1. Intermediate Format: Marshall Marchetti Krantz Suspension
Procedures
This procedure for women involves resuspension of urinary bladder in correct anatomical position.
Alternate Names : Burch Procedure, Marshall-Marchetti Operation, MMK, Pubo-Vaginal Sling, Trans-Vaginal Tape Procedure, Urethral Suspension, Vesicourethral Suspension
Overview & Description
Open bladder and urethral surgeries are usually performed to prevent urine leakage associated with stress incontinence (involuntary leakage of urine when laughing, coughing, sneezing, or lifting, which can result from deformity or damage to the urethra and bladder from decreased muscle tone caused by multiple births, menopause, or other causes).
This problem is usually associated with a cystocele. A cystocele is when the bladder sags into or even outside the vagina. The patient can often feel this during sexual intercourse or may even see the bladder protruding outside of the vagina.
Surgery attempts to return the bladder and urethra to its normal position in the pelvis. This surgery can be performed in many different ways, depending of the patient's anatomy and the severity of the problem.
The two most common ways of performing this surgery is through the abdominal wall or though the vagina.
An MMK suspension is performed for the correction of stress incontinence caused by an abnormal urethrovesical angle. The intent is to bring the bladder and urethra into the pelvis by suturing paraurethral vaginal tissue to the back of t he symphysis pubis. A modification of t his technique is called the Birch procedure. This procedure mimics the MMK until the placement of buttressing sutures. Instead of attempting difficult periosteal sutures, the surgeon places nonabsorbable size 0 sutures into the Cooper ligament from each side of the bladder neck. The Birch is technically easier, and long-term results about the same.
Intermediate Format:
Marshall Marchetti Krantz Suspension

2. Objectives
Assess the related terminology and pathophysiology of the MMK.
Analyze the diagnostic interventions for a patient undergoing a MMK.
Plan the intraoperative course for a patient undergoing MMK.
Assemble supplies, equipment, and instrumentation needed for the procedure.
RETROPUBIC SUSPENSION Retropubic suspension is used to describe a group of surgical procedures that are performed to elevate the bladder and urethra within the pelvic region. These procedures are performed through an abdominal incision. The procedures (Burch colposuspension and Marshall-Marchetti-Krantz -- MMK) differ based on the structures that are used to anchor and support the bladder.

3. Objectives Choose the appropriate patient position.
Identify the incision used for the procedure.
Analyze the procedural steps for MMK.
Describe the care of the specimen.

4. Terms and Definitions Urinary Incontinence
Stress Urinary Incontinence: inability to retain urine during stress (eg laughing, lifting, sneezing)
Weakened musculature
Urethrocele: pouchlike protrusion of the urethral wall in the female
Cystocele: bladder hernia that protrudes into the vagina
MAVCC Unit 6 Terms and definitions
Urinary incontinence: inability to retain urine
SUI:
Weakened musculature (p. 127 Unit 5): the normal supporting structures of the uterus no longer perform their functions resulting in prolapse of the uterus or various herniations (cystocele, rectocele, enterocele).
Cystocele: injury to the vesicovaginal fascia during delivery may allow the bladder to pouch into the vagina, causing a cystocele.
Enterocele: a hernia of the intestine thru the vagina (a posterior vaginal hernia)
Rectocele: Protrusion or herniation of posterior vaginal wall with the anterior wall of the rectum thru the vagina

5. Definition/Purpose of Procedure
Suspension of the bladder to the symphysis pubis to correct stress incontinence
Performed to alleviate stress urinary incontinence
Definition
This is a surgery to control involuntary urination by elevating the urethra and bladder.
Indications
Repair of the bladder and urethra may be recommended for treatment of stress incontinence (inability to prevent urine leakage when coughing, sneezing, laughing, jumping, walking, sitting, or standing).

