Department of Gynecological Surgery, CHU Estaing, Clermont-Ferrand, France (Drs. Aleksandrov, Meshulam, Rabischong, and Botchorishvili); Department ofObstetrics and Gynecology, Specialised Hospital for Obstetrics and Gynecology SBAGAL Pr. Dimitar Stamatov Varna, Medical University Varna, Bulgaria (Dr. Aleksandrov).
Department of Gynecological Surgery, CHU Estaing, Clermont-Ferrand, France (Drs. Aleksandrov, Meshulam, Rabischong, and Botchorishvili); Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Dr. Meshulam).
J Minim Invasive Gynecol. 2021 Jan;28(1):24-25. doi: 10.1016/j.jmig.2020.04.018. Epub 2020 Apr 24.
To demonstrate a modification of the classic Burch procedure, called "laparoscopic transobturator tape (TOT)-like Burch colposuspension." The technique does not involve any type of prosthesis placement, and it is an alternative for patients with stress urinary incontinence in a future without meshes. Describing and standardizing the procedure in different steps makes the surgery reproducible for gynecologists and safe for the patients.
Step-by-step educational video, underlining and focusing on the main anatomical landmarks.
A university tertiary care hospital.
The patient is set under general anesthesia and in lithotomy position. The distinct steps of the procedure are performed as followed: Step 1: Installation. Two 10-mm trocars are positioned in the midline and 2 5-mm trocars in the suprapubic region. The recommended intra-abdominal pressure is 6 to 8 mm Hg, and excessive Trendelenburg is not needed. Step 2: Entry in the Retzius space. The median umbilical ligament and the vesicoumbilical fascia are transected. Step 3: Exposure of the Retzius space and the anatomical structures. The dissection is continued consecutively toward the pubic bone and the Cooper's ligament, laterally toward the external iliac vessels and the corona mortis and medially toward the bladder neck. Step 4: Vaginal dissection. The pubocervical is dissected at the level of the pubourethral ligaments. Step 5: Suspension of the vagina to the Cooper's ligament. In contrast to the standard technique, with the TOT-like Burch, the sutures on the pubocervical fascia are placed at the level of the attachment of the arcus tendinous fascia pelvis and the pubourethral ligament. This way of suspension ensures a lateral traction on the bladder neck, resembling the effect of the TOT, which leads to lower incidence of dysuric symptoms. Step 6: Peritoneal closure.
The classic colposuspension was created in 1961 for the treatment of stress urinary incontinence prolapse [1]. In the following years, vaginal meshes gained popularity as a treatment option for prolapse and for incontinence owing to their ease of use and satisfying results, which led to a decreased use of the Burch procedure [2,3]. In 2019, the Food and Drug Administration forbid the production of the transvaginal meshes for prolapse [4], an interdiction that could influence the use of synthetic meshes for incontinence in the future [5]. Owing to these recent events, searching for an effective way of management for patients with stress urinary incontinence without any synthetic prostheses, gynecologists have turned back to the 60-year-old Burch colposuspension. One of the drawbacks of the original technique is the high incidence of voiding difficulties-up to 22% [6]. Owing to the knowledge of the exact course of traction with the TOT, in our modified technique, the lateral direction of the suspension provides a tension-free support on the urethra and the bladder neck. The laparoscopic TOT-like Burch colposuspension is a safe and effective treatment for patients with stress urinary incontinence with low rates of dysuric symptoms and represents a valuable alternative for gynecologists in a future without meshes.
展示一种经典的 Burch 手术改良方法，称为“腹腔镜经闭孔吊带（TOT）样 Burch 阴道悬吊术”。该技术不涉及任何类型的假体放置，是未来无网片时代治疗压力性尿失禁患者的一种选择。描述并规范不同步骤的手术过程，使妇科医生能够重复进行手术，并且对患者安全。
分步教学视频，强调并突出主要解剖标志。
大学三级保健医院。
患者全身麻醉，截石位。手术的具体步骤如下：步骤 1：安装。在中线放置两个 10mm 套管针，在耻骨上方放置两个 5mm 套管针。建议的腹腔内压为 6 至 8mmHg，不需要过度头低脚高位。步骤 2：进入 Retzius 间隙。切开脐正中韧带和膀胱脐筋膜。步骤 3：显露 Retzius 间隙和解剖结构。连续向耻骨和 Cooper 韧带方向、向髂外血管和冠状 Mortis 外侧、向膀胱颈内侧方向进行解剖。步骤 4：阴道解剖。在耻骨尿道韧带水平切开耻骨宫颈筋膜。步骤 5：将阴道悬吊至 Cooper 韧带。与标准技术不同，TOT 样 Burch 中，耻骨宫颈筋膜上的缝线放置在骨盆弓状肌腱筋膜和耻骨尿道韧带附着处。这种悬吊方式确保了膀胱颈的侧向牵引，类似于 TOT 的效果，从而降低了排尿困难症状的发生率。步骤 6：腹膜闭合。
经典的阴道悬吊术于 1961 年创建，用于治疗压力性尿失禁脱垂[1]。在随后的几年中，由于其使用方便和满意的效果，阴道网片作为脱垂和失禁的治疗选择而受到欢迎，这导致 Burch 手术的使用减少[2,3]。2019 年，美国食品和药物管理局禁止生产用于脱垂的经阴道网片[4]，这一禁令可能会影响未来用于治疗压力性尿失禁的合成网片的使用[5]。鉴于最近的这些事件，为了寻找一种治疗压力性尿失禁患者而不使用任何合成假体的有效方法，妇科医生们又回到了已有 60 年历史的 Burch 阴道悬吊术。该原始技术的一个缺点是排尿困难的发生率较高，高达 22%[6]。由于对 TOT 确切牵引方向的了解，在我们的改良技术中，悬吊的外侧方向为尿道和膀胱颈提供了无张力的支撑。腹腔镜 TOT 样 Burch 阴道悬吊术是治疗压力性尿失禁患者的一种安全有效的方法，排尿困难症状发生率低，是未来无网片时代妇科医生的一种有价值的选择。
