A randomized comparison of transobturator tape and Burch colposuspension in the treatment of female stress urinary incontinence

This study was performed to compare the efficacy of transobturator tape (TOT) and Burch colposuspension in the treatment of female stress urinary incontinence (SUI). This is a prospective randomized single blind study of 100 women diagnosed as with urodynamic SUI who were randomized either to TOT procedure (n = 49) or Burch procedure (n = 51). The outcome was evaluated at 1 and 2 years. The mean operation time and hospital stay were significantly shorter in the TOT group compared to Burch group (p < 0.001). Procedure-related complications and postoperative voiding problems including postoperative urinary retention, de novo voiding difficulties and de novo urge incontinence were similar in the two groups. Both the subjective and objective cure rates of SUI at 1 year were 85.7 and 87.5%, respectively, in the TOT group. This was similar to subjective and objective cure rates at one year of 84.3% (p = 0.8) and 80.3% (p = 0.4) in the Burch group, respectively. At the end of 2 years, 32 patients were available in the TOT group and 31 patients were available in the Burch group for analysis. Both the subjective and objective cure rates of SUI at 2 years were 87.5 and 87.5% in the TOT group which was similar to the 87% (p = 0.9) and 83.8% (p = 0.6) in the Burch group, respectively. TOT procedure results in similar cure rates of SUI at 1 and 2 years compared to Burch procedure. The TOT procedure has a shorter operative time and length of hospital stay.     

经阴道前入路悬吊修补术治疗膀胱膨出（附19例报告）

目的探讨Avaulta网片经阴道前入路悬吊修补术治疗老年女性膀胱膨出的适应症、安全性和有效性。 方法回顾性研究2013年1月至2016年10月中山大学附属第三医院岭南医院收治的老年女性膀胱膨出患者（POP-Q III-IV期）行Avaulta网片经阴道前入路悬吊修补术病例资料。记录患者一般临床资料和围手术期手术资料,出院后电话和门诊定期随访,测量患者POP-Q各指示点位置,评价治愈率和手术并发症发生情况。 结果19例老年女性膀胱膨出患者纳入研究,手术均顺利完成,围手术期均无腹腔脏器损伤、大出血等严重并发症发生。平均手术时间55 min（45～70 min）,其中1例膀胱膨出患者术前尿动力学诊断合并隐匿压力性尿失禁,单纯行膀胱膨出悬吊修补术后咳嗽、大笑时仍有明显尿失禁发生,二期行TVT治愈。平均随访时间6.5个月（1～24个月）,所有膀胱膨出患者均完全修复,无膀胱膨出复发、网片侵蚀和尿潴留等严重并发症发生。 结论Avaulta网片经阴道前入路悬吊修补术治疗老年女性中重度膀胱膨出患者安全有效,远期疗效尚需长期大样本临床随机对照研究资料进一步循证。     

Long-term results of Burch colposuspension

BACKGROUND: We aimed to determine the long-term results of Burch colposuspension. METHODS: Patients who had undergone Burch colposuspension due to stress urinary incontinence (SUI) in our department between 1991 and 1995 were asked to participate in the study by telephone or mail. Fifty of 78 patients (64%) responded and these formed the study group. Patients were evaluated by a detailed questionnaire, pelvic examination, uroflowmetry and postvoid residual urine determination. Provocative stress test and urodynamic evaluations were performed in those who claimed leakage. Additionally, follow-up charts were retrospectively reviewed from the patients' files. RESULTS: Mean follow-up time was 50.6 months. The subjective cure rate was 52% and the surgical success rate was 84%. The patient satisfaction rate in terms of incontinence was 86%. No correlation was found between pre-operative patient characteristics (i.e. age, number of vaginal deliveries and pregnancies, menopause, previous anti-incontinence surgery and presence of detrusor instability) and outcome of surgery. Although no patient was performing clean intermittent catheterization in the long term, two patients had significant residual urine and obstructive flows. Three patients had severe pelvic prolapse that required surgical correction. CONCLUSIONS: Our results indicate that Burch colposuspension operation is an effective and durable choice of treatment with low complication rates for the treatment of SUI.     