6. Pathophysiology
Relaxation of pelvic floor leads to stress urinary incontinence.
Urinary continence requires a bladder to expand and contract and sphincters that can maintain a urethral pressure higher than in the bladder. Incontinence occurs when the pressure within the urinary bladder exceeds urethral resistance, allowing urine to escape. Any condition causing higher than normal bladder pressures or reduced urethral resistence can potentially result in incontinence.
Definition
Stress incontinence is an involuntary loss of urine that occurs during physical activity, such as coughing, sneezing, laughing, or exercise.
Stress incontinence is a bladder storage problem in which the strength of the urethral sphincter is diminished, and the sphincter is not able to prevent urine flow when there is increased pressure from the abdomen.
Stress incontinence may occur as a result of weakened pelvic muscles that support the bladder and urethra, or because of malfunction of the urethral sphincter. Prior trauma to the urethral area, neurological injury, and some medications may weaken the urethra.
Sphincter weakness may occur in men following prostate surgery or in women after pelvic surgery. Stress incontinence is often seen in women who have had multiple pregnancies and vaginal childbirths, or who have pelvic prolapse (protrusion of the bladder, urethra, or rectal wall into the vaginal space), with cystocele, cystourethrocele, or rectocele.
Studies have documented that about 50% of all women have occasional urinary incontinence, and as many as 10% have frequent incontinence. Nearly 20% of women over age 75 experience daily urinary incontinence.
Stress urinary incontinence is the most common type of urinary incontinence in women. Risk factors for stress incontinence include female sex, advancing age, childbirth, smoking, and obesity. Conditions that cause chronic coughing, such as chronic bronchitis and asthma, may also increase the risk of stress incontinence.

7. Diagnostics Pelvic Exam Urinary journal Urinary stress test Q-Tip test
Stress Incontinence Diagnosis & Tests
A physical examination will include an abdominal and rectal exam, a genital exam in men, and a pelvic exam in women. In some women, a pelvic examination may detect cystocele or urethrocele (protrusion of the bladder or urethra into the vaginal space).
Patients may be asked to keep a urinary diary, recording how many times you urinate during the day and night, and how often urinary leaking occurs.
Tests may include:
Post-void residual (PVR) to measure amount of urine left after urination
Urinalysis or urine culture to rule out urinary tract infection
Urinary stress test (the patient is asked to stand with a full bladder, and then cough)
Pad test (after placement of a pre-weighed sanitary pad, the patient is asked to exercise -- following exercise, the pad is re-weighed to determine the amount of urine loss)
A pelvic or abdominal ultrasound
X-rays with contrast dye of the kidneys and bladder
Cystoscopy (inspection of the inside of the bladder)
Urodynamic studies (tests to measure pressure and urine flow)
Rarely, an EMG (electromyogram) is performed to study muscle activity in the urethra or pelvic floor
Other tests may include the measurement of the change in the angle of the urethra when at rest and when straining (Q-tip test). An angle change of greater than 30 degrees often indicates significant weakness of the muscles and tissues that support the bladder.

8. Surgical Intervention: Special Considerations? Op Preparation
Patient Factors
Room Set-up
Planning: General Anesthesia preferred, pt will be supine w/Trendelenburg, Prep; remove anterior pubic hair, insert Foley, Draping considerations—under-the-buttocks drape, may cut disposable lap sheets to accommodate frog-leg position and provide vaginal access; towel may be used to temporarily cover opening in drape providing vaginal access

9. Surgical Intervention: Positioning
Position during procedure
Supine w/ Trendelenburg; frog-leg OR
Modified Lithotomy
Supplies and equipment
Allen stirrups or other knee-supporting type
Special considerations: high risk areas (peroneal nerve)
p. 587 Alexander: a large % of patients with SUI are obese or have diabetes. It is important that pt is evaluated for these conditions and prepare for proper mgt: 1. Positioning concerns related to peripheral vascular circulation and pressure points, skin breakdown, risk for infection, wound healing.

10. Surgical Intervention: Special (Practical) Considerations/Incision
Special considerations
Extra gloves & maybe an additional gown will be necessary for the assistant—change after providing intravaginal urethral support/vaginal manipulation during suturing
Foley cath may be inserted by circulator during prep or from the sterile field
STSR should be especially aware of potential for contamination of field dur to vaginal and abdominal areas being incorporated in the same drape.
State/Describe incision: Pfannenstiel
STST Procedure 20-3 p. 772

