Burge Culpa Suspension has long been recognized as one of the most effective surgical procedures for stress urinary incontinence. Traditionally, described as an open procedure, this surgery can be performed laparoscopically. When compared to the open procedures, laparoscopic Burge Culpa Suspension has been shown to be equally effective. The minimally invasive approach offers additional benefits such as low perioperative complication rates, shorter hospital stay, and faster return to daily activities. In recent years, the midurethral sling has replaced Burge Culpa Pexi as the new gold standard method of surgical management for stress urinary incontinence, owing to its minimally invasive approach and evidence that it has similar long-term efficacy as the Burge. Nevertheless, Burge remains an important procedure for recurrent incontinence and has its role as a primary treatment. Options for treatment of recurrent incontinence include urethral bulking agents, repeat sling fascial or synthetic, and Burge Culpa Suspension. As a primary procedure, Burge Culpa Suspension has a role in treating urinary incontinence when a patient is undergoing a concomitant abdominal procedure such as a sacrocopopexy or when the patient desires a surgical option that does not involve graft placement. Since 2008 and 2011, after FDA warning regarding the use of vaginal mesh, patients are increasingly more interested in non-graft options in the treatment of prolapse and incontinence. In this video, we will illustrate anatomy pertinent for the Burge Culpa Suspension procedure and describe technical aspects of Burge when performed by minimally invasive approaches. Burge Culpa Suspension is a procedure that requires access to the retropubic space, also known as a space of retios. This area is extremely vascular with the rich, thin-walled venous plexus that should be avoided if possible. The position of the urethra and the lower edge of the bladder is determined by palpating the foley balloon. Cooper's ligament, otherwise known as a pectineal ligament, is identified running on the pectineal line of the pubic bone. In carefully clearing off the Cooper's ligament, one must be aware of the proximity of the obturator canal. In this cadaveric dissection, the location of the obturator canal containing artery, vein, and nerve can be clearly visualized. On average, the obturator canal is located approximately 6 cm lateral to the pubic synthesis and 2 cm inferior to the superior pubic remus. In addition, external iliac vessels are located approximately 1 cm lateral to the obturator canal and 7 cm lateral to the pubic synthesis. We will now demonstrate surgical techniques pertinent for laparoscopic Burch procedure. The patients that have undergone these procedures have had prior sling surgeries which resulted in mesh erosions. Thus, they desired surgical treatment for recurrent stress urinary incontinence that did not utilize a graft material. For dissecting the retropubic space, we fill the bladder via a three-way catheter in order to identify the margins. Applying gentle pressure with a blunt instrument, we identify the superior border of the bladder dome. The parietal peritoneum is then incised 2 cm above the bladder dome. Incision is extended transversely between the obliterated umbilical ligaments. A combination of blunt and sharp dissection is used to dissect the space of rhetzius. During this dissection, the correct plane is identified when the loose areola tissue is visualized. If previous retropubic or other bladder neck suspension procedures have been performed, dense adhesions and or mesh fragments from the anterior vaginal and bladder wall and urethra to the synthesis pubis are often present. Dissection is aimed toward the pubic bone and extended laterally to expose Cooper's ligaments. Water is then drained and the dissection is continued deep into the area until the archostendineous fascia pelvis is identified and the paravaginal space is developed if a paravaginal defect repair is planned at the time of a Burch-Copper suspension. To identify the paravaginal defects, the assistant elevates the anterior vaginal wall with a finger in the vagina. The archostendineous fascia pelvis is identified and the paravaginal defect is repaired using several interrupted stitches. When paravaginal repair is performed concurrently with the Burch-Copper suspension, it is easier to repair the paravaginal defect prior to placing the Burch stitches. Several techniques can be used for placement of the sutures. In order to avoid locking the sutures, we use two 10-millimeter ports and zero ethabond on double-armed SH or CT2 needle. When suturing on the right side, we introduce the stitch on the left side. The stitch is then taken through the periurethral endopelvic fascia. The needle is then passed through the Cooper's ligament and taken out the right port. The second needle is then introduced through the left port and the stitch is repeated or simply taken through the Cooper's ligament. The suture is tied on the right side, above the ligament. Alternatively, using one 10-millimeter port on the right, the surgeon places all four stitches from the right side, while the second surgeon assists from the left side with a laparoscopic instrument in the right hand and provides vaginal manipulation with the left hand. Occasionally we place gel foam behind the sutures to facilitate scarring. When using robotic assistance, a monofilament permanent stitch may be placed through the Cooper's ligament first and then through the periurethral endopelvic fascia. This illustrates the final placement of the sutures. The distal suture is placed approximately two centimeters lateral of the mid urethra and the proximal suture is placed approximately two centimeters lateral to the bladder wall at the level of the urethral vesicle junction. When tying the sutures, the surgeon must be particularly aware not to over-tension the suspension, as this may lead to urinary retention and dysfunctional voiding. The appropriate tensioning of the repair is a particular challenge of the laparoscopic and robotic approaches, as the primary surgeon may need to rely on the assistant to provide guidance with vaginal manipulation. The rich vascular venous bundle in the space of Rhetzius predisposes to bleeding during the dissection of the space, particularly at the time of a repeat retropubic procedure. When excessive bleeding occurs, it can be controlled by direct pressure, sutures, or vascular clips. Less severe bleeding usually stops with pressure alone and after tying the suspension sutures. Sutures may also be inadvertently placed too medial. Thus, cystoscopy is warranted to ensure that there are no stitches penetrating the bladder. Knowledge of the anatomy, particularly the distance to the obturator canal and the external iliac vessels, is paramount, as injury to these vessels may lead to catastrophic hemorrhage. In conclusion, vertical suspension remains an important management option of stress urinary incontinence. It is appropriate for patients who have failed treatment with sling or who decline synthetic mesh placement. This procedure is particularly suitable when performed at the time of another abdominal surgery.

Burge Culpa Suspension

stress urinary incontinence

midurethral sling

recurrent incontinence

laparoscopic Burch procedure