Historical Perspective Anterior vaginal repair (also termed anterior colporrhaphy) was described by Howard Kelly in 1914, and this operation remained the standard first approach to stress incontinence until the middle of the 20th century (68). Many different operations are lumped together under the term anterior colporrhaphy, including simple plication of the bladder neck, elevation of the bladder neck by plicating the fascia under the urethra, and elevation and fixation of the bladder neck by passing sutures lateral to the urethra and driving the needles anteriorly into the back of the pubic symphysis for fixation. As noted previously, the problem with most techniques of anterior colporrhaphy is that they do not hold up well over time (69–71). In essence, this operation attempts to take weak support from below and push it back up from below, with hope that these structures will maintain their strength and position over time. Although there were excellent longterm results shown with anterior colporrhaphy, most of these cases involve specific techniques requiring skillful dissection of the endopelvic fascia, deep bold bites of suture, and fixation of permanent sutures to the pubic bone from below: in essence, a transvaginal retropubic bladder neck suspension (72,73). Most surgical series that evaluated techniques of anterior colporrhaphy for stress incontinence show long-term success rates of only 35% to 65%, a figure that most would regard as unacceptably low. Anterior colporrhaphy should be reserved primarily for patients requiring cystocele repair who do not have significant stress incontinence.
Needle suspension procedures are so named because they suspend the urethra and bladder neck through a technique that involves passage of sutures between the vagina and anterior abdominal wall using a specially designed long needle carrier. Although initial cure rates are between 70% to 90%, rates decrease significantly over time in many series, with 5-year success rates of 50% or less (67,74–77). Therefore, these operations are no longer recommended.
The modern era of retropubic surgery for stress incontinence began in 1949, when Marshall et al. described their technique for urethral suspension in a man with postprostatectomy incontinence (78). A variety of modifications of this operation were described, all of which share at least two characteristics: They are performed through an open low abdominal incision or with laparoscopically assisted exposure of the space of Retzius, and they all involve attachment of the periurethral or perivesical endopelvic fascia to some other supporting structure in the anterior pelvis (Fig. 26.10). In the MMK operation, the periurethral fascia is attached to the back of the pubic symphysis. Another approach, the Burch colposuspension, involves the attachment of the fascia at the level of the bladder neck to the iliopectineal ligament (Cooper’s ligament) (79,80). With the paravaginal repair, the lateral endopelvic fascia along the urethra and bladder is reattached to the arcus tendineus fascia pelvis (81,82). In the Turner-Warwick vagino-obturator shelf procedure, the endopelvic fascia, vagina, or both are attached to the fascia of the obturator internus muscle (83,84).
Figure 26.10 Points of reattachment of the endopelvic fascia during retropubic bladder neck suspensions. A: Arcus tendineus fascia pelvis (for paravaginal repair). B: Periosteum of pubic symphysis (for Marshall-Marchetti-Krantz procedure). C: Ileopectineal, or Cooper’s, ligament (for Burch colposuspension). D: Obturator internus fascia (also used for paravaginal, or obturator shelf, repair).