11. Surgical Intervention: Supplies
General: Basic Pack, Double basin, gloves, Blades # 10 x 2, Transverse Lap Drape, Impervious ½ sheet, ESU pencil, NaCl irrigation, ESU extension tip, suction tubing, 4 x 4s, Laps, Kittners or Peanuts
Specific
Suture:
Medications on field (name & purpose)
Catheters & Drains : Foley at beginning of surgery; Possible wound drain
Dressing: possible vaginal packing; 3-layer
STST Procedure 20-3 p. 772

12. Surgical Intervention: Instruments
General: Major instrumentation set
Specific: Long instrument set, Heaney needle holders x 2, several long Allis clamps; self-retaining retractor, hemoclip appliers on standby

13. Surgical Intervention: Equipment
General: ESU, Positioning Aids
Specific: If modified lithotomy, may need knee-support stirrups and padding

14. Surgical Intervention: Procedure Steps
Pfannenstiel incision is used to approach the retropubic space
A # 10 blade on # 3 knife handle is uded for incision. Provide cautery and suction.
The bladder and urethra are freed from behind the symphysis pubis using blunt dissection techniques.
Surgeon may use fingers, peanut sponges on a long Mayo clamp, or a sponge on a stick for dissection. Prepare supplies in advance of need.
Alexander p. 587:
a suprapubic transverse incision is made to expose the prevesical space of Retzius.
The bladder retractor is positioned w/ small, moist lap pads in place
The bladder and urethra are freed from the posterior surface of the rectus muscle and symphysis pubis by gentle blunt manipulation

15. Surgical Intervention: Procedure Steps Cont’d
The endopelvic fascia is incised to allow for displacment of the bladder.
A # 10 blade on #3 Long knife handle may be needed, according to patients’s size (depth).
Assistant inserts 2 gloved fingers into the vagina to elevate the base of the bladder—to facilitate suture placement and reduce tension.
Protect sterile field from contamination during this process
5. Assistant places 2 fingers into the vagina, lifting the urethra upward against the symphysis pubis to facilitate ease of repair of the periurethral musculofascial structures.

16. Surgical Intervention: Procedure Steps Cont’d
Four heavy absorbable sutures are placed in strategic locations in the anterior wall bilaterally to the urethra and are secured in the posterior symphysis or Cooper’s ligament
Load sutures on Heaney needle holders for placement. Anticipate the use of all four sutures sequentially. A series of hemostats may be requested to “tag” the sutures until all have been placed and are ready for tying.
A heavy nonabsorbable atraumatic suture on a Heaney needle holder is placed thru the supporting fascia of the vaginal wall on each side of the urethra. The suture is passed thru the symphysis pubis, providing support to the urethra and bladder neck. Generally, a row of three heavy nonabsorbable sutures is placed on each side of the urethra, the most proximal being located just at the vesical neck.
Fuller p. 390 cites sutures as “interrupted sutures of Dexon or Dacron, size 2-0, mounted on small, stout, tapered needle, are placed thru the tissue surrounding the urethra. The needle is passed thru the cartilage placed in succession and are left long.

17. Surgical Intervention: Procedure Steps Cont’d
All sutures are positioned and then tied sequentially for optimum elevation of the bladder
Provide suture scissors as needed. Assist circulator in changing assistant’s gown and gloves as necessary. Provide towel to cover site following bladder elevation. Prepare drain, if requested. Anticipate would closure and prepare suture.
Fuller: The assistant is the required to place a finger in the vagina to release the pressure on the sutures while the surgeon ties them in place. Following this maneuver, the STSR must reglove the assistant.

18. Surgical Intervention: Procedure Steps Cont’d
A wound drain may be placed (eg. Lg penrose) in the space of Retzius. The wound is closed and dressed..
Count. Provide 3-layer dressing material
Vaginal packing may be inserted to temporarily reduce tension on the suture line.
Vaginal packing is inserted after abdominal dressing is in place.
7. The wound is drained, and the wound is closed in layers and dressed.
8. The vagina may be packed with 2-in packing, which should be removed after hrs. The foley catheter is connected to a closed urinary drainage system.