Stress urinary incontinence after transobturator mesh for cystocele repair

Cystocele repair can lead to de novo stress urinary incontinence (SUI) or exacerbate pre-existing SUI. This study was designed to determine the effect of cystocele repair by transobturator mesh on SUI. In a retrospective observational study, we saw 93 patients after a transobturator mesh procedure. Of those, 57 women had not undergone a concomitant anti-incontinence procedure. We analyzed their clinical data and ultrasound datasets. At a median follow-up of 9 months, 21 of 24 preoperatively stress incontinent women reported cure/improvement, one patient reported worsened SUI. Seven of 33 preoperatively continent women complained of de novo SUI. There is a net positive effect on SUI (McNemar χ² exact test p = 0.013) after transobturator mesh. A narrower gap between symphysis pubis and mesh was associated with a positive outcome (p = 0.015 on ANOVA). Transobturator mesh for cystocele repair appears to have a net positive effect on SUI.     

Tension Free Vaginal Tape Versus Burch Colposuspension for Treatment of Female Stress Urinary Incontinence

Introduction: Many surgical procedures have been proposed for treatment of stress urinary incontinence (SUI) but none of them has proved completely successful. The aim of this study is to compare the efficacy and safety of tension free vaginal tape (TVT) with Burch colposuspension in the treatment of SIU. Patients and Methods: Fifty female patients, presenting with SUI were randomly divided into two equal groups. SUI was confirmed using urodynamic study in all patients. Group 1 (n=25) patients underwent Burch colposuspension while Group 2 (n=25) underwent TVT. Patients with high grade cystocele, previous surgical failure for SUI, uninhibited detrusor contraction during bladder filling on urodynamic study and incompetent internal sphincters were excluded from this study. A patient was declared cured of SUI, if 3–6 months after surgery she had no SUI. The procedure was judged to be a failure if 3–6 months after surgery, patient had SUI. Results: In group 1 patients, 72% were completely cured, 16% improved and 12% showed no improvement. In group 2 patients, 72 were completely cured, 20% improved and only 8% showed no improvement. There was no difference between the two groups in terms of cure rates. Operative time for TVT was significantly less compared to Burch. Postoperative pain was less in TVT than Burch. Return to normal activity was earlier in TVT compared to Burch group. Intra operative perforation of the urinary bladder occurred in 8% of patients in group 2. Urine retention occurred in 12% of patients in group 1 compared to 20% in group 2. This was successfully managed conservatively. De novo urgency developed in 12% in group I and 8% in group II and was successfully managed by medical treatment. Conclusion: The success rates of TVT and Burch colposuspension in the treatment of SUI in our experience are very similar. However, TVT is associated with less morbidity. We recommend TVT procedure for females with genuine SUI.     

An alternative statistical approach for predicting prolonged catheterization after burch colposuspension during reconstructive pelvic surgery

Our objective was to use an alternative statistical approach to identify clinical and urodynamic predictors of prolonged catheterization following Burch colposuspension. Seventy women with genuine stress incontinence underwent Burch colposuspension with suprapubic catheter placement at Rush Presbyterian-St. Luke’s Medical Center from 1 July 1992 to 1 October 1993. Patient charts were retrospectively reviewed to extract pertinent variables from their history, examination and preoperative urodynamic evaluation. The day of suprapubic catheter removal was considered the endpoint ‘event’ for the purposes of survival analysis. This statistical model allowed us to identify preoperative clinical parameters important in determining the percentage of patients requiring catheters as a function of time. The need for defining prolonged postoperative catheterization was eliminated. Aging (P=0.01), increasing maximal urethral pressures (P=0.02) and menopausal status (P=0.02) were important in determining the percentage of patients requiring catheters as a function of time. Data from our preoperative voiding studies were not predictive of prolonged catheterization following Burch colposuspension. EDITORIAL COMMENT: Voiding dysfunction remains a significant reality associated with anti-incontinence surgery. Patients should be counseled preoperatively regarding this risk, as voiding dysfunction can dramatically affect quality of life. Many investigators have tried to identify preoperative variables that place the patient at increased risk for postoperative voiding difficulties, with various recommendations given owing to different definitions of abnormal voiding following colposuspension. This paper presents an alternative method to approach prolonged catheterization after incontinence surgery, using survival statistical analysis rather than an arbitrary interval as in previous studies. Using this approach, preoperative voiding study parameters had no association with the length of catheter use. The only significant variable predicting prolonged catheterization was age. These are very different results from previous investigations, which found that decreased detrusor pressure during voiding and maximum flow rates were both associated with prolonged voiding dysfunction. Further investigation is needed in this area, with other centers applying survival statistical analysis to fully clarify whether this approach is valid and, if so, to pinpoint clinically significant variables which would predict postoperative voiding dysfunction.     

