Between January 1997 and February 1998, 8 patients with genuine urinary stress incontinence underwent a laparoscopic-assisted extraperitoneal Burch procedure3. The average was 52 years (range 35 to 65). None of these patients had any systemic pathology and none of them was subject to medications. Let us mention that 1 patient also underwent Laparoscopic tubal sterilization during the same procedure. The preoperative evaluation included a complete history and physical examination, with demonstration of stress urinary incontinence and detection of medial or lateral defects because of cystocele or prolapse. Office tests included a urinalysis and urine culture. A cystometrogram was performed to rule out a neurogenic or unstable bladder.
Under a general anesthetic, the patient is placed in lithotomy position with the legs extended laterally and supported by Allen’s Stirrups. A 16 French Foley catheter is inserted to empty the bladder and is left in situ. A 10-mm laparoscope is inserted through a 10-mm transverse incision at halfway between the pubic symphysis and the hollow of the umbilicus (figure 1). Through the incision, the laparoscope is inserted into the retropubic area and the prevesical space is insufflated with CO2 gas at a rate of 1 to 2 l/min, until a pressure of 12 mm Hg has been reached. The bladder is mobilized and the Cooper’s Ligament dissected exclusively by the optica. There are no additional puncture sites. Two cutaneous transverse incisions are made laterally at the upper border of the symphysis pubis, to the left and right side. By laparoscopic monitoring, a Tonigham needle with the prolene 1 is inserted through the Cooper’s Ligament (figure 2). Two fingers are inserted in the vagina and the anterior vaginal wall is lifted upward and forward to aid needle passing. The needle is subsequently passed through the vagina wall and the prolene is taken out. The Tonigham’s needle is taken out only from vagina and Cooper’s ligament but it is maintained inside the prevesical space. Afterwards the needle is passed into the vagina again and the Prolene is threaded through the orifice of the Tonigham needle, and is withdrawn into the suprapubic area. Two sutures are done on each side. The knots are made extracorporally and tied. The same procedures are performed in the contralateral side. All surgical steps are observed through the laparoscope and the elevation of bladder neck is assessed by cystoscopy.