JOURNAL OF ENDOUROLOGY

Volume 6, Number 2, 1992

Mary Ann Liebert, Inc., Publishers

Laparoscopic Bladder Neck Suspension

DAVID M. ALBALA, M.D.,* WILLIAM W. SCHUESSLER, M.D.,t
and THIERRY G. VANCAILLIE, M.D.t

ABSTRACT

The authors describe a laparoscopic technique similar to the Marshall-Marchetti-Krantz operation for the
correction of true stress incontinence. In the reported experience with 22 patients, the technique was successful
in all, although the follow-up is only 9.5 months. Laparoscopic bladder neck suspension is not appropriate in
patients with extensive adhesions, a history of sepsis and peritonitis, a dilated large bowel, or an uncorrectable
coagulopathy.

INTRODUCTION
STRESS
voluntary
URINARY INCONTINENCE, defined as the in¬
loss of urine from thè urethra associated with a
sudden increase in intra-abdominal pressure, has long been an
interesting problem for many innovative urologie and gyneco¬
logic surgeons. Loss of continence occurs when intravesical
pressure exceeds the maximum urethral pressure in the absence
of detrusor activity.12 During stress, the vesical neck and prox¬
imal urethra descend below the limits of the abdominal cavity.3
This change in pressure gradient as well as anatomic position
results in the leakage of urine.
mic were placed into the anterior vaginal wall as well as through
the urethral wall, without, it was hoped, entering the lumen of
the urethra. These sutures were placed on either side of the
urethra and the bladder neck and secured to the periosteum of
the pubic bone and the cartilage of the symphysis (Fig. 1). After
the anterior vaginal wall was elevated, these sutures were tied to
elevate the urethra and bladder neck to a high, well-supported
position. The MMK technique has been modified subsequently
to avoid suture placement into the urethral wall.
Since the original description of the MMK procedure, more
than 60 surgical procedures designed to correct stress inconti¬
nence have been described. The surgical procedure used to

The technology and expertise exist that should permit the
cure of urinary incontinence in most motivated patients, includ¬
ing those with significant physical and neurologic disabilities.
Surgical procedures designed to correct stress urinary inconti¬
nence elevate the bladder neck to a position behind the symphy-
sis pubis. Since 1914, when Goebell, Stroekl, and Frangenheim
introduced their retropubic surgical procedures for stress incon¬
tinence, various attempts at improving the results and decreas¬
ing the morbidity have produced several major changes in the
operative technique. In 1949, Marshall, Marchetti, and Krantz
(MMK) introduced their procedure, which modified the tech¬
nique and indications for retropubic urethropexies.4 Their oper¬
ative technique employed a suprapubic incision and extraperito¬
neal mobilization of the retropubic space, exposing the anterior
vaginal wall, urethra, and bladder neck. Sutures of No. 1 chro¬
correct incontinence is based on the degree of relaxation of the
pelvic diaphragm and other anatomic findings revealed during
the initial pelvic examination. This article examines a new
approach using the laparoscope to perform a bladder suspen¬
sion. This technique, which is similar to the MMK procedure,
is described herein and the results summarized.
PATIENT SELECTION
The success of any surgical procedure designed to cure stress
incontinence is based on accurate selection of patients who
actually have stress incontinence and the exclusion of those
who have other forms of incontinence. A patient's history is
critical both in relating the incontinence to elevation of intra-