Urodynamics: role in incontinence and prolapse: a urology perspective

Changes in pelvic floor as well as urethral anatomy and function occur with aging, which can result in prolapse and urinary incontinence. Aside from the socially debilitating impact incontinence has on patient's lives, it significantly affects the health care systems economically. Rates of incontinence and pelvic organ prolapse (POP) in women of this age demographic is estimated to be 30% to 94%, and 1 in 8 women may require surgical repair for POP or incontinence by their eighth decade, with a reoperation rate of 30%. This article reviews the role of UDS in the evaluation of urinary incontinence and POP.     

Results of modified burch colposuspension in patients with genuine stress incontinence and hypotonic urethra or recurrent stress incontinence

Forty-eight stress-incontinent patients were evaluated before and after a modified Burch colposuspension. Group 1 (n=37) had a hypotonic urethra, and other patients with previous incontinence surgery (n=6) or with reasons for primary laparotomy without pelvic floor relaxation (n=5) formed group 2 (n=11). If pelvic reconstruction was necessary, the Burch procedure was combined with vaginal repair (n=25). After surgery 12 patients (32%) in group 1 complained of subjective recurrent incontinence; four (10%) of them were dissatisfied and 8 (22%) were satisfied with their improvement. Urodynamic examination indicated recurrent stress incontinence in 4 patients. Other reasons for subjective dissatisfaction were detrusor instability, large postvoid bladder volume, voiding difficulties such as straining to void or poor urinary stream, and cystitis. Eight patients with low urethral closure pressure (<=20 cmH₂O) were included in group 1. Only two failed to become continent after Burch colposuspension. Only 1 (9%) patient in group 2 suffered from detrusor instability. Resting urethral closure pressure increased significantly after Burch colposuspension in patients with preoperative hypotonic urethra, including those with low closure pressure. The rate of rectoceles and enteroceles doubled after the Burch procedure if reconstruction of the pelvic floor was not performed. In this study patients who were at high risk for recurrent stress incontinence benefited from the modified Burch colposuspension, but its increased side effects limit its use and require strict indications.Dedicated to Prof Dr med Heinrich Maass on the occasion of his 65^th birthday.     

腹腔镜Burch手术治疗女性压力性尿失禁(附12例报告)

目的:探讨腹腔镜下膀胱颈Cooper韧带悬吊术(Burch手术)治疗女性压力性尿失禁的使用方法和临床价值。方法:采用经腹腔途径,在腹腔镜辅助下,为12例女性压力性尿失禁患者施行Burch手术。结果:平均手术时间75m in。12例均获得随访,随访时间6~18个月,治愈11例。所有病例均无明显并发症。结论:采用腹腔镜Burch手术治疗张力性尿失禁临床效果满意,创伤及疤痕小、恢复快、住院时间短。     

Updated Systematic Review and Meta-Analysis of the Comparative Data on Colposuspensions,Pubovaginal Slings,and Midurethral Tapes in the Surgical Treatment of Female Stress Urinary Incontinence

Context

Burch colposuspension, pubovaginal sling, and midurethral retropubic tape (RT) and transobturator tape (TOT) have been the most popular surgical treatments for female stress urinary incontinence (SUI). Several randomized controlled trials (RCTs) have been published comparing the different techniques, with conflicting results.

