Women's Cancer Information Center: WCC Research - Use of Vascular Clips To Minimize Blood Loss In Colpourethropexy

The Use of Vascular Clips To Minimize Blood Loss In Colpourethropexy

Nick M. Spirtos, M.D., and Charles A. Ballard, M.D., Los Angeles, California.

A serious intraoperative and postoperative complication associated with colpourethropexy as described by Burch and Tanagho and others is hemorrhage. We performed the Tanagho modification of the Burch procedure in 13 patients, as the sole procedure in the treatment of genuine stress incontinence. Vascular clips were used to circumscribe the fat overlying the anterior part of the vaginal wall, thereby allowing en bloc resection of the vascular fat pad. Suspensory sutures of 1-0 Vicryl (polyglacin 910) were placed; no retroperitoneal drains were used. The blood loss was estimated to be less than 50 milliliters in three. The average hospital stay was 4.2 days. All of the patients were given antibiotic prophylaxsis and were discharged home with suprapubic drainage of the bladder. There were no intraoperative or postoperative complications. Thus, one of the serious complications of colpourethropexy can be avoided by using vascular clips to facilitate the removal of the periurethral and paravesical fat from the anterior part of the vaginal wall.

$FOOTNOTE1

A serious intraoperative and postoperative complication associated with colpourethropexy as described in another study is hemorrhage (1-4) . Serious bleeding is most often encountered when resecting the fat overlying the anterior part of the vaginal wall. Venous bleeding associated with colpourethropexy is problematic enough that many surgeons recommend the routine use of retropubic drains postoperatively (3,4). In attempting to reduce the blood loss associated with this procedure, we used vascular clips to resect the paravesical fat en bloc.

Materials and Methods

Thirteen patients underwent colpourethropexy as described by Tanagho as the sole operative procedure in the treatment of genuine stress incontinence. The retropubic space was entered through a transverse incision made approximately 2 centimeters above the symphasis pubis. The fat overlying the anterior vaginal wall was then resected en bloc by using vascular clips in a manner similar to that used when performing a pelvic lymphadenectomy. In order to accomplish this, it was important to first identify the plane between the endopelvic fascia and the fat which was to be resected. This was best done with sharp dissection using a tissue forceps to elevate the fat overlying the fascia and a Metzenbaum scissors to cut down to the fascial plane. The vascular clips were then secured in a paired manner approximately 2 to 3 millimeters apart and the intervening tissue incised, as seen in Figure 1. By circumferentially placing the clips about the fat one wishes to resect, the vascular supply was severed pre-emptively.

Fig. 1. Initiation of the resection of the fat overlying the anterior vaginal wall is illustrated.

In our experience, this led to a remarkable decrease in the blood loss associated with this procedure. After this resection, suspensory sutures of 1-0 Vicryl (polyglactin 910) were placed (Fig. 2). No retroperitoneal drains were used. The anterior part of the fascia of the abdominal wall was closed using 1-0 Vicryl suture placed in a continuous manner. The skin was closed with 3-0 Prolene (polypropylene) sutures using a vertical mattress stitch.

Fig. 2. The completed resection and placement of the suspensory sutures are shown.

Results

All 13 patients undergoing colpourethropexy and en bloc resection of the fat overlying the anterior vaginal wall had estimated blood losses of less than 75 milliliters and ten of 13 had estimated losses of less than 50 milliliters. No retropubic drains were used and there were no complications noted. As a means of comparison, the charts of a similar group of patients whose operation was done by one of us without using the aforementioned technique were examined. Only five of 20 patients had estimated blood losses of less than 75 milliliters. Four patients had estimated blood losses of less thanor equal to 100 milliliters and 11 lost between 150 and 350 milliliters. Six patients required retropubic drainage and one patient had a retropubic hematoma develop and was transfused with 2 units of packed erythrocytes.

Discussion

Colpourethropexy as described by Burch and modified by others had proved to be a highly successful operation in the treatment of genuine stress incontinence (2-4) . These authors all used absorbable suspensory sutures and claim that long term success of the procedure is due to scarification of the vagina to Cooper's ligament. To further this scarification, it was stated in one study (3) that most of the fat overlying the anterior vaginal wall must be removed. Illustrations in three articles (1,2,4) also indicated that both surgeons resect most of this fat.

All three surgeons warn of the vascular nature of this tissue; two (3,4) go as far as to recommend routine drainage postoperatively. None of the authors mention the number of patients who required transfusion related to this operation. To date, we have been able to minimize the blood loss associated with this procedure by the method described and eliminate one serious complication associated with this operation.

Summary

A technique is described using vascular clips to resect the fat overlying the anterior vaginal wall during colpourethropexy. This technique may decrease the need of transfusion and the use of drains.

References

1. Burch, J.C. Urethrovaginal fixation to Cooper's ligament for correction of stress incontinence, cystocele, and prolapse. Am. J. Obstet. Gynecol., 1961, 281: 218-290.

2. Idem. Cooper's ligament urethrovesical suspension for stress incontinence. Am. J. Obstet. Gynecol., 1968, 100:764-773.

3. Tanagho, E. A. Colpourethropexy: The way we do it. J.Urol., 1976, 116: 751-753.

4. Stanton, S.L., and Cardozo, L.D. Results of the colposuspension operation for incontinence and prolapse. Br. J. Obstet. Gynecol., 1970, 86:693-697.

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