Laparoscopic Bladder Neck Suspension
C. Y. Liu, M. D., F. A. C. O. G.
Linda is a 46-year-old secretary in one of the local law firms
who came into my office for her annual check up. She voiced no special
health problems. However, I found that she had gained 12 pounds
over the past year. Although she knew that she had gained some weight,
she did not realize that she had gained so much. She had always
kept her weight under good control. There had been no change in
her eating habits, but she did admit that she had not been exercising
as before. When I inquired further about this she became somewhat
embarrassed and with a big sigh she said, "I use to enjoy outdoor
activities, jogging, playing tennis or hiking, but now I can't do
any of them." As our conversation continued, I realized that Linda
had not only given up exercising, but she had also been avoiding
social activities. "Whenever I go anywhere, I have to make sure
that my bladder is empty, and even then, whenever I laugh or sneeze,
I automatically tighten my thighs hoping the urine won't leak out,"
she stated. Linda was suffering from a disorder called urinary incontinence,
which is very common among women.
In 1928, Dr. Howard Kelly, who was one of the most prominent pioneers
in modern gynecology, made the following statement. "There is no
more distressing lesion than urinary incontinence - a constant dribbling
of the repulsive urine soaking the clothes which cling wet and cold
to the thighs, making the patient offensive to herself and her family
and ostracizing her from society." This statement still holds true
An estimated 20-30% of middle-aged and elderly women living at
home have problems with urinary incontinence. The prevalence among
institutionalized elderly women is even higher, an estimate of more
than 50% that suffer from urinary incontinence. Despite its high
prevalence, most affected individuals do not seek medical help,
primarily because of embarrassment or because they think that urinary
incontinence is a result of aging and an inevitable problem with
which all women must contend.
Urinary incontinence can be caused by pathologic, anatomic or physiologic
factors affecting the urinary tract as well as the area around it.
Many of these factors can be reversed and most of them can be treated
either with medication or behavioral modification or a combination
of both. However, certain types of urinary incontinence, especially
those caused by anatomical alterations due to pelvic relaxation
may require surgical treatment. This includes the dropping of the
bladder neck and the urethra (the tube between the bladder and opening
of the vagina) which is due to the loss of normal vaginal support,
most commonly secondary to previous childbirth injury. The goal
of the surgery in this instance is to restore the normal anatomical
position of the bladder neck and the urethra, thus preventing the
leakage of the urine during the physical stress.
Traditional surgical treatment involves a large incision about
5-6 inches in the lower abdomen; the abdominal wall is then opened
up to the retropubic space (the space behind the pubic bone and
above the bladder and the vagina). The bladder is then mobilized
and sutures are placed on each side of the bladder neck, attaching
it to a very tough ligament called Cooper's ligament, which is located
on the upper lateral margin of the pubic bone. This lifts up the
bladder neck and restores the normal anatomy.
With recent advances in laparoscopic and video technologies we
can perform nearly every non-malignant gynecological surgery through
the laparoscope. A laparoscope is a tiny telescope that allows the
surgeon to look into the abdomen and perform a variety of surgical
procedures without making a large incision. We can cut, suture,
coagulate, repair, and remove organs - all through the laparoscope.
Some of the procedures done laparoscopically include removal of
the uterus, ovaries, ovarian cysts, ectopic pregnancies, endometriosis,
and scar tissue in the abdomen or pelvis. We can also perform some
very sophisticated fertility promoting procedures such as opening
or untying the blocked tubes. Since early 1990 I have pioneered
the laparoscopic bladder neck suspension with very good results.
The results have been published in major medical journals, and over
2,000 gynecologists from across the U.S. and abroad have come to
Chattanooga to learn this innovative laparoscopic procedure from
After further inquiry into Linda's bladder problem and running
routine tests, I decided that Linda might benefit from pelvic muscle
exercises and a bladder training program. However, after three months
Linda returned to the office - this time with her husband, Phil.
Her bladder leakage remained bothersome and she inquired about the
laparoscopic bladder neck suspension. As with all my pre-surgery
consultations, I began to explain the surgery to Linda and Phil.
"I must first make a tiny incision, less than an inch long in the
patient's navel, through which I insert the laparoscope. With a
very bright light source going through the laparoscope and with
a sophisticated video camera, the internal organs are greatly magnified
on the television monitor. I then proceed to inspect the internal
organs, which of course, include the female organs. In all cases,
I routinely obliterate the space between the vagina and the rectum
to prevent future hernia formation. I then enter the retropubic
space and after the bladder has been mobilized, sutures are placed
and the bladder neck and the proximal part of the urethra are lifted
up and the normal anatomy in restored.
"How long will the surgery take?" asked Phil.
"About 70 minutes, on the average, but, of course, it depends on
the extended pathology that we find at the time of surgery."
"What about the pain after surgery? Will I have much of it?" asked
"Yes, you will have some discomfort, but nothing compared to the
traditional surgery. You will not have a large incision on the abdomen.
That is one of the biggest advantages of having the laparoscopic
approach. You will be able to get up and walk the very next morning
after the surgery and take a shower, if you like. You will also
be able to eat a regular meal and most likely go home the day after
"That doesn't sound bad at all. Are there any other advantages
of laparoscopic bladder neck suspension?" asked Linda.
"Indeed, there are a lot more advantages. In addition to less postoperative
pain and discomfort and shortened hospital stay, the surgical complication
rate is less. Since you won't have a large abdominal incision there
will not be wound infection, hematoma of the wound, poor healing,
splitting of the incision, or an ugly scar. Laparoscopic surgery
also has the advantage of having the operative field magnified up
to 7-10 times, and when you can see better you can do a better job!
The suture placement can he more precise, thus obtaining the better
result. Also, the blood vessels can be avoided or cauterized before
cutting them resulting in minimal blood loss, averaging less than
two tablespoons. In our series of more than 120 cases of laparoscopic
bladder neck suspensions, we haven't had to put drains into the
operative site to evacuate the blood. In short, the laparoscopic
approach to the bladder neck suspension provides good results, yet
offering much less pain, a much shorter hospital stay, quicker recovery
time, and less blood loss and other complications, as well as no
"Well, Dr. Liu, this is all quite impressive, " Phil interjected.
"How soon after the surgery can Linda go back to work?"
"Since Linda's job is a desk job, as long as she can avoid any
lifting or bending, she should he able to return to her job 7 to
10 days after surgery."
"That's really good, this will make everybody in the office happy,
since this is a busy time of year. By the way, I heard that you
always videotape the surgery. Is it possible for us to view the
videotape later on?" Linda asked.
"Certainly As a matter of fact, you will get a copy of the videotape.
We routinely videotape and voice record the entire surgery, so the
patient can know how her insides look before the surgery and how
the procedure is performed."
With continued improved surgical techniques and advanced technology,
sophisticated procedures such as laparoscopic bladder neck suspension
can now be performed effectively and safely.