Things go better with Burch
CARE trial: Burch colposuspension at the time of prolapse surgery improves postop urinary control
IN THIS ARTICLE
KOHLI: The results of this study are very procedure-specific. If similar results are borne out when other approaches to prolapse and incontinence are analyzed, the value and utility of preoperative uro-dynamic testing in all patients may be questionable.
However, in my practice, I use the results of preoperative urodynamic testing not only for diagnosis, but also to make subtle adjustments when performing incontinence procedures—especially in regard to suburethral slings.
- Surgeons should be comfortable with more than 1 incontinence procedure
- We should not jump to untested conclusions
WEBER: Ideally, well trained and experienced gynecologic, urologic, or urogynecologic surgeons perform more than 1 type of incontinence procedure, to meet the needs of different patients.
As yet, we have no direct, evidence-based answers to issues such as these:
Can a midurethral sling be substituted for a Burch colposuspension and have the same average results in preventing post-operative stress incontinence without increasing urgency symptoms…
- …when abdominal sacrocolpopexy is performed for prolapse in a preoperatively stress-continent patient?
- …when vaginal apical suspension is performed for prolapse in a preoperatively stress-continent patient?
Although it is tempting to jump 1 or 2 steps ahead and apply CARE trial data to situations that have not been tested directly, I would be cautious. We want to avoid creating long-lasting or refractory urgency symptoms—especially in a woman who had no such symptoms before surgery—because of a prophylactic procedure.
I think this is especially true because it is relatively easy to salvage patients who do develop bothersome stress incontinence after prolapse surgery.
Bonus: Burch helps anterior vaginal prolapse
WALTERS: I wonder whether prophylactic placement of a midurethral sling would yield the same results as a prophylactic Burch procedure. If your midurethral sling of choice is a tension-free vaginal tape (TVT), I would be cautious about placing it prophylactically, because the TVT has a 2% to 3% risk of prolonged voiding dysfunction requiring transection of the tape.
However, it is possible that prophylactic placement of a transobturator sling, which is associated with much less voiding dysfunction and fewer major surgical complications, might have a different outcome—though this requires further study.
In addition, midurethral slings would not be as effective as Burch colposuspension in treating anterior vaginal prolapse, so I would expect to see more anterior wall prolapse failures if slings replaced colposuspension.
What if you prefer the vaginal approach?
- Further study is needed
WALTERS: I wonder whether a prophylactic transobturator midurethral sling at the time of transvaginal prolapse repair would yield similar results. I do cystocele repair with suburethral (“Kelly”) plication, which seems to work well at stabilizing the urethra in women without stress incontinence. But this approach is not as popular these days, and future studies may demonstrate that a prophylactic midurethral sling will result in better long-term function without significantly increasing the long-term risk.
WEBER: The CARE trial results are relevant to all pelvic surgeons because they demonstrate the need for and benefit from well-designed randomized surgical trials. Another benefit will be extended follow-up in what will become a prospective cohort study of women with advanced prolapse treated by abdominal sacrocolpopexy—providing higher-quality evidence than retrospective case series. Although not as valuable as randomized trials, these data can help guide clinical recommendations.
If long-term results support the effectiveness and durability of abdominal prolapse repair, then gynecologists can reflect on the evidence and choose the approach that best fits the patient’s needs.
Need for other studies?
- Randomized, multicenter trials addressing almost any surgical treatment of prolapse and incontinence are sorely needed