Objective

Our aim was to evaluate the efficacy, complication, and reoperation rates of midurethral tapes compared with other surgical treatments for female SUI.

Evidence acquisition

A systematic review of the literature was performed using the Medline, Embase, Scopus, Web of Science databases, and Cochrane Database of Systematic Reviews.

Evidence synthesis

Thirty-nine RCTs were identified. Patients receiving midurethral tapes had significantly higher overall (odds ratio [OR]: 0.61; confidence interval [CI]: 0.46–0.82; p = 0.00009) and objective (OR: 0.38; CI: 0.25–0.57; p < 0.0001) cure rates than those receiving Burch colposuspension, although they had a higher risk of bladder perforations (OR: 4.94; CI: 2.09–11.68; p = 0.00003). Patients undergoing midurethral tapes and pubovaginal slings had similar cure rates, although the latter were slightly more likely to experience storage lower urinary tract symptoms (LUTS) (OR: 0.31; CI: 0.10–0.94; p = 0.04) and had a higher reoperation rate (OR: 0.31; CI: 0.12–0.82; p = 0.02). Patients treated with RT had slightly higher objective cure rates (OR: 0.8;CI: 0.65–0.99; p = 0.04) than those treated with TOT; however, subjective cure rates were similar, and patients treated with TOT had a much lower risk of bladder and vaginal perforations (OR: 2.5; CI: 1.75–3.57; p < 0.00001), hematoma (OR: 2.62; CI: 1.35–5.08; p = 0.005), and storage LUTS (OR: 1.35; CI: 1.05–1.72; p = 0.02). Meta-analysis demonstrated similar outcomes for TVT-O (University of Liège, Liège, Wallonia, Belgium) and Monarc (AMS, Minnetonka, MN, USA).

Conclusions

Patients treated with RT experienced slightly higher continence rates than those treated with Burch colposuspension, but they faced a much higher risk of intraoperative complications. RT and pubovaginal slings were similarly effective, although patients with pubovaginal slings were more likely to experience storage LUTS. The use of RT was followed by objective cure rates slightly higher than TOT, but subjective cure rates were similar. TOT had a lower risk of bladder and vaginal perforations and storage LUTS than RT. The strength of these findings is limited by the heterogeneity of the outcome measures and the short length of follow-up.     

Pelvic floor neuropathy in relation to the outcome of burch colposuspension

The aim of the study was to determine the role of neurogenic damage to pelvic floor muscles on the outcome of Burch colposuspension. Thirty women objectively continent after Burch colposuspension and 18 women with recurrent stress urinary incontinence (RSUI) were investigated with concentric needle electrode electromyography (EMG) in both pubococcygeus muscles and the external anal sphincter muscle. Neurogenic EMG patterns were significantly more often seen in the pubococcygeus muscles in women with RSUI than in women continent after the colposuspension (P<0.05). The distribution of neurogenic EMG patterns in the investigated muscles was significantly more pronounced in women with RSUI than in continent women: at least one pubococcygeus muscle with neurogenic EMG pattern, 72% vs. 34% (P<0.05); both pubococcygeus muscles, 50% vs. 13% (P<0.05); and all three investigated muscles 41% vs. 10% (P<0.05). In conclusion, the results imply an association between the outcome of the Burch colposuspension and the occurrence of neuropathy in the pelvic floor muscles. Occurrence of neurogenic damage in the pubococcygeus muscles seems to impair the outcome of Burch colposuspension.     

Complication Rates of Tension-Free Midurethral Slings in the Treatment of Female Stress Urinary Incontinence: A Systematic Review and Meta-Analysis of Randomized Controlled Trials Comparing Tension-Free Midurethral Tapes to Other Surgical Procedures and Different Devices

Objectives

To evaluate the complication rates of tension-free midurethral slings compared with other surgical treatments for stress urinary incontinence, including other tension-free midurethral slings.