*Department of Urology, Loyola University Medical Center, Maywood, IL

tTexas Endosurgery Institute, San Antonio, TX

137
138
FIG. 1. Suture placement site ( ), as originally described by
Marshall, Marchetti, and Krantz. U urethra, V vagina,
= =
=
bladder.
abdominal pressure and in correlating the severity of inconti¬
nence with physical activity. The progressive worsening of
incontinence with decreasing degrees of physical stress can
often be elicited through a careful history. A thorough physical
examination requires neurologic, gynecologic, and urologie
evaluation. Significant stress incontinence may be demonstra¬
ble in either the supine or the standing position. On the other
hand, milder forms of stress incontinence may be demonstrable
only when the patient stands.
Control of stress incontinence can be demonstrated by elevat¬
ing tissue lateral to the urethral-vesical junction. For this exam¬
ination, the use of one finger rather than two avoids the possi¬
bility of urethral compression and inaccurate interpretation of
the test. A urinalysis and urine culture are essential during
evaluation to exclude either hematuria or urinary infection.
Formal urodynamic testing can characterize bladder dysfunc¬
tion in a quantitative and reproducible fashion.5 This is espe¬
cially important if a patient's symptoms of stress incontinence
cannot be demonstrated objectively. In stress incontinence,
urodynamic studies show normal bladder function with a low¬
ered urethral pressure profile and reduced functional length.
Urodynamic studies will also define bladder capacity and relate
bladder capacity to intravesical pressures.
The problem of detrusor instability in patients with stress
incontinence is not resolved simply by urodynamic testing.
Even if the syndrome is identified preoperati vely, a clear idea of
how much trouble a patient will have after a successful opera¬
tion for stress incontinence is largely a matter of conjecture.
Urodynamic and radiographie investigations will uncover a
small group of patients without stress incontinence who should
not be treated through surgery. This type of testing may help the
ALBALA ET AL
surgeon select an appropriate operative procedure; however, by
itself, it does guarantee freedom from problems related to
not
detrusor contractile activity after surgery.
A laparoscopic bladder neck suspension is not indicated in
patients with extensive adhesions from multiple prior open op¬
erations, those with a history of sepsis and peritonitis, those
with a dilated large bowel, and those with an uncorrectable
coagulopathy. In patients with atrophie vaginitis or a poorly
compliant vagina, topical estrogen cream may be used for 2
weeks before surgery.
OPERATIVE CONSIDERATIONS
Before surgery, all patients should undergo a mechanical
bowel preparation to decompress the intestine and protect
against infection should any bowel injury occur during the
procedure. A broad-spectrum parenteral antibiotic should be
given 1 hour before the procedure. Blood should be typed and
cross-matched in all patients. A nasogastric tube and Foley
catheter are inserted to decompress the intestine and bladder,
respectively. All patients should receive a general anesthetic.
SURGICAL TECHNIQUE
With the patient placed in a modified lithotomy position, a
small incision is made, and a Veress needle is advanced through
the fascia and peritoneum.6 Carbon dioxide gas is used to insuf¬
flate the abdomen at a rate of 1 to 6 L/minute. Once the abdo¬
men is well distended to a pressure of 15 mmHg, four trocars
are placed: an 11-mm trocar in the umbilicus, an 11-mm mid-
line trocar halfway between the pubic bone and umbilicus, a
5-mm trocar lateral to the rectus muscle halfway between the
anterior iliac spine and umbilicus on the right, and a 5-mm
trocar lateral to the rectus muscle halfway between the anterior
iliac spine and the umbilicus on the left. Once all trocars are in
place, the abdomen should be inspected for trocar-induced in¬
jury or any concomitant pathology. All adhesions in the pelvis
should be lysed.
Using electrosurgery scissors, the initial incision is made
along the medial border of the left umbilical ligament. Once the
peritoneum is opened, the posterior aspect of the pubic bone is
identified (Fig. 2). Using an atraumatic grasper, the surgeon's
assistant retracts the bladder away from the surgical field while
the surgeon opens the retropubic space and dissects the pubic
arch. Meticulous hemostasis is necessary, as blood tends to
pool in the space of Retzius, making anatomic identification
difficult.
An Ethibond 2/0 suture (Ethicon, Sommerville, NJ) is in¬
serted through the suprapubic trocar and placed just lateral to
the urethra. Placement of this suture is aided by displacing the
vagina away from the pubic bone with the surgeon's hand in the
patient's vagina (Fig. 3). The needle is then brought through the
symphysis of the pubic bone. The bladder neck is elevated to
the appropriate level under direct vision by pulling up on the
suture. The knot is made extracorporeally using the technique
described by Weston7 (Fig. 4). The above maneuver is repeated
on the opposite side; a total of two sutures are placed (Fig. 5).
LAPAROSCOPIC BLADDER NECK SUSPENSION
FIG. 2. View of space of Retzius after
Closure of the peritoneal defect is optional and may be done
with either sutures or clips. At the end of the procedure, after all
trocar sites have been inspected for bleeding, fasciai and subcu¬
taneous sutures are placed at the 11-mm trocar sites, and adhe¬
sive strips placed at the 5-mm trocar sites. The Foley cathe¬
are
ter and nasogastric tube are removed before the general
anesthesia is reversed.
Postoperatively, the patient is given one dose of a parenteral
antibiotic followed by a broad-spedtrum oral antibiotic for 5
days. A clear liquid diet is begun as soon as the patient is awake
and alert. Early ambulation is encouraged. Residual urine is
measured after the patient voids. The need for pain medication
is minimal, and acetaminophen usually is sufficient. Most pa¬
tients are discharged within 18 hours of their surgery.
FIG. 3. Placement of first suture in periurethral tissue. Surgeon puts left hand in vagina to elevate anterior wall at level of bladder
neck. (Courtesy of TEI, Inc.)
139
peritoneum is incised. (Courtesy of TEI, Inc.)
RESULTS
Vancaille and Schuessler have performed 22 bladder neck
