Debate: Is there still a place for open surgery
for incontinence?
By Kristin Jenkins

QUEBEC CITY, Que. -- Is there still a place for open surgery in the treatment of female stress urinary incontinence?

“Absolutely, yes,” says Dr. Vincente Lucente, medical director of the Institute for Female Pelvic Medicine & Reconstructive Surgery, New Orleans, LA. “It is just a matter of when and where,” he told delegates to Urogynecology Quebec 2007.

Dr. Lucente conceded, however, that for primary surgical correction of female stress urinary incontinence (SUI) in the uncomplicated patient with simple urethral hypermobility, “the role of open colposuspension is probably a decreasing role at best.”

Nevertheless, he added, the evidence-based literature shows that there are many benefits to open colposuspension. Among them:

* It is as effective at curing SUI as any other procedure in primary or secondary surgery (level 1) [Ward et al, 2000]

* The efficacy is very much the same long-term (level 3) [Langer et al, 2001].

* When a patient has urinary stress incontinence after a first surgery, an open second surgery can achieve a high cure rate.

When outcomes using open colposuspension are compared against tension-free vaginal tape procedures (TVT), however, there are marked differences. With open surgery, for instance, there is a prolonged operative time and length of stay as well as a higher incidence of delayed voiding than with a mid-urethral sling procedure. In addition, the patient’s return to normal activity takes longer after colposuspension, noted Dr. Lucente. Finally, he pointed out, more women will undergo re-operation for pelvic organ prolapse after colposuspension than with TVT (Kwan et al, 2003; Ward, 2004). “There’s the downside,” said Dr. Lucente.

So when do you consider colposuspension and in which patients?

For starters, any patient who requires concomitant pelvic surgery is a candidate for the open approach, said Dr. Lucente. This includes patients with gynecologic cancer or large benign tumors. “It just seems silly to close the woman and go down below and do a mid-urethral sling when you’re right there,” he noted.

There is also a role for open surgery in selected complicated failures of prior SUI surgery as well as in patients who are poor candidates for a mid-urethral sling due to decreased urethral mobility.

And finally, there’s the matter of surgeon experience. “If you do a great Burch and get great outcomes but haven’t always felt comfortable with a mid-urethral supra-vaginal sling procedure, then there’s a good case for doing what you’re doing because it ensures your patients are well cared for,” said Dr. Lucente.

On the other side of the debate, Dr. J. Christian Winters, professor and chairman, Louisiana State University Health Sciences Center, New Orleans, LA, gave open procedures in general and the Burch in particular, a qualified thumbs-down.

“I do not believe that there’s a role for open surgery procedures at the present time, particularly for the primary patients,” said Dr. Winters. ‘I think the mid-urethral slings are better procedures and achieve equivalent results with less morbidity, less obstructive voiding and faster recovery. Plus, no laparoscopic skills are needed.”

Improved efficacy and the potential to better handle any complications is why Dr. Winters is doing mid-urethral slings with colpopexies as opposed to Burch procedures.  “An open abdomen is not a reason to select an operation that has a 24% failure rate at three months and is harder to release if there is obstruction,” he said. “I’d rather do a procedure that I know I can reverse completely.”

The reproducibility offered by a mid-urethral sling procedure is another reason to choose it over an open procedure, said Dr. Winters. “As I train residents and fellows—and it’s certainly much easier to teach a mid-urethral sling than it is a Burch--I want to be able to make sure that they are able to reproduce the procedure and get the results that they’re getting with me.”

Open procedures such as the Burch don’t provide that kind of reproducibility, noted Dr. Winters. “I’m not sure that your Burch is similar to my Burch,” he said. “We have variable numbers of sutures, variable locations of sutures. Then there’s the question of whether we’re using mesh, tapes and what’s the tension.”

There’s also the matter of complication rates. A 1997 meta-analysis by the American Urology Association Guidelines Panel showed that even though retropubic suspensions are as efficacious as pubovaginal slings (and superior to anterior repair and needle suspensions) there was a higher incidence of complications after a Burch. These complications included a 3-8% incidence of blood transfusion, and post-colposuspension syndrome or groin pain 7-12% of the time (Galloway 1987; Demerit 2001).

In addition, a SUI Guidelines Panel noted a 5% incidence of temporary retention lasting more than four weeks in patients who underwent retropubic suspension. (The risk of permanent retention in these patients was less than 5%.) The incidence of postoperative voiding dysfunction after a Burch ranged from 3-12% and the incidence of de novo detrusor overactivity was 3.4-18% following a Burch procedure. A Burch procedure also predisposed to enterocele in 3-17% of patients, noted Dr. Winters.

While a number of randomized trials comparing open versus sling procedures show similar efficacy, patients receiving the mid-urethral sling did better in the overall quality of life (QOL) and there was less recurrent surgery for prolapse. In addition, one randomized trial comparing a laparoscopic retropubic suspension to the mid-urethral sling demonstrated that not only is the cure rate better for the mid-urethral sling, so is patient satisfaction and QOL.

“If we put together all the data that we have showing similar efficacy with decreased recovery time, less retention and less obstructed voiding with the mid-urethral slings, I think this certainly makes a compelling argument that open procedures should not be the first-line therapy for stress incontinence,” said Dr. Winters.

What about occult stress incontinence and abdominal sacralcolpopexy? The AUGS Care trial (Brubaker et al NEJM 2006;354(15);1557-1566) makes “a compelling argument” that the women who did not have a Burch had a higher incidence of stress incontinence even though they didn’t have stress incontinence prior to surgery, noted Dr. Winters.

“The question I take home from this landmark data is should we be doing Burches or should we be doing anti-incontinence procedures on these patients? I still like to offer the patient the procedure that I think is best. And I think this makes the case for considering the mid-urethral sling even in this scenario,” said Dr. Winters.

A Medline analysis of all procedures for stress incontinence shows that the retropubic procedures also have the highest incidence of voiding dysfunctions. “I think that many of these women are probably obstructed,” said Dr. Winters.

A comparison of treatment of obstruction in these patients—sling incision versus transvaginal urethrolysis — comes out strongly in favour of sling lysis with some reporting 100% relief of obstructed voiding symptoms. “In my hands, relief of obstruction is more certain and complete following sling incision versus urethrolysis,” said Dr. Winters.