SPOTLIGHT ON URINARY INCONTINENCE
With prevalence reported to range from 18% to 46% in women 25 to 64 years old, SUI is a serious problem. Concomitant anti-incontinence procedures are typically considered in women who have documented SUI at the time of surgical prolapse repair. The decision is less straightforward in women who do not have preoperative symptoms of SUI at the time of surgery for prolapse.Just 2 years ago, when Brubaker and colleagues published initial findings from the colpopexy and urinary reduction efforts (CARE) trial in the New England Journal of Medicine,1 Burch colposuspension was a well-established anti-incontinence procedure utilized by many urogynecologists. The procedure remains a reliable intervention, although midurethral sling procedures have surpassed it in popularity and (some would say) efficacy. This issue’s installment of Examining the Evidence highlights two recent investigations of the antiincontinence procedure:
- 2-year follow-up from the CARE trial, which compared sacrocolpopexy, with and without a concomitant Burch procedure, in women who did not have symptoms of stress urinary incontinence (SUI) at the time of surgery
- a comparison of laparoscopic Burch colposuspension and the tension-free vaginal tape (TVT) technique.
The CARE trial was designed to determine whether prophylactic concomitant Burch colposuspension is indicated in these women when they undergo planned abdominal sacrocolpopexy. In this latest update, CARE investigators present 2-year outcomes.
Functional and anatomic findings
The addition of a Burch procedure at the time of sacrocolpopexy reduced the rate of postoperative SUI symptoms to a greater degree than sacrocolpopexy alone (control group) did, with 32% of women in the Burch group experiencing symptoms (versus 45.2% of controls; p=.026). Women in the Burch arm also had a lower rate of bothersome SUI (11.6% versus 25.2%; p=.004) and a tendency to a lower rate of urge symptoms (32% versus 44.5%; p=.085). In addition, the study demonstrated that sacrocolpopexy played a beneficial role in reducing bothersome irritative and obstructive urinary symptoms after surgery, regardless of concomitant Burch.
Anatomic outcomes were similar in both arms of the trial, with the apex within 2 cm of total vaginal length in 95% of women (p=.18).
Strengths, limitations of this study
WHAT THIS EVIDENCE MEANS FOR PRACTICE
The strengths of this randomized trial include the generalizability of its results, with multiple geographic sites and surgeons participating and with long-term follow-up of patients. Its major limitation is that Burch colposuspension is now somewhat obsolete. More data on prophylactic sling procedures are needed.Concomitant prophylactic Burch colposuspension confers sustained protection against SUI in women who are continent at the time of sacrocolpopexy. And midurethral synthetic slings—which require a shorter operative time and hospital stay and carry a low rate of perioperative complication—offer success rates similar, if not superior, to Burch. Both procedures require specialized training to perform safely.
It is reasonable to consider a prophylactic, concomitant anti-incontinence procedure in the form of a Burch colposuspension at the time of sacrocolpopexy. We believe that a concomitant or staged (interval) midurethral sling operation is a sound alternative 1) depending on the patient’s preference and 2) after review of the available evidence and potential risks and benefits.—BELA I. KUDISH, MD, MS, AND CHERYL IGLESIA, MD