To demonstrate a modification of the classical Burch procedure, called “Laparoscopic TOT – like Burch colposuspencion”. The technique does not involve any type of prothesis placement and it is an alternative for the patients with stress urinary incontinence in a future without meshes. Describing and standardising the procedure in different steps makes the surgery reproducible for the gynecologists and safe for the patients.
Step-by-step educational video, underlining and focusing on the main anatomical landmark SETTING: A university tertiary care hospital INTERVENTIONS: The patient is set under general anaesthesia and in lithotomy position. The distinct steps of the procedure are performed as followed: Step 1: Installation. Two 10 mm trocars are positioned in the midline and two 5 mm trocars – in the suprapubic region. The recommended intraabdominal pressure is 6-8 mmHg and excessive Trendelenburg is not needed. Step 2: Entry in the Retzius space. The median umbilical ligament and the vesicolumbilical fascia are transected. Step 3: Exposure of the Retzius space and the anatomical structures. The dissection is continued consecutively towards the pubic bone and the Coopers ligament, laterally towards the external iliac vessels and corona mortis and medially towards the bladder neck. Step 4: Vaginal dissection. The pubocervical is dissected at the level of the pubourethral ligaments. Step 5: Suspension of the vagina to the Coopers ligament. In contrast to the standard technique, with the TOT- like Burch the sutures on the pubocervical fascia are placed at the level of the attachment of the arcus tendinous fascia pelvis and the pubourethral ligament. This way of suspension ensures a lateral traction on the bladder neck, resembling the effect of the transobturator tape (TOT), which leads to lower incidence of dysuric symptoms. Step 6: Peritoneal closure.
The classical colposuspension was created in 1961 for treatment of stress urinary incontinence prolapse. In the following years the vaginal meshes gained popularity as a treatment option for prolapse and for incontinence due to their ease of use and satisfying results, which led to decreased use of the Burch procedure. In 2019, the FDA forbid the production of the transvaginal meshes for prolapse, an interdiction that could influence the use of the synthetic meshes for incontinence in the future. Due to these recent events, searching for an effective way of management for the patients with stress urinary incontinence without any synthetic prothesis, the gynecologists turned back to the 60 years old Burch colposuspension. One of the drawbacks of the original technique is the high incidence of voiding difficulties – up to 22%. Owing to the knowledge of the exact course of traction with the transoburator tape, in our modified technique, the lateral direction of the suspension provides a tension- free support on the urethra and the bladder neck. The laparoscopic TOT – like Burch colposuspension is a safe and effective treatment for the patients with stress urinary incontinence, with low rates of dysuric symptoms and represents a valuable alternative for the gynecologists in a future without meshes.

Copyright © 2020. Published by Elsevier Inc.