Burch procedure compared with sling for stress urinary incontinence: a decision analysis

OBJECTIVE: To compare the relative risks and benefits of Burch colposuspension and sling procedure for primary genuine stress urinary incontinence in women. METHODS: We developed a decision analytic model to compare Burch procedure and sling for primary surgical treatment of genuine stress incontinence with urethral hypermobility in women. Risks and benefits were estimated from published literature. The main outcome measure was effectiveness of treatment, defined as cure of incontinence after initial and secondary treatments. We considered four outcomes of primary surgical treatment: cure, persistent incontinence (either caused by intrinsic sphincter deficiency without urethral hypermobility or genuine stress incontinence with hypermobility), de novo detrusor instability, and permanent urinary retention. Secondary treatment included repeated surgery for genuine stress incontinence, collagen injection for intrinsic sphincter deficiency, medical treatment for detrusor instability, and urethrolysis for retention. One-way sensitivity analyses were used to estimate the effect of varying each characteristic through its range; all other characteristics were fixed at their baseline values. RESULTS: The overall effectiveness of Burch and sling operations (percentages of women cured after initial and secondary treatments) was similar (94.8% and 95.3%, respectively). In sensitivity analyses, the Burch arm of the model was more effective than sling when the risk of retention after sling was higher than 9.0% or when the risk of de novo detrusor instability after sling was higher than 10.3%. Conversely, when the risk of de novo detrusor instability after Burch was higher than 6.8%, the sling arm of the model was more effective. CONCLUSION: The Burch and sling procedures are similarly effective for primary surgical treatment of genuine stress incontinence in women. Overall effectiveness is substantially influenced by relative rates of complications.