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A Retrospective Review of Perioperative Complications in 360 Patients who had Burch Colposuspension

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A Retrospective Review of Perioperative Complications in 360 Patients who had Burch Colposuspension
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  Aust NZ J Obsret Gynaecol 1999; 39: 4: 472 475 A Retrospective Review of Perioperative Complications in 360 Patients who had Burch Colposuspension Fuat Demir~i'.~, ese Y~cel',~, elcuk O~den~,~, uri Delikara2,s, Serap Yalti2,5 and Elif Demir~i~,~ Departments of Obstetrics and Gynaecology, Medical School of Abant luet Baysal University4 and Zeynep Kamil Women and Children Hospital5, Turkey EDITORIAL COMMENT We accepted this paper for publication because it reports a large experience with the Burch colposuspension operation and presents the complications encountered. It also provides a detailed review of the complications reported by others. In this series zyxwv 360 patients, 75.8 had an abdominal hysterectomy performed at the time of the Burch colposuspension. Our urogynaecologist reviewer tells zyxwv   that this is a very high proportion o hysterectomies although there is a body of opinion that believes that a hysterectomy improves the results when the Burch operation is done in the treatment o women with genuine stress incontinence of urine. The incidence of hysterectomy has to be factored in to the data presented in this paper with regard to the complications that followed the operation. N.B. AUTHORS RESPONSE TO EDITORIAL COMMENT Most o our patients had hysterectomy together with the Burch procedure but not because we believe that a hysterectomy improves the results when a Burch colposuspension is performed. The prevalence o genuine stress incontinence is high in Turkey, being associated with a high birth rate and poor obstetric care. Turkish women who sufSer from genuine stress incontinence view incontinence as a normal consequence of bearing children andor growing older. Only a few seek therapy for incontinence. Most attend hospital for other gynaecological pathology and clinicians become aware o their urinary incontinence while taking the history and add anti-incontinence surgery to any other necessary procedure, which is commonly hysterectomy. A recent study of incontinence in Turkish menopausal women showed the prevalence o urinary incontinence to be 37 but only 7 sought treatment. O women with urinary incontinence 62 viewed the incontinence as a normal consequence o bearing children or growing older; 8 did not know that is was treatable, and 23 were too embarrassed to speak to their physician about it. Summary: This retrospective study reviews intraoperative and early complications of Burch colposuspension of 360 patients. Ten patients had massive haemorrhage and 8 of them had a blood transfusion. Three patients had a haematoma. Bladder injuries were noticed in 10 patients, 3 of whom were diagnosed postoperatively. One patient had unilateral ureteral kinking. Urinary retention occurred in 20 patients for more than 10 days and 2 required catheterization for 26 and 32 days respectively. Eighteen patients had a wound infection and 4 had a wound abscess. Twenty nine patients had a urinary infection. Urinary tract injury, haemorrhage and blood transfusion were significantly more common in women having secondary surgery than those having primary surgery. Deep venous thrombosis was diagnosed in 3 patients who had a Burch colposuspension with concomitant abdominal hysterectomy. Knowledge 1. Assistant Professor 2. Staff specialist. 3. Medical officer. Address for correspondence: Dr Fuat Demirci, Selahattin Pinar Sok, 121/8 Mehtap Apt, 81 160 Uskudar, Istanbul, Turkey.  FUAT DEMIRCI T AL 473 of possible risks and complications of Burch colposuspension may help plan a better preoperative work-up of patients and may minimize the intraoperative complications and increase surgical success and patient satisfaction. Genuine stress urinary incontinence GSI) is the most common cause of female incontinence. Despite advances in conservative treatment, the most effective therapy of GSI is surgical. Numerous surgical techniques have been developed as treatment for patients with genuine stress urinary incontinence, one of the most commonly performed operations being the Burch colposuspension. Complications of colpo- suspension vary from simple, such as urinary retention