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Bladder and Ureter

Insertion of Suprapubic Catheter

Retropubic Urethropexy:
and Burch Operations


and Ureteroneocystostomy
With Bladder Flap

End-to-Side Anastomosis

Intestinal Loop
Urinary Diversion



Clam Gastrocystoplasty

Retropubic Urethropexy:
And Burch Operations

The Marshall-Marchetti-Krantz (MMK) and Burch operations for stress incontinence of urine are two of the retropubic urethropexy "pin-up" operations that essentially return the urethrovesical angle to its role as an intra-abdominal organ and change the focal points of pressure applied through the abdomen during a Valsalva maneuver (coughing, sneezing, etc.)

Unlike other stress incontinence operations, the Marshall-Marchetti-Krantz and Burch operations do not, by themselves, produce significant changes in intraurethral or intravesical pressure to restore urinary continence.

The operations have evolved with several alterations since their original introduction by Marshall-Marchetti-Krantz and Burch. These procedures can be performed at the time of pelvic surgery for uterine or adnexal pathology.

The purpose of these operations is to eliminate stress incontinence of urine.

These operations do not correct a cystourethrocele. When this is present, it should be surgically corrected through the vagina.

Physiologic Changes. The Marshall-Marchetti-Krantz and Burch operations rarely change the relationship between intraurethral pressure and intravesical pressure. They make the proximal urethra and bladder neck and intra-abdominal organ and equalize intra-abdominal pressures on the bladder wall that are precipitated by a Valsalva maneuver.

Points of Caution. To ensure the integrity of the bladder and ureters, a cystotomy should be performed, and the bladder should be inspected under direct vision.

When operating in the space of Retzius, bleeding from the plexus of Santorini can be difficult to control. Total hemostasis is essential before these operations are completed.


For the Marshall-Marchetti-Krantz and Burch operations, the patient is placed in the supine lithotomy position, i.e., the ski position. There are two acceptable incisions, the lower midline incision and the transverse incision. Each has its advocates. It is difficult to demonstrate superior results with either incision. The supine lithotomy position (ski) with a transverse incision is preferred unless the patient is undergoing surgery for a gynecologic oncologic problem.

The patient is prepped and draped, and a Foley catheter with a 30-mL bag is inserted.

The incision is made in the rectus fascia. The fascia is excised.

The space of Retzius is entered. The bladder and the urethrovaginal angle are identified with the aid of the Foley catheter.



A finger is inserted in the vagina to identify the perivaginal and periurethral areas for placement of 0 Prolene suture. We prefer permanent monofilament suture. A small, curved Mayo needle is used, and the position of the suture is confirmed by palpating the bladder and inserting a finger in the vagina before making each suture. Notice blanching of the blood vessels in the plexus of Santorini. The blood vessels should be avoided in placing the sutures in the periurethral tissue.

In a, showing the MMK operation, the suture that has been placed in the periurethral tissue is tied to the periosteum of the pubic symphysis. In b, showing the Burch operation, the suture that has been placed in the periurethral tissue has been brought through the conjoined tendon or Cooper's ligament.

In a, bleeding has been produced from the vessels in the plexus of Santorini.

The bleeding produced from the plexus of Santorini can be easily stopped by elevating the finger in the vagina. This allows for fulgurating or grasping and tying each of the bleeders specifically. The blood vessels form the plexus of Santorini and are difficult to control if elevation of the vagina is not used to slow the bleeding process. The suture placed in the periurethral tissue is tied, respectively, to either the periosteum (MMK) (a) or Cooper's ligament (Burch) (b).

The sutures have been completely placed but not tied.

In a (MMK), two vaginal fingers are used to tent up the anterior wall of the vagina while the sutures are being tied. The same is noted in b (Burch), as the sutures are tied to Cooper's ligament.

In a (MMK), the sutures are completely tied to the periosteum of the symphysis pubis. An additional one or two sutures can be placed if desired. In b (Burch), a finger is inserted between the conjoined tendon or Cooper's ligament and the suture in the periurethral tissue. A 2-cm space (1 fingerbreadth) is desirable to prevent total occlusion of the urethra and postoperative urinary retention.

In a (MMK), the periurethral tissue with the adjacent pubovesical cervical (PVC) fascia sling is sutured to the periosteum of the symphysis pubis. The bladder (B) and proximal urethra have been brought back into the abdomen where intraurethral and intravesical pressures can be stabilized. In b (Burch), the urethra has been suspended by the pubovesical cervical fascia sling sutured to Cooper's ligament.

In reality, the pubovesical cervical fascia in both operations has been made into a sling to bring the proximal one-third of the urethra and the neck of the bladder back into the abdomen. This new position allows even disposition of external pressures on all surfaces of the bladder and proximal urethra. The rectum (R) and vagina (V) are shown in a.

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