Laparoscopic Burch Colposuspension for Urinary Stress Incontinence

To date we have performed 58 laparoscopic Burch colposuspensions, 28 by the extraperitoneal route and 30 with the transperitoneal approach. The 58 women (mean age 48.9 yrs, mean weight 71.1 kg) all underwent urodynamic studies. Sixteen had mixed findings of stress and urge incontinence. The operative technique involved dissection into the space of Retzius. Laparoscopic suturing techniques were employed using either 0 Dacron or polyester between the paravaginal fascia and the iliopectineal ligaments. Satisfactory elevation of the bladder neck was obtained. Associated procedures were predominantly laparoscopic hysterectomy. Comparison of the two approaches showed equivalent blood loss, return to normal activity, operating times, and duration of postoperative catheterization. Hospitalization was significantly longer in the extraperitoneal group. Significant complications were cystotomy in four women and conversion to laparotomy in four. Duration of follow-up was equivalent in both groups, ranging from 6 to 33 months. Success rates were also equivalent, with only one failure in total, occurring in the transperitoneal group. Laparoscopic Burch colposuspension is a safe, effective procedure and should replace the conventional approach by laparotomy.

Endocervicosis of the urinary bladder.

A further case of endocervicosis of the urinary bladder is described. It is important that gynaecologists and pathologists be aware of this entity and its possible relationship to previous Caesarean section to avoid confusion with a neoplastic process.

Laparoscopic Burch Colposuspension-New Approaches

Endoscopic surgical developments have produced considerable benefits in reduction of postoperative morbidity and healthcare costs for the community. The Burch colposuspension via a transverse lower abdominal incision has achieved widespread acceptance in the management of stress incontinence. However, the potential benefits of laparoscopic Burch colposuspension include decreased perioperative and postoperative morbidity, shortened hospitalization, reduction of blood loss, and early return to normal activity. We present our initial 10 cases, 7 via the transperitoneal approach, and 3 using balloon distension of the retropubic space via an extraperitoneal approach. In all cases, the bladder neck and iliopectineal ligaments were clearly visualized laparoscopically. Sutures were placed between the paravaginal fascia and iliopectineal ligaments bilaterally, producing good bladder neck elevation. A suprapubic catheter was subsequently inserted. This initial group (N = 10), mean age 41 years (range 35-54 years) all had preoperative urodynamic studies confirming stress incontinence. A mean operating time of 3 hours 7 minutes (range 2-5 hrs) was achieved using the transperitoneal approach. However, switching to the balloon extraperitoneal method (N = 3), mean surgical time diminished to 65 minutes. All patients were managed with postoperative suprapubic catheterization with hospital discharge after 5.5 days (range 4-7 days) and minimal postoperative blood loss. All patients returned to normal activity within 18 days. Initial follow-up confirmed the absence of stress incontinence. Laparoscopic colposuspension would now appear to be the surgery of choice for stress incontinence.

Methotrexate injection of tubal ectopic pregnancy. A logical evolution?

OBJECTIVE: To test the efficacy and possible side effects of a single 20 mg dose of methotrexate injected at the time of laparoscopy, in the treatment of tubal ectopic pregnancy. DESIGN: The study was a non-randomised non-blinded prospective clinical trial. SETTING: The study was carried out at two tertiary referral hospitals. PATIENTS: Eighteen patients with unruptured tubal ectopic pregnancies and in a stable haemodynamic condition were offered entry into the study and all of these agreed. INTERVENTIONS: At diagnostic laparoscopy, 20 mg of methotrexate in 0.8 mL was injected by fine needle in or around the ectopic gestation. MAIN OUTCOME: Patients were followed up as outpatients by serial blood tests until resolution of the ectopic pregnancy was demonstrated by a return of the level of beta-human chorionic gonadotrophin to the normal range. RESULTS: There was one failure of treatment. The ectopic pregnancy resolved in the remaining 17 patients. There were no side effects attributable to methotrexate and tubal patency was demonstrated in the eight patients tested by hysterosalpingography.