to severe, such as ureteral obstruction with loss of a kidney. An increased awareness of potential surgical complications of colposuspension may help both in appropriate preoperative patient assessment and decreasing the complication rates. The main objective of the study was to assess the intraoperative and early postoperative complications of Burch colposuspension in a large series of patients. MATERIALS AND METHODS This retrospective study was conducted at 2 medical centres. The available hospital records of the patients who underwent the Burch colposuspension operation from March 1994 to February 1999 were evaluated. Perioperative and early postoperative complications were recorded. The Burch colposuspension was performed only on patients who suffered from genuine stress incontinence with or without other gynaecological pathologies (uterine myoma, endometrial polyp, endometrial hyperplasia). Suprapubic bladder drainage was used at the first medical centre and transurethral catheterization was used at the second. The rate of urinary infection was compared in the 2 groups. Patients who had primary surgery and patients who had secondary surgery were compared in terms of urinary tract injury (bladder injury, urethral kinking and urethral injury), haemorrhage, blood transfusion, urinary retention, febrile morbidity and wound infectiodabscess. Statistical analysis was performed with the statistical package for social sciences SPSS) on a computer. The chi-squared test for trend, or Fisher exact test was used to compare proportions relating to subjects in different groups. RESULTS Of the 360 patients included in the study, 316 had primary surgery and 44 had secondary surgery. Prior to our surgery, 38 of 44 had had an anterior repair and 6 had had a Marshall-Marchetti-Kantz (MMK) operation. There was a significant difference in terms of urinary tract injury, haemorrhage and blood transfusion between the 2 groups (table 1). Of the patients, 87 had only a Burch colposuspension and 273 had the Burch procedure with concomitant abdominal hysterectomy. The average age of the patients at the time of surgery was 47.4 years (range 29-62) with the average parity 3.8 (range 0-12). The average hospital stay was 9.2 days (range 6-22). Table 1. Comparison of Complications in Women Having Primary and Secondary Surgery Complications Primary surgery Secondary surgery p n=318) n=44) Urinary tract zyxwv   Haemorrhage 4 injury Blood 6 transfusion Urinary 15 retention zyxwv 10 days Febrile 28 morbidity Wound infection/ 18 abscess 7 <0.001 4 <0.01 z   10.01 5 NS z   NS 4 NS NS = not significant Table 2. Complications of Burch Colposuspension in 360 Patients ~ ~~ Complications No. Bladder injury Ureteral kinking Urethral injury Haemorrhage Haematoma Wound infection Wound abscess Urinary retention >10 days Catheterization >30 days 10 1 1 10 3 18 4 20 1 Urinary infection 29* Reoperation zyxw   *236 patients’ data were available Ten patients had massive haemon-hage and 8 of them received a blood transfusion. Three patients who had a haematoma in the space of Retzius related to the Burch colposuspension required blood transfusion and reoperation.  474 AUST ND NZ JOURNAL F OBSTETRICS ND GYNAECOLOGY Bladder injuries were noticed during operation in 7 of the 10 patients who had this complication. Three were diagnosed in the postoperative period and were reoperated upon for repair of the bladder. Seven of the 10 women with bladder injury were having secondary surgery (3 MMK, 4 anterior repair). An inadvertent suture placement through the urethra and the Foley catheter was noticed following the operation in 1 woman. Another patient had unilateral ureteral kinking postoperatively which caused oliguria and lumbar pain, a ureteral stent could not be inserted and the sutures were removed unilaterally at reoperation (table 2). One of 31 patients (3.2 ) who had suprapubic drainage had urinary infection, whereas 28 of the 205 (13.7 ) patients who had transurethral drainage had urinary infection. This difference was not significantly different (p>O.O5). Urinary retention occurred in 20 patients for more than 10 days and 2 required catheterization for 26 days and 32 days respectively. Eighteen patients had a wound infection and 4 had a wound abscess which required drainage. Deep venous thrombosis was found in 3 patients who had Burch with concomitant abdominal hysterectomy. Complications of the Burch colposuspension are shown in table 2. DISCUSSION