Prophylactic Surgery Reduces Urinary Stress Incontinence

By age 80 years, 11% of women will have had surgery for pelvic organ prolapse or urinary incontinence. A third of those women require a second surgery. Prolapse commonly coexists with lower urinary tract dysfunction, but in some women, the prolapsed pelvic organs cause urethral kinking, “essentially protecting them from incontinence,” says UAB urogynecologist Holly E. Richter, MD, PhD. “Once we repair the prolapse and straighten the urethra, these patients may experience incontinence.”

Patients who develop incontinence after sacrocolpopexy — an abdominal prolapse repair that anchors the vagina to the sacrum — often undergo a Burch colposuspension to support the urethra. “Surgeons have not routinely performed prophylactic colposuspension because of possible risks of causing other lower urinary symptoms such as urgency and difficulty with voiding,” she says.

In a National Institutes of Health-funded study published in The New England Journal of Medicine, Richter and colleagues found that performing a Burch colposuspension along with abdominal sacrocolpopexy significantly reduced postoperative urinary stress incontinence in women without preoperative symptoms of stress incontinence and did not increase other lower urinary tract symptoms (2006;354:1557-1566).

The Colpopexy and Urinary Reduction Efforts (CARE) trial randomized 322 women undergoing sacrocolpopexy to receive either Burch colposuspension or no additional surgery. The two primary endpoints were stress incontinence and urge symptoms.

Three months after surgery, investigators characterized women as having stress incontinence if they reported subjective leakage, experienced stress incontinence during standardized stress testing, or required incontinence treatment. During the first interim analysis, 23.8% of the Burch group met one or more criteria for stress incontinence compared with 44.1% of the sacrocolpopexy alone group. Because of the overwhelmingly positive results, enrollment was halted.

Furthermore, addition of a Burch colposuspension did not increase the frequency of urinary retention, urge incontinence, urgency, urinary tract infections, or intraoperative or postoperative complications. “Urinary incontinence procedures are potentially obstructive and may cause urge leakage or voiding difficulty,” Richter says, “but the Burch procedure reduced urgency.”

Surprisingly, even women who had the Burch procedure reported stress incontinence postoperatively; however, the prevalence of “bothersome” stress incontinence was significantly less common in the Burch group than in the control group (6.1% vs 24.5%). “This amount of ‘any’ leakage is interesting,” Richter says. “Those patients’ baseline bladder study measures may have been different than others undergoing the Burch, and an alternate procedure, such as a sling, may have been more effective.

“Preoperative urodynamic testing may not identify those who will benefit from the addition of the Burch surgery,” says Richter, “but such testing may help determine which women would respond better to other incontinence procedures.”

Investigators will continue to analyze these data. “While the study’s primary outcome measure evaluated incontinence at 3 months after surgery, we are following participants for several years to determine long-term results,” she says.

For more information:
Dr. Holly Richter
1.800.UAB.MIST
mist@uabmc.edu