suspensions using the laparoscope on patients with Grades I and
II stress incontinence (personal communication). In their series,
the average operating time ranged from 35 to 175 minutes, with
a mean of 65 minutes. Eighteen patients were discharged from
the hospital in less than 18 hours. Nine patients were discharged
without a Foley catheter, while 13 patients required placement
of the catheter for 3 days. Nineteen patients resumed their
normal activities within 5 days of their surgery. In all patients,
stress incontinence was cured; however, follow-up is short
(mean 9.5 months).
Complications early in this series included urinary retention
patients, for which a cystotomy tube was placed. Three
in two
140
FIG. 4. First suture has been tied according to Weston technique. (Courtesy of TEI, Inc.)
patients required a laparotomy: in two patients, technical diffi¬
culty prevented the placement of the periurethral suture, while
in one patient, abladder injury occurred during dissection in the
space of Retzius. These three patients were discharged from the
hospital on the third postoperative day, and all were cured of
their stress incontinence.
DISCUSSION
The cause of urinary stress incontinence in women is a de¬
rangement of the normal anatomy and physiology of the bladder
and urethra. The urethra is closed and continence maintained by
the activity of the smooth and skeletal musculature of the prox¬
imal urethra. Although the viscoelastic properties of the urethra
and surrounding
supporting structures and "inner wall softness"
objective means to study these parameters are
also play a role,
only now being developed. In women, the functional urethral
sphincter extends from the vesical neck to the urogenital dia¬
FIG. 5. Laparoscopic bladder neck suspension has been completed. (Courtesy of TEI, Inc.)
ALBALA ET AL
phragm. Impairment of this proximal sphincter mechanism usu¬
ally results in urinary incontinence.
Even when smooth and skeletal muscle function in the ure¬
thra are normal, the urethra may lose its supporting structures.
When this occurs, during increases in intra-abdominal pressure,
the urethra is pushed out of its normal retropubic position into
the vagina. When the urethra falls out of its normal position, the
transmission of intra-abdominal pressure to the urethra be¬
comes unequal. Thus, whenever the pressure in the bladder
becomes greater than the pressure in the urethra, incontinence
ensues. The normal act of micturition also may foreshorten the
urethra sufficiently to contribute to stress incontinence.
The MMK operation functions by restoring mechanical effi¬
ciency to an intrinsically intact sphincter mechanism by restor¬
ing firm attachments. Such elevation away from the introitus
and toward the umbilicus, as in the stress test, can cure stress
incontinence. In fact, any procedure that does this permanently
will produce favorable results. Early reports of MMK retropu¬
bic suspensions produced success rates of 87%; however, Spen-
LAPAROSCOPIC BLADDER NECK SUSPENSION
cer and colleagues reported a less optimistic 57%
rate of
cure
stress incontinence in 54 women followed for of 68.2
a mean
months after MMK urethropexy.8'9 Parnell and coworkers re¬
ported a 90% success rate in 140 patients followed for a mean of
45.7 months.!0 In this series, postoperative urinary retention
occurred in 27% of patients.
The results of surgery for incontinence reinforce the concept
that incomplete pressure transmission to the proximal urethra
secondary to anatomic descent is the principal etiologic factor
in stress incontinence. The goal of surgery is to restore the
proximal urethra and urethrovesical junction to their normal
intra-abdominal location. This goal is accomplished with both
the standard MMK technique and the laparoscopic bladder neck
suspension. Surgical correction has been shown to restore trans¬
mission ratios to normal, in spite of the fact that no significant
increase occurs in closure pressure or functional length. '
Overall, the laparoscopic bladder neck suspension offers the
patient a less morbid alternative to the standard MMK. Al¬
though this procedure may be slightly more time-consuming,
the hospital stay and presumably the convalescence are greatly
reduced by a laparoscopic approach. A steep learning curve
exists, however, and the procedure itself is not innocuous. In
the Vancaille and Schussler series, three patients required an
open laparotomy.
As with laparoscopic varicocelectomy, the laparoscopic
bladder neck suspension must compete against other less inva¬
sive "needle" suspension techniques that accomplish a similar
goal: the Gittes-Loughlin, Stamey, and Raz bladder neck sus¬
pensions.12'5 Each of these procedures involves either no inci¬
sion or a small vaginal incision and a short hospital stay ( 1 to 3
days) and produces a continence rate of 80% to 90%. Suspen¬
sion procedures may fail because of improper patient selection
or if the suspending sutures are tied too tightly and erode
through the fascia. One advantage of the laparoscopic ap¬
proach, when compared with the blind needle suspensions, is
that the suture is placed and tied at the appropriate level under
direct vision. During tightening of the knot, the surgeon can
closely observe the change in anatomic position of the bladder
neck. Bone fixation with the laparoscopically placed suture
results in decreased postoperative discomfort because the ante¬
rior abdominal wall is not used as the fixation point for the
suspension sutures. Suture fixation also takes place without the
use of a foreign pledget material.
A longer follow-up period is required to evaluate the laparo¬
scopic bladder neck suspension fully. Prospective clinical stud¬
ies comparing this technique with the standard MMK as well as
other needle suspension techniques are needed. Virtually all
previous studies comparing these various techniques have been
retrospective and uncontrolled.
The goal of surgery for anatomic incontinence is to elevate
and support the bladder neck in a high, fixed, retropubic posi¬
tion by resuspending of the urethropelvic ligaments. Using the
laparoscopic approach, this goal is realized in a minimally
invasive way.
141
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Address reprint requests to:
David M. Albala, M.D.
Dept. of Urology
Loyola University Medical Center
2160 S. First Ave.
Maywood, IL 60153