Haemorrhagic complications include excessive intraoperative blood loss, the need for transfusion and haematoma formation. Haemorrhage can occur rapidly in the space of Retzius with trauma to the paravaginal veins during dissection. If the dissection is performed carefully drainage is usually unnecessary, but if bleeding occurs, drainage of the paravaginal area is recommended. Bleeding may be controlled by diathermy, ligaclip, and usually stops when elevation of the paravaginal fascia is completed. In the present study, we found haemorrhage in 10 and haematoma in 3 of 360 patients. Haemorrhage was reported by van Geelen et a1 (1) in of 34 patients, by Solh et a1 (2) in 7 of 33 patients and by Wang (3) in 2 of 294 patients. Baker and Drutz (4) reported the necessity for blood transfusion in 102 of 289 patients. Stanton and Cardozo zyxwvutsrq 5) reported haemorrhage requiring laparotomy in 1 of 186 patients. Haematoma was noted by Galloway et a1 (6) in 6 of 174 padents, by Kiilholma et a1 (7) in 5 of 186 patients and by De Goeij 8) in 4 of 37 patients. Bladder injury mainly occurs in patients who have had previous surgery especially MMK. In these women sharp rather than the usual blunt dissection may be necessary in order to transsect scars and enable visualization of anatomical structures. Additionally, the bladder may be filled with lOOmL of saline with methylene blue to determine the margins of the bladder and allow recognition of sutures perforating the bladder wall. Bladder injury was reported by Stanton and Cardozo (5 in 0.6 of patients, by Wang (3) in 2.4 of patients, by Enzelsberger et a1 (9) in 2 of 36 patients 5.6 ) and by Christensen et a1 (10) in 1 of 91 patients (1.1 ). We found bladder injury in 10 patients (2.8 ); 7 were cases of secondary surgery (3 MMK, 4 anterior repair). Women who had undergone MMK seemed to have a special risk of bladder injury. De Goeij 8) also reported bladder injury in 2 of 37 patients both of whom had undergone MMK. Ureteral kinking or ureteral injuries are not uncommon after colposuspension. Previous surgery causes fibrosis, scarring and even dislocation of local tissues. We noticed unilateral ureteral kinking in 1 woman who had not had any previous operation. Ericsen et a1 (11) found 1 of 75 patients(l.3 ) followed 5 years after Burch operation who had absent unilateral renal function due to presumed complete ureteral obstruction. Galloway et a1 (6) reported 1 urinary diversion in 50 patients (2 ) and Korda et a1 (1 2) reported unilateral kinking in 2 of 174 patients (1.1 ). Apart from these cases, Rosen et a1 (13) reviewed case reports in the literature and reported 17 women with ureteric damage; usually these women had undergone previous pelvic surgery. Postoperative voiding difficulties which are a well known complication after Burch colposuspension are associated with the degree of bladder neck elevation. De Goeij 8) and van Geelen et a1 (1) reported voiding difficulty in 5.7 and 5.9 of patients respectively. We found urinary retention for more than 10 days in 5.6 of patients. In contrast to these studies with a low rate of morbidity, Galloway et a1 (6) reported voiding difficulties in 16 of patients and 6 of them required urethral dilatation. Kremer and Freeman (14) and Korda et a1 (12) reported catheter drainage for more than 10 days in 22.4 (1 1 of 49) and 24.1 respectively. Kjolhede and Ryden (15) reported indwelling catheter drainage for more than 2 weeks in 22 patients (9.1 ). Permanent self-catheterization was reported at 1.1 by Korda et a1 (12), 2 by Kremer and Freeman (14), 2.2 by Christensen et a1 (10) and 3 by Solh et a1 (2). De Goeij 8) reported a patient who had catheterization which lasted for 87 days. Hodkinson and Stanton (16) also reported a patient in whom satisfactory voiding occurred after 215 days of catheterization. Our 2 most troublesome patients required catheterization for 26 and 32 days. In this study, we found urinary infection in 29 of 236 patients (12.3 ). Urinary tract infection was reported in 6.8 by Wang (3), 14 by Kiilholma et a1 (7), 15.1 by Solh et a1 (2), 28.7 by Kjolhede and Ryden (15),29 by Hodkinson and Stanton (16) and 45.4 by Korda et a1 (12). in this study, urinary infection was found in 13.6 of patients who had transurethral catheterization and in 3.3 of patients who had suprapubic bladder drainage. However, there  FUAT DEMIRCI T AL 475 was no significant difference (p>0.05) between the 2 groups. The routine use of a suprapubic