What is the role of Burch colposuspension in treating stress urinary incontinence (SUI) in women?

Burch Colposuspension for Stress Urinary Incontinence

Primary Recommendation

Burch colposuspension remains a viable surgical option for stress urinary incontinence (SUI), but is now primarily reserved for women who refuse synthetic mesh or who are undergoing concurrent open/minimally invasive abdominal-pelvic surgery. 1

Current Position in Treatment Algorithm

When to Offer Burch Colposuspension

• First-line consideration: Women with SUI who specifically decline synthetic mesh after thorough counseling about mesh risks and benefits 1
• Opportunistic indication: Women undergoing concomitant open, laparoscopic, or robotic abdominal-pelvic surgery (e.g., hysterectomy, sacrocolpopexy) 1
• Acceptable alternative: When autologous fascia pubovaginal sling is not feasible or desired 1

Efficacy Data

• Short-term success (12-23 months): 81-82% cure/dry rates for open Burch 1
• Medium-term (24-47 months): 76% cure/dry rates 1
• Long-term (≥48 months): 73-78% cure/dry rates 1, 2
• Laparoscopic approach: 69-74% cure/dry rates, with comparable outcomes to open technique 1, 3

Comparative Effectiveness

Burch vs. Autologous Fascial Sling

The SISTEr trial demonstrated autologous fascial pubovaginal sling superiority over Burch colposuspension, with 66% vs. 49% success rates and lower re-treatment rates at 5-year follow-up. 1 This represents the highest quality comparative data and should guide decision-making when both options are available.

Burch vs. Synthetic Midurethral Slings

• Retropubic midurethral slings (TVT) show essentially equivalent outcomes to Burch colposuspension in multiple RCTs 1
• Synthetic midurethral slings demonstrate 84% cure/dry rates at short and long-term follow-up 1
• Critical distinction: Midurethral slings have become the most studied anti-incontinence procedure with comparable efficacy but less invasive approach 1

Complication Profile

Urge Incontinence Risk

• De novo urge incontinence: 8% for open Burch without concurrent prolapse repair 1
• De novo urge incontinence with prolapse repair: 14% 1
• Preexisting urge incontinence: 17% postoperative persistence without prolapse repair, 22% with concurrent prolapse repair 1

Urinary Retention Risk

• Retention >1 month or requiring intervention: 3-4% for open Burch 1
• With concurrent prolapse repair: 1% retention rate 1
• Notably lower than autologous fascial slings (8% retention) and synthetic bladder neck slings (9-10% retention) 1

Operative Considerations

• Temporary urinary retention is the most common postoperative complaint 4
• 19% experience urgency at 6-12 months postoperatively 4
• 12% develop rectocele or enterocele requiring surgical correction after one year 4

Special Clinical Scenarios

Concomitant Prolapse Surgery

When performing abdominal sacrocolpopexy in women without preoperative stress incontinence symptoms, adding Burch colposuspension significantly reduces postoperative stress incontinence (33.6% vs. 57.4%, P<0.001) without increasing urge symptoms. 5 This represents high-quality evidence (NEJM, 2006) supporting prophylactic Burch during prolapse repair.

Recurrent Stress Incontinence

• Primary surgery success rate: 95% 4
• Recurrent SUI after prior surgery: 82% cure rate 4
• Most failures occur within the first 6 months postoperatively 4, 2

Patients with Low Urethral Closure Pressure

For patients with intrinsic sphincter deficiency (low urethral closure pressure), vaginal sling procedures are preferable to Burch colposuspension. 2 This represents a critical patient selection factor to avoid predictable failure.

Technical Approach Options

Open vs. Laparoscopic

• Open approach: 81-82% cure rates at 12-23 months 1
• Laparoscopic/extraperitoneal approach: 69% cure rates with significant quality of life improvements and fewer apparent compromises in outcomes 1, 3
• Both approaches show durable long-term results without significant differences 3

Suture Material

• No significant differences between polyglycolic acid (Dexon) and polyglyconate monofilament absorbable sutures (Maxon) 4

Critical Pitfalls to Avoid

• Patient selection error: Do not offer Burch to patients with intrinsic sphincter deficiency/low urethral closure pressure—these patients require pubovaginal slings or bulking agents 2
• Inadequate preoperative counseling: Must discuss that autologous fascial slings have superior long-term outcomes with lower re-treatment rates 1
• Ignoring concurrent prolapse: When performing sacrocolpopexy, prophylactic Burch significantly reduces postoperative SUI 5
• Expecting mesh-equivalent outcomes: Burch has lower success rates than synthetic midurethral slings in most comparative studies, though differences may be modest 1

Preoperative Evaluation Requirements

• Mandatory urodynamic evaluation to identify low urethral closure pressure patients who will fail Burch 2
• Postoperative urodynamic studies unnecessary if clinical results are satisfactory 2
• Cured patients demonstrate significant rise in pressure transmission from bladder to urethra 2