An increasing number of women with urinary stress incontinence are turning to surgery, with its relatively high rate of success, to manage or correct the condition. Researchers in the Urinary Incontinence Treatment Network recently evaluated two common surgical procedures, the pubovaginal fascial sling and the Burch colposuspension, to determine which is superior in treating stress incontinence specifically and incontinence in general. Both well-established, the Burch colposuspension procedure permanently sutures the iliopectineal ligament to suspend the anterior vaginal wall at the level of the bladder neck, whereas the fascial sling procedure harvests an autologous segment of rectus fascia secured from above to the rectus fascia itself with permanent sutures to create a sling under-neath the proximal urethra.

There were two sets of outcomes: those for urinary stress incontinence and those for overall urinary incontinence. Successful treatment of urinary stress incontinence was determined by a negative cough and Valsalva stress test, the patient's report of the absence of symptoms, and the absence of a second treatment. The successful treatment of overall urinary incontinence additionally included a negative pad test and the absence of episodes of incontinence, as recorded in a three-day diary.

A total of 655 women with positive stress tests were enrolled in the study and randomized while in the operating room to undergo either the Burch colposuspension procedure (n = 329) or the sling procedure (n = 326).

After two years, the results showed that among women who underwent the pubovaginal fascial sling procedure, there was a 66% success rate in stress incontinence, compared with 49% among those who had undergone the Burch colposuspension procedure; in overall incontinence, the success rates were 47% and 38%, respectively. Women who had undergone the sling procedure also reported greater satisfaction with the outcome than the women in the Burch group did (86% and 78%, respectively). The favorable results of the sling procedure were countered by higher rates of noted complications, 63% of women experiencing adverse events with the sling, compared with 47% after the Burch procedure, urinary tract infections accounting for most of the events (305 and 203 events, respectively). Difficulties in voiding and postoperative urge incontinence were also more prevalent after the sling procedure.

The authors conclude that health care professionals should discuss the benefits and liabilities of the two surgical options with patients and inform them that a complete surgical cure for urinary incontinence is improbable.-AK