of laparoscopy and mini-incision laparotomy to enter the retropubic space and perform these and similar procedures is expanding, both in terms of clinical experience and in research. A thorough critique of the use of operative laparoscopy for urinary incontinence and prolapse is described elsewhere.

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