Methods

A systematic review of the literature using MEDLINE, EMBASE, and Web of Science was performed in January 2007. Meta-analysis was conducted by using the Review Manager software 4.2.

Results

Our search identified 33 randomized controlled trials reporting data on complication rates. Our meta-analysis showed that complication rates were similar after tension-free vaginal tape (TVT) and Burch colposuspension, with the exclusion of bladder perforation, which was more common after TVT (p = 0.0001), and reoperation rate, which was significantly higher after Burch colposuspension (p = 0.02). TVT and pubovaginal sling were followed by similar complication rates. With regards to the comparisons among retropubic tapes, TVT and intravaginal slingplasty had similar complication rates, whereas suprapubic arc sling (SPARC) was complicated by higher rates of voiding lower urinary tract symptoms (LUTS) (p = 0.02) and reoperations (p = 0.04). Comparing retropubic and transobturator tapes, the occurrence of bladder perforations (p = 0.007), pelvic haematoma (p = 0.03), and storage LUTS (p = 0.01) was significantly less common in patients treated by transobturator tapes.

Conclusions

Tension-free slings were followed by lower risk of reoperation compared with Burch colposuspension, whereas pubovaginal sling and tension-free midurethral slings had similar complication rates. With regards to different tension-free tapes, voiding LUTS and reoperations were more common after SPARC, whereas bladder perforations, pelvic haematoma, and storage LUTS were less common after transobturator tapes. The quality of many evaluated studies was limited.     

Long-term results of Burch colposuspension and anterior colpoperineorraphy in the treatment of stress urinary incontinence and cystocele

OBJECTIVE: Female urinary incontinence and bladder prolapse are very common conditions whose treatment is not standardized. The aim of this study was to evaluate retrospectively the long-term results of Burch colposuspension and anterior colpoperineorrhaphy in the treatment of stress urinary incontinence (SUI) and cystocele, respectively. MATERIALS AND METHODS: We reviewed 36 female patients with a mean follow-up of 53 months. Mean patient age at time of surgery was 57.3 +/- 9.6 years (range 37-76). All patients were submitted to urodynamic investigation. Anterior colpoperineorrhaphy was performed in 18 cases (13 with cystocele, one with SUI and four with both). Burch colposuspension was performed in 14 cases (six with SUI and eight with both cystocele and SUI). The association of the two surgical procedures was used in four cases with both cystocele and SUI. RESULTS: Satisfactory results, such as disappearance of SUI with Burch colposuspension and cystocele with colpoperineorrhaphy, were obtained in the 88.8% and 85.8% of the cases, respectively. These results are even more excellent considering that 22.5% of the patients failed previous surgery. We observed no significant complications. CONCLUSIONS: The high percentage of long-term success confirms that anterior colpoperineorrhaphy and Burch colposuspension are two effective therapeutic choices for cystocele and SUI, respectively. The new mini-invasive techniques have to be compare with these traditional surgical treatments which efficacy is consolidated.     

Is Transabdominal Repair of Mild to Moderate Cystocele Necessary for Correction of Prolapse during a Modified Burch Procedure?

A nonconcurrent cohort study by chart review of cases was carried out at the Urogynecology Unit of Mount Sinai Hospital in Toronto, Canada, in 380 patients with stress urinary incontinence (SUI) undergoing Burch retropubic urethropexy (RPU) with or without transabdominal internal anterior repair (TIAR). There were 191 subjects (group A) who had both RPU and TIAR, and 189 (group B) who had RPU alone. The main outcome measures were postoperative recurrence of cystocele and SUI. Statistical analysis was performed using multiple regression analysis; P<0.05 was considered statistically significant. Of patients with preoperative cystocele grade 1 and 2 (mild to moderate) followed-up at 1 year, recurrence in groups A and B, respectively, was found in 13/114 (11.4%) vs. 4/99 (4.0%) (P<0.05). Regression analysis showed this trend of greater recurrence with TIAR to persist at 5 years, although a significant number of patients were lost to follow-up. There was no statistically significant difference in the cure of SUI between the groups. There was a 2.1% incidence of inadvertent cystotomy during TIAR (with no bladder injuries in group B), although this complication was always recognized and repaired without sequelae. In patients with both SUI and mild to moderate cystocele, TIAR may not be a necessary addition to RPU for treatment of the cystocele, although a randomized clinical trial is needed to determine the optimal transabdominal treatment in such cases. There is no detrimental effect of TIAR on the Burch procedure’s success in curing SUI.     