19. From Fuller p. 390 Vesicourethral suspension
From Fuller p Vesicourethral suspension. After entering the pelvis, the surgeon gains access to the ureter by placing his hand over the bladder to retract it upward.
B—the surgeon suspends the bladder neck by placing several sutures thru the tissue surrounding the urethra and attaching them to the cartilage of the sumphysis. (Fuller p. 390)

20. Counts Initial; sponges, sharps, instruments First closing
Final closing
Sponges
Sharps
Instruments

21. Specimen & Care
Identified as n/a
Handled: routine, etc.

22. Misc Post –op Info Immediate Post op Care
Blood tinged urine may be noted in Foley drainage bag
Foley cath may be removed in PACU—the patient is expected to void normally
Prevention: Perform Kegal excercises, limit caffeine intake, which can reduce frequency and urgency, good perineal care; avoid straining & Valsalva Maneuver postop
Desired outcome: Urinary continence
Also: Suggest measures such as increasing fluid and fiber intake and using a stool softener to prevent postoperative constipation. Straining and increased abdominal pressure during the Valsalva maneuver may place excessive stress on suture lines and interfere w/healing.
You will usually return from surgery with a Foley catheter and/or a suprapubic catheter in place. The urine may initially appear bloody, but this should gradually resolve.
The Foley or suprapubic catheter may be removed several days after surgery when you are able to completely empty your bladder. Occasionally, the catheter will need to remain in place for as long as 3 months, depending on the person's ability to empty the bladder completely.

23. Prognosis & Complications
70-95% cure rate
Complications
Hemorrhage (hematuria, excessive vaginal drainage, or incisional), Infection, Recurrence of SUI, increased risk of UTI w/catheter or instrumentation of urinary tract, inability to urinary, new onset of urge incontinence
Women treated with these procedures have a 75-90% cure rate. Possible complications include urinary tract infection, inability to urinate, wound infection, fistula (rarely), and new onset of urge incontinence.

24. Other Procedures for SUI
Bladder Neck Suspension
Sling Procedure
Anterior Vaginal Repair/Paravaginal
BNS: There are several surgical procedures that are performed in women through a minor abdominal incision as well as a vaginal incision to repair the bladder and urethral dysfunction.
These procedures are called needle procedures because special needle instruments are utilized during the surgery, which requires only a minor or small abdominal incision. The various procedures (Modified Pereyra and Stamey procedure) differ based on the structures that are used to anchor and support the bladder.
Women treated with these procedures have a 40-80% cure rate. Because the success rate tends to be lower than that achieved with retropubic suspensions or sling procedures, these procedures are being performed less often than in the past. Possible complications include urinary tract infection, inability to urinate, wound infection, fistula (rarely), and new onset of urge incontinence.
Sling: This procedure is rarely performed in men, but is more often used to treat women who have stress incontinence caused by weakened urethral sphincter muscles. A sling is formed by taking a piece of the abdominal tissue (fascia) or a piece of synthetic material and using it to compress the urethral sphincter, thus preventing leakage of urine during stress maneuvers.
These procedures require a small abdominal incision and a vaginal incision. Many modifications of the sling procedure have been developed, including recently the transvaginal tape procedure. This type of sling procedure is performed through smaller incisions and can be done as an outpatient surgery.
Among the people who have had sling procedures to correct their stress incontinence, there is an 80-90% cure rate. Possible complications include infection, erosion of the sling, non-healing vaginal wall, fistula or abscess formation, urgency, urge incontinence, and urinary retention.

25. Resources Alexander’s p. 587-588 Goldman pp. 200-202
Lemone & Burke p. 734, 735, 739, 740, 1566
MAVCC Info Sheets Unit 5 &Terms & Definitions Unit 6
STST p. 772 Procedure 20-3
ANTERIOR VAGINAL REPAIR OR PARAVAGINAL REPAIR These vaginal procedures are often performed in women when the bladder is prolapsing into the vagina (also called a cystocele). An anterior vaginal repair is performed through a vaginal incision, and a paravaginal repair is performed through either a vaginal or an abdominal incision.
In an anterior repair, the pubocervical fascia (the supportive tissue between the vagina and bladder) is folded and stitched together to bring the bladder and urethra in proper position. In a paravaginal repair, the pubocervical fascia is stitched to the fascia covering the pelvic floor muscles to support the bladder and urethra.
Studies have shown that the cure rate for stress urinary incontinence from these procedures is only about 40 to 65%, and because other surgeries are more effective, these are usually performed to repair a cystocele, but not for stress urinary incontinence. Often, these procedures are performed along with another