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 today.

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 me.

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 Linda.

"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 surgery."

"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 scar."

"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.