43 Robotic assisted burch urethropexy

Abstract

We present our approach and technique for robotic assisted Burch urethropexy in the management of a patient with stress urinary incontinence. Our patient was a 41-year-old G4P4 with history of stress urinary incontinence with urethral hypermobility. The patient desired surgical management without mesh placement, and chose robotic assisted Burch urethropexy. In the operating room, we placed four robotic trocars with one assistant arm, and utilized the Davinci Xi model. The bladder was retrograde filled, which allows identification of the upper limit of the bladder, otherwise known as the abdominovesical junction. The anterior peritoneal incision was made 1cm above the abdominovesical junction between the obliterated obturator ligaments. Blunt dissection was performed to reach the pubic symphysis bone anteriorly with Cooper’s ligaments located laterally on each side. The bladder was drained with dissection continued laterally to visualize the obturator muscle and arcus tendineus fascia. Gentle traction on the Foley catheter shows the urethrovesical junction. Dissection was continued to reach the paravaginal endopelvic fascia on each side. We introduced two CT needles with 2-0 nonabsorbable suture. The first suture was placed on the midurethral level of the endopelvic fascia 1-2 cm away from the bladder. The second suture was placed 1-2 cm cephalad to the previous suture, 1-2 cm lateral to the bladder, and 1-2 cm distal from the previous suture on Cooper’s ligament. The suture was tied using sliding knots technique with tension adjusted to lift the endopelvic fascia 1 cm above the edge of the pubic symphysis bone. Two sutures were placed in similar fashion on the contralateral side. The peritoneum was closed in continuous fashion with 3-0 barbed suture. The patient reported complete resolution of her stress urinary incontinence at her six-month postoperative visit. Robotic assisted Burch urethropexy is a safe and effective technique to manage stress urinary incontinence.