The long-term outcome of laparoscopic colposuspension: a 10-year cohort study

Introduction and hypothesis  The aim of this study is to provide long-term outcome data, at least 10 years, following laparoscopic colposuspension. Methods  The study includes a control group who underwent open colposuspension. A consecutive series of 139 women who had undergone laparoscopic colposuspension were reviewed and compared to 52 women who had an open colposuspension in the same unit. Subjects were contacted by telephone, at least 10 years post-operatively, at which time a structured interview was performed which included the short-form Bristol Female Lower Urinary Tract Symptom questionnaire. Results  There was deterioration in subjective cure rates from 71% and 67% at 6 months to 52% and 36% at 10 years for the laparoscopic and open procedures, respectively. Conclusion  This study provides evidence that laparoscopic colposuspension is probably as durable as open colposuspension. However, cure rates for both procedures appear to deteriorate over time, emphasising the importance of long-term follow-up.     

Burch bladder neck suspension for cystocele repair: the necessity of combined vaginal procedures for severe cases.

BACKGROUND: Burch operation is an accepted form of bladder neck suspension for small cystoceles. The purpose of the present study was to evaluate the efficacy of Burch repair for severe cystoceles compared with Burch repair along with vaginal procedures. METHODS: A total of 14 patients with severe cystocele (grade III-IV) treated with open Burch operation were evaluated retrospectively. Of these patients, eight were Burch only and the remaining six underwent combined Burch with vaginal repair (anteroposterior vaginal wall plasty and hysterectomy). RESULTS: After a mean follow up of 40 months (range 6-80), cystocele recurred in one patient at 1 month, and rectocele became prominent in three patients, including one who also presented uterine prolapse among the Burch-only group. Conversely, all six patients who underwent the combined operation showed no occurrence of cystocele or rectocele. The proportion of patients not failing treatment was significantly higher in the combined operation group than in the Burch-only group. Intermittent self-catheterization was needed in one patient from the combined operation group for 6 months, but all other patients had restored smooth urination within a few weeks after the operation. CONCLUSIONS: The results suggest that, for severe cystoceles, Burch-only repair is insufficient and combined Burch with vaginal repair should be used to manage various pelvic hypermobility symptoms.     

Transvaginal colposuspension for the treatment of genuine stress incontinence combined with vaginal hysterectomy: a preliminary report

The authors used a new, simple, modified transvaginal needle colposuspension technique in combination with vaginal hysterectomy for uterine prolapse and cystocele repair. The technique was used in 20 women with genuine stress incontinence which was urodynamically proven. One year after operation, 90% of patients were clinically normal and 85% were urodynamically cured. The advantages of this new technique are that the cost of the needle is low, it can be applied in all cases where a vaginal approach is necessary, and the method of needle insertion avoids perforation of the bladder.EDITORIAL COMMENT: It is still uncommon to have studies of new operative procedures employ urodynamic studies both pre- and post-operatively. Although 1-year results give an indication of how the new procedure will fare in comparison to other similar procedures already reported in the literature, long-term results are the most valuable. This editor would like to encourage these and other authors who report 1-year results to follow up their patients at 5 years, and report these results as well.     