catheter has been reported to significantly reduce the incidence of postoperative urinary infection (2). Wound infection was reported in 1.1 by Christensen et a1 (lo), 2.9 by Galloway et a1 (6), 4.1 by Wang zyxwvutsr 3), 4.3 by Kiilholma et a1 (7) and 10.8 by De Goeij (8). Retropubic abscess was reported in 8.1 by De Goeij (8) and 2.4 by Baker and Drutz (4). We found wound infection in 5 and abscess in 1.1 zyxwvuts   of patients. Urinary tract injury, haemorrhage and blood transfusion were more significantly common in the cases of secondary surgery than in the cases of primary surgery. However, there was no significant difference in terms of febrile morbidity, wound infectiodabscess and urinary retention (table 1). It is emphasized that the complication rate was higher in the women with secondary surgery zyxwv 4, 3, 15). Deep venous thrombosis was reported in 0.6 by Stanton and Cardozo (5), 0.6 by Galloway et al 6), 1 by Baker and Drutz (4), 1.1 by Kiilholma et a1 (7) and by Christensen et a1 (10) and 3 by Solh et a1 (2). Solh et a1 zyxwvutsr 2) reported an incidental colostomy and declared all complications increased when a con- comitant procedure followed Burch colposuspension. Stanton and Cardozo (5) reported cerebrovascular accident in 0.6 of patients. Pulmonary embolism was reported in 0.5 by Kiilholma et a1 (7) and in 0.3 by Baker and Drutz (4). De Goeij (8) reported 1 death due to urosepsis on the postoperative 44th day. In conclusion, although the Burch colposuspension is a simple, effective and frequently-used method for surgical correction of genuine stress urinary incontinence, the complications which are described above sometimes occur. Therefore, knowledge of possible risks and complications may help plan a better preoperative work-up of patients and may minimize the intraoperative complications and increase surgical success and patient satisfaction. References 1 van Geelen JM, Theeuwes AG, Eskes TK, Martin CB. The clinical and urodynamic effects of anterior vaginal repair and Burch colposuspension. Am J Obstet Gynecol 1988;159: 137- 144. 2. Solh S Holschneider H, Lebherz TB, Montz FJ. Retropubic urethropexy. A 15-year review of perioperative complications. Int Urogynecol J 1994; 5: 349-352. 3. Wang AC. Burch colposuspension vs. Starney bladder neck suspension. J Reprod Med 1996; 41: 529-533. 4. Baker KR, Drutz HP. Retropubic colpourethropexy. Clinical and urodynamic evaluation of 289 cases. Int Urogynecol J 1991; 2: 196-200. 5. Stanton SL, Cardozo LD. Results of the colposuspension operation for incontinence and prolapse. Br Obstet Gynaecol 6. Galloway NT, Davies N, Stephanson TP. The complications of colposuspension. Br J Urol 1987; 60: 122-124. 7. Kiilholma P, Makinen J Chancellor MB, Pitkanen Y Hirvonen T. Modified Burch colposususpension for stress urinary incontinence in females. Surg Gynecol Obstet 1993; 176: 11 1- 115. 8. De Goeij WBMK. Incontinence of urine in women. A urodynamical and rontgenogical study. Catholic University of Nijmegen, Nijmegen, The Netherlands. Thesis, 1976. 9. Enzelsberger H, Helmer H, Schatten C. Comparison of Burch and lyodura sling procedures for repair of unsuccessful incontinence surgery. Obstet Gynecol 1996; 88: 25 1-256. 10. Christensen H, Laybum C, Eickhoff JH, Frimodt-Moller C. Long-term result of the Stamey Bladder neck suspension procedure and of the Burch colposuspension. Scand J Urol Nephrol 1997; 31: 349-353. 11.Eriksen BC, Hagen B, Eik-Nes SH, Molne K, Mjolnerod OK Romslo I. Long term effectiveness of the Burch colposuspension in female urinary stress incontinence. Acta Obstet Gynecol 12.Korda A, Ferry J, Hunter P. Colposuspension for the treatment of female urinary incontinence. Aust NZ J Obstet Gynaecol 13.Rosen D, Korda AR, Waugh RC. Ureteric injury at Burch colposuspension. 4 case reports and literature review. Aust N Z Obstet Gynaecol 1996; 36; 3: 354-358. 14.Kremer CC, Freeman RM. Which patients are at risk of voiding difficulty immediately after colposuspension? Int Urogynecol J 15.Kjolhede P, Ryden G. Prognostic factors and long term results of z he Burch colposuspension A retrospective study. Acta Obstet Gynecol Scand 1994; 73: 642-647. 16. Hodkinson CP, Stanton SL. Retropubic urethropexy or colposuspension. In: Stanton SL, Tanagho E, eds. Surgery of female incontinence. New York, Springer Verlag, 1980; 12: 55-68. 1979; 86: 693-697. 1990; 69: 45-50. 1989; 9: 146-149. 1995; : 257-261.
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