SPOTLIGHT ON URINARY INCONTINENCE
Since introduction of the TVT technique by Ulmsten and colleagues in 1996, midurethral tension-free sling procedures have become the most commonly performed antiincontinence operations in the world, rapidly replacing Burch colposuspension as the first choice for women who have urodynamically confirmed SUI.1 In 2004, a prospective, randomized trial by Ward and Hilton demonstrated that the TVT was equal and perhaps even superior to the Burch procedure.2 The same year, Paraiso and associates reported on a two-center prospective randomized trial of laparoscopic Burch colposuspension versus TVT.3 Although that trial was underpowered, the investigators found a higher rate of objective urodynamic SUI and subjective urinary incontinence 1 year after laparoscopic Burch colposuspension, compared with TVT.3 The study by Jelovsek and colleagues represents the long-term follow-up of this cohort, 4 to 8 years after the original operation.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.
Details of the study
Seventy-two women were originally enrolled from 1999 to 2002; 74% of them (25 in the TVT group and 28 in the laparoscopic Burch group) were available for long-term followup 4 to 8 years after surgery. Fifty-seven percent (16/28) of women had subjective urinary incontinence after laparoscopic Burch colposuspension versus 48% (12/25) after TVT. There were no differences between the groups in subjective or objective findings or urinary incontinence. However, the study was severely underpowered to be able to show any difference between the groups.
These cure rates are low, but the authors note that only 11% of the laparoscopic Burch group and 8% of the TVT group had bothersome SUI. Quality of life on the urogenital distress inventory and incontinence impact questionnaire short forms was improved in both groups equally by 2 years and maintained throughout the rest of the trial.
These poor objective results are similar to those found in a 5-year follow-up by Ward and Hilton of their prospective, randomized, controlled trial of Burch versus TVT procedures. There, only 39% of the TVT group and 46% of the Burch group reported no incontinence.
The original trial by Paraiso and colleagues3 showed better outcomes in the TVT group 1 year after surgery, but that difference did not remain 4 to 8 years later. One explanation for that observation may be type-II error resulting from the small number of subjects in the trial.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
Laparoscopic Burch colposuspension and the TVT procedure appear to have equal long-term outcomes. Because placing TVT is less invasive, however, it may be the preferable procedure until larger trials or meta-analyses conclusively determine which operation is superior.—PETER K. SAND, MD