Burch against Stamey. Comparison of two competing operative procedure

Summary Stress incontinence is the most frequent form of incontinence found in females. The usual method of surgery for this is to lift the bladder neck towards cranial and ventral. Two competitive techniques – bladder neck suspension in accordance with Stamey and colposuspension in accordance with Burch – were retrospectively investigated. A total of 95 women underwent surgery and it was possible to evaluate the postoperative course in 46 and 30 (total 76) patients respectively. Initially, both surgical techniques demonstrated a very good success rate (91.3 % and 96.7 % resp.). However, the continence rate of the Stamey patients deteriorated after 6 weeks down to 78.3 % and after more than 2 years only 28.6 % of these patients were still completely continent (mean follow-up 40.4 mths), whereas deterioration in the Burch patients was only 87 % (mean follow-up 44.25 mths). The disappointing results with the Stamey technique did not correlate with the degree of initial continence. It was noted here that obese patients showed a greater tendency towards regression. The three cases of recurring incontinence after Burch colposuspension were already relapses at the time of surgery. With respect to long-term follow-up, our results with the Stamey method were distinctly poorer than with the Burch technique. Therefore, in our opinion, the Burch colposuspension procedure and fascioplasty should be the method of choice for the management of stress incontinence.      

Minimally invasive surgical treatment of female stress urinary incontinence

The purpose of this study was to evaluate the safety and efficacy of a new minimally invasive surgical procedure for the treatment of female stress urinary incontinence (SUI). Four miniature bone anchors, each attached to a suture, are inserted transvaginally into the retropubic bone using an inserter on each side of the urethra without opening the vaginal mucosa. Tying the suture on each ipsilateral side creates colposuspension, as is the aim of previously described procedures such as the Marshall-Marchetti-Krantz. Sixty-one women (mean age 52±SD 9.9 years) with a mean follow-up of more than 12 months (range 12–30 months) were treated for SUI. Fifty patients (82%) are dry, 7 (14%) reported great improvement and 4 are considered surgical failures. The data presented suggest that our new minimally invasive procedure provides an effective treatment for female SUI. Its main advantages over other procedures are the transvaginal approach and short operating time.Editorial Comment: The search for the best surgical therapy for stress urnary incontinence continues with this presentation of a minimally invasive procedure involving no vaginal incisions, bone anchors and the tying of sutures in the vagina. The study is well designed except for a few issues that are important for the long-term determination of the viability of the procedure. Of particular importance is that the authors recognized that osteomyelitis is a problem with bone anchor procedures, and therefore used a 3-day 91 day preoperative and 2 postoperative) coverage of antibiotics, consisting of a thirdgeneration cephalosporin and gentamicyin, which is required to achieve therapeutic levels of antibiotic in bone. Bone anchor procedures have to date been done in a relatively contaminated environment, either by pulling sutures in and out of the vagina into the retropubic space or, as in this study, by directly penetrating the vaginal wall with bone anchors, with the attendant risk of driving bacteria into the bone along with the anchor. Postoperative X-rays were not done routinely to detect osteomyelitis, so that the true incidence of this problem remains unknown. Patients must be informed of this major potential complication and that the frequency is low, but yet an exact estimation of this frequency cannot be made. One case in 70 has been reported with the Vesical bone anchor procedure, by Appell [1]. The two major problems with this study are the lack of prospective comparison to a standard operation for stress incontinence, and the lack of objective postoperative follow-up. The success rate stands at 80% at 12 months based on mostly subjective data. The literature is clear that objective success rates are always lower than subjective success rates, so the objective success rate of this procedure may be lower. In this study pad testingor counts were used to determine success. Unfortunately, the exact type of pad test is not specified. Objective documentation of lack of urine loss under specific volumes of bladder filling and stress maneuvers was not done. Pad counting alone introduces a new element of subjectivity into the postoperative follow-up. Of concern with any minimally invasive procedure is that the retropubic space is relatively unviolated, and little occurs that may induce scarification of the paraurethral tissue to the pelvic sidewall or the retropubis. It is well known that sutures in tissue under tension tend to pull through tissue. All retropublic urethropexies suffer from this problem, and reliance on patient rest until enough scarification occurs is necessary to ensure a reasonable chance of success. Concern with this procedure is that in the long term sutures may pull through, with little chance for scarification to occur. Future reports from the authors on this same group of patients will be necessary to answer these concerns, along with more objective postoperative determinates of success.