A 2009 Cochrane review found that 69% to 88% of women treated with Burch colposuspension were largely continent, and 5 years after surgery the continence rate remained high at 70%. Twelve trials were available that compared colposuspension with various forms of suburethral slings; there were no significant differences in failure rates between slings and colposuspension at any time interval studied (85).
The long-term success of laparoscopic colposuspension is unclear, but there is limited evidence to suggest the results are less favorable than with open colposuspension, although this may reﬂect a learning effect and be unreliable in isolation (86).
Sling operations traditionally were performed using a combined vaginal and abdominal approach (Fig. 26.11). The anterior vagina is opened, the space of Retzius is dissected on each side of the bladder neck, and a sling is passed around the bladder neck and urethra and then attached to the anterior rectus fascia or some other structure to cradle the urethra in a supporting hammock. This supports the urethra and allows it to be compressed during periods of increased intra-abdominal pressure (87–97). The sling can be made of organic or inorganic materials. Organic materials can be autologous tissues harvested from the patient (e.g., fascia lata, rectus fascia, tendon, round ligament, rectus muscle, vagina), processed allografts from human donors (e.g., fascia lata, dermis), or heterologous tissues harvested from another species and processed for surgical use (e.g., ox dura mater, porcine dermis). Synthetic materials (e.g., Silastic, Gore-Tex, Marlex) are popular because of their consistent strength and availability, but historically these substances were plagued by problems with erosion and infection when used around the urethra (67,98,99).
The multicenter Urinary Incontinence Treatment Network conducted a randomized clinical trial comparing Burch colposuspension and fascial pubovaginal sling in 655 women with stress urinary incontinence (100). The primary outcome, success, was rigorously defined as a negative pad test, no urinary incontinence (as recorded in a 3-day diary), a negative cough and Valsalva stress test, no self-reported symptoms, and no retreatment for the condition. At 24 months, success rates were higher for women who underwent the sling procedure than for those who underwent the Burch procedure for the overall category of success (47% vs. 38%; p = .01). However, more women who underwent the sling procedure later had urinary tract infections, difficulty voiding, and postoperative urge incontinence. This study highlights the wide range in success depending on how it is defined: for example, based on a cough stress test, success rates were 71% in the Burch group and 87% in the sling group, while based on a pad test, rates were 84% and 85%, respectively.
Figure 26.11 A completed traditional suburethral sling procedure with the fascia located at the bladder neck with the ends of the sling tied to or above the rectus fascia. The classic procedure uses autologous fascia; however, some surgeons use allograft or xenograft tissue performed in a similar fashion. (Redrawn from original by Jasmine Tan.)
Minimally Invasive Sling In the 1990s, various orthopedic bone anchors were marketed to implant into the pubic bone to suspend the urethra with sutures or slings. Despite a lack of medical evidence to support either the bone anchor or the allograft use, bone anchor systems became the quick and minimally invasive method to suspend allograft slings (101). Although bone anchors were not superior to standard fixation techniques, their use led to increased complications in several series.