Things go better with Burch

For ObGyns who do not perform sacrocolpopexy, the CARE trial will have no direct clinical effects. Nevertheless, these clinicians need to be aware of the findings so they can discuss the options with patients before decisions on route or type of prolapse surgery are made.

The CARE trial and its results remind us of the high prevalence of pelvic floor disorders in women, potentially even after corrective surgery—and the need to actively screen all women for pelvic dysfunction.

Warn of potential incontinence even with the Burch

KOHLI: How does this study affect counseling of candidates for prolapse surgery?

BRUBAKER: I would offer stress-continent women a Burch procedure at the time of sacrocolpopexy. That much is clear. The interesting discussions come from “similar” clinical scenarios, where data are not yet available. For example, should a stress-continent woman facing a suspension via the vaginal route undergo a concomitant continence procedure?

WEBER: It is important to keep in mind that even when Burch colposuspension was performed, a number of women still experienced urinary incontinence (some stress, some urge, some mixed) after surgery; and the vast majority of women have urinary symptoms of some kind both before and after surgery. So preoperative counseling should include the information that urinary symptoms are very common after abdominal sacrocolpopexy—some as persistent or recurrent, and some as new symptoms.

As longer follow-up data from the CARE trial become available, we will learn how many women have urinary symptoms that are temporary versus long-lasting.

Is routine Burch best?

• When not all women benefit, should a procedure be offered prophylactically? In this case, experts say, “Yes”
  
• Some physicians favor other incontinence procedures
  
• Final decision rests with the patient
  

WALTERS: It is an easy decision for me. As I said earlier, women are particularly unhappy if they go from continent to incontinent after a surgery. In fact, some women are more displeased with that outcome than with a failure of the prolapse surgery. Because most women with prolapse have substantial anterior vaginal wall prolapse, the Burch procedure—with or without a paravaginal defect repair—also serves as part of the prolapse repair of the anterior wall. And now we know it also improves postoperative urinary function.

BRUBAKER: Doing a Burch procedure at the time of sacrocolpopexy is a time-efficient and low-morbidity addition, so it is worthwhile for me and my patients. It is clearly not the same as doing a secondary, standalone procedure for new symptoms.

Over the next 2 years, we will see how many women who were moderately or greatly bothered by stress incontinence went on to a surgical treatment.

WEBER: Please note a careful distinction: I would be willing to recommend Burch colposuspension to 100 stress-continent women who are planning to undergo abdominal sacrocolpopexy for prolapse, with the expectation that this will prevent postoperative stress incontinence in roughly half the women who would have developed it otherwise. It is up to the patient to accept this recommendation or not.

Based on the CARE trial results, 44 of 100 previously continent women after only abdominal sacrocolpopexy develop postoperative stress incontinence, compared with about 24 of 100 women after Burch and abdominal sacrocolpopexy. Even more striking is the difference in women affected by bothersome stress incontinence: almost 25% in the control group versus 6% in the Burch group. Women in the Burch group did not experience an excess of adverse events, or a clinically significant difference in operative time or estimated blood loss, compared with women in the control group.

Is “wait and see” better?

KOHLI: Because I favor minimally invasive midurethral sling procedures, which can often be performed on an outpatient basis under local anesthesia, I counsel women undergoing prolapse surgery via an abdominal or vaginal route that it is best to treat the incontinence postoperatively if it occurs. Obviously, this applies to women who have no incontinence and do not demonstrate potential stress incontinence on urodynamic testing preoperatively.

Anecdotally, I have not found a high rate of new-onset urinary incontinence following prolapse procedures. We may retrospectively look at these patients more critically in light of this new data.

WALTERS: I think most women would be dissatisfied with a 44% risk of postoperative stress incontinence requiring a second surgery. Even if you counseled them appropriately, many women would ask that you try to manage everything at the first surgery.

What are nonclinical effects of the trial?