A randomized controlled trial comparing a modified Burch procedure and a suburethral sling: long-term follow-up

The aim of this study was to compare the long-term results of a modified Burch procedure with a sling procedure for the treatment of stress incontinence with a low-pressure urethra. Thirty-six women with urodynamic stress incontinence, low-pressure urethra, urethral hypermobility and no significant pelvic organ prolapse were randomly assigned to undergo either a modified Burch procedure (n=19) or a sling placement (n=17). Cure of the stress incontinence (defined as a negative stress test and negative pad-weight test) was the primary long-term endpoint. Secondary endpoints included subjective cure of stress incontinence (defined as no incontinence episodes on a 1-week voiding diary) and voiding function studies. Comparisons of group means were performed with the Mann–Whitney U-test, pooled variance t-tests and separate variance t-tests. Proportions were compared with Fisher's exact test. A logistic regression analysis was performed to control for covariates that differed in our two groups despite randomization. Long-term follow-up (mean=72.6 months) was available for 82% (28/34) of the original study group. The objective cure rates for the Burch and sling groups were 84.6% and 100%, respectively (P=0.17). Mean uroflowmetry rates for the Burch and sling groups were 7.38 and 6.8 ml/s, respectively (P=0.58, 95%CI –2.5, 4.4). Mean postvoid residual volumes for both groups were 35 ml (P=0.97, 95% CI –23.8, 65.9). Two sling patients (12%) required partial resection of their slings because of erosion. Both patients remained continent. In terms of voiding function and stress incontinence cure, there were no differences between groups undergoing modified Burch or sling procedures for treatment of urodynamic stress incontinence with low-pressure urethra.Abbreviations SI Stress incontinence - UI Urge incontinencePresented at the American Urogynecologic Society 21st Annual Scientific MeetingEditorial Comment: The authors have to be congratulated on their effort to provide evidence-based results. They used different techniques to perform the Burch procedure from used in the 1987 paper, and compared it to another technique they no longer use. Their power calculation is based on unsatisfactory results reported in 1987 for the Burch colposuspension. These results made the difference in outcome, thereby decreasing the number of subjects needed for the study. In addition, they did not report results as ITT. In spite of these shortcomings the study provides clinically useful data that can be built on for future research. I find it interesting that the super-Burch is good for low-pressure urethras, contrary to the belief that excessive tension can lead to ISD.