Laparoscopic Burch Cystourethropexy Compared with the Transperitoneal and Extraperitoneal Approaches

Twenty transperitoneal and 20 extraperitoneal Burch procedures were compared. All women had preoperative multichannel urodynamics documenting true urinary stress incontinence (USI) and normal urethral closure pressures (>20 mm Hg). Those with mixed incontinence were treated medically without resolution before surgical intervention. If hysterectomy was indicated and could be performed vaginally, total vaginal hysterectomy, necessary vaginal repairs, and culdoplasties were performed first. The Burch was then performed with a balloon system to dissect the space of Retzius. If not amenable to a vaginal approach, laparoscopic-assisted vaginal hysterectomy, laparoscopic culdoplasties, and transperitoneal Burch were performed. In all cases the cystourethropexy was performed with one to two permanent sutures bilaterally in the periurethral fascia 1 to 2 cm from the urethra, then passed twice through Cooper's ligament. Operating time averaged 55 minutes less and hospital costs averaged $1855 less in the extraperitoneal group than in the transperitoneal group when similar procedures were performed. Length of hospitalization, complication rates, return to normal activity, and long-term success rates did not differ significantly between the groups. Two cases were converted to a transperitoneal approach after attempts at extraperitoneal access were unsuccessful. Currently, all patients remain continent, with follow-up ranging from 1 to 4.5 years. When feasible, the extraperitoneal approach to laparoscopic Burch cystourethropexy is an excellent alternative to transperitoneal laparoscopic Burch.