When you’re weighing surgical options for stress urinary incontinence, you want to know one thing above all: does it work? For years, doctors have relied on two primary operations to provide support and stop leaks. A landmark study directly compared these two techniques, giving us valuable insight into the burch procedure vs sling discussion. While the sling procedure showed higher success rates for keeping women dry, it also came with a different set of side effects. This article will explore those findings, helping you understand the trade-offs and what they might mean for your personal health and quality of life.

In the largest and most rigorous U.S. trial comparing two traditional operations for stress urinary incontinence (SUI) in women, a team of urologists and urogynecologists supported by the National Institutes of Health (NIH) has found that a sling procedure helps more women achieve dryness than the Burch technique. The study is being released early by the New England Journal of Medicine (NEJM) to coincide with a presentation at the annual meeting of the American Urological Association on May 21, 2007. Results will appear in the May 24 print edition of NEJM. For the first time, we have a meticulous, relatively long-term comparison of these common surgeries in women, said Leroy M. Nyberg Jr., Ph.D., M.D., director of urology research at the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Women who participated in this study have made it possible for many women with stress incontinence and their doctors to make more-informed choices based on clear benefits, risks and personal preferences. The Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr) found that significantly more women with a sling made from the patients own tissue and placed around the urethra for additional support were dry, compared to women with a Burch colposuspension, in which sutures are attached to a pelvic ligament to support the urethra. Both approaches are illustrated below. Two years after surgery, 47 percent of women who had the sling procedure and 38 percent who had a Burch were dry overall, including leakage that could have been caused by urge incontinence. Considering only stress-specific leakage, 66 percent of women with a sling and 49 percent with a Burch procedure were dry. SISTEr randomized 655 women with either pure SUI or a combination of stress and urge incontinence to receive a fascial sling or a Burch. Complete information on measures used to assess urinary incontinence was available for 520 participants (79 percent) 24 months after surgery. Quality of life, patient satisfaction and side effects were also studied. While most women in the study were satisfied with the results of treatment, those with a sling were significantly more satisfied. Eighty-six percent with a sling were satisfied, compared to 78 percent of the Burch group. Side effects were more common among women with slings, tempering the positive results of the procedure. The most common side effect was urinary tract infections, which occurred in 63 percent of women with a sling and 47 percent of the Burch group. Women with a sling also had more voiding problems (14 percent versus 2 percent) and persistent urge incontinence, the loss of urine just before feeling a strong, sudden urge to empty the bladder (27 percent versus 20 percent). Nineteen women with slings who had difficulty voiding after treatment needed surgery to correct the problem; none in the Burch group needed corrective surgery for voiding problems. Stress urinary incontinence, in which coughing, laughing, sneezing, running or lifting heavy objects causes urine to leak, is commonly treated with surgery designed to provide additional support to the bladder neck and urethra during increases in abdominal pressure that occur with these kinds of activities. However, randomized, controlled trials comparing these operations are rare. Studies predating SISTEr were small, short-term, or less stringent about diagnostic criteria and outcome measures, producing inconsistent results across studies. SISTEr set a higher bar by standardizing definitions, clinical evaluations, and surgical procedures at all sites and by using composite outcome measures and a more rigid definition of success compared to other studies, according to the study. SISTEr defined two levels of treatment success. Stress-specific success required that women have no symptoms of leakage during physical activities, no leakage during a valsalva and cough stress-test, and no re-treatment for the problem. Overall success required that women meet SUI-specific treatment goals, have a negative pad test and have no leakage episodes recorded on a three-day voiding diary. This higher bar may account for lower success rates in SISTEr than in earlier trials, but it also establishes a template for conducting surgical trials for urinary incontinence and for other urological conditions, said John W. Kusek, Ph.D., co-director of kidney and urology trials at NIDDK. NIH½s National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Child Health and Human Development and Office of Research on Womens Health funded the Urinary Incontinence Treatment Network, a group of nine clinical centers and a biostatistical center, to conduct a series of rigorous, long-term trials of common incontinence therapies. Urinary incontinence is a common and costly condition that reduces quality of life for American women. NIDDKs Urologic Diseases in America project reports that up to three-fourths of women have some degree of incontinence, and the direct cost of incontinence for women was $12.4 billion in 1995. Sling National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health Suspension National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health SISTEr is the first trial completed by UITN, with two other studies in the wings. Results of the second trial, the Behavior Enhances Drug Reduction of Incontinence (BE-DRI), for urge incontinence, are expected later this year. BE-DRI asked 307 women to make changes such as emptying the bladder on a regular schedule and to practice Kegel exercises to strengthen pelvic muscles to learn if these common treatments would allow women to stop drug therapy and maintain the same degree of bladder control. The third UITN study, the Trial of Mid-Urethral Slings (TOMUS), is recruiting patients to compare two minimally invasive surgeries for the treatment of SUI. Both procedures include placement of a synthetic mesh sling and have been approved by FDA for stress incontinence. For a list of centers enrolling patients for TOMUS, visit www.uitn.net or search for TOMUS at www.clinicaltrials.gov.  The NIDDK, a component of the NIH, conducts and supports research in diabetes and other endocrine and metabolic diseases; digestive diseases, nutrition, and obesity; and kidney, urologic and hematologic diseases. For more information about NIDDK and its programs, see www.niddk.nih.gov. The National Institutes of Health (NIH) The Nation’s Medical Research Agency includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov

Frequently Asked Questions

So, which surgery is actually better: the sling or the Burch procedure? There isn’t a simple “better” option—it’s more about which is better for you. The study showed that the sling procedure was more likely to result in complete dryness from stress-related leaks. However, the Burch procedure had a lower rate of certain complications. Your decision will come down to a personal conversation with your doctor about what you value most: the highest chance of staying dry versus a lower risk of side effects like infections or trouble urinating.

The sling seems more effective, but what are the trade-offs? You’re right, the sling had higher success and satisfaction rates, but it wasn’t a clear win. The primary trade-offs were the side effects. Women who received a sling had significantly more urinary tract infections and issues with emptying their bladder. In some cases, another surgery was needed to correct this. It’s a classic risk-versus-reward scenario that you’ll need to weigh for your own health and lifestyle.

This study is from 2007. Is this information still relevant today? Yes, this was a foundational study that still informs how we think about these procedures. However, medical techniques are always improving. Since this trial, different types of slings have become more common, including those using synthetic materials. Think of this study as providing the core principles of the debate, but be sure to ask your doctor about the most current techniques and materials available now.

The post mentions different “success rates.” What does that actually mean? The researchers were very specific, which is great for science but can be a little confusing for the rest of us. They had two main definitions. “Stress-specific success” meant you didn’t leak during physical activity like coughing or exercising. “Overall success” was a much higher bar to clear—it meant you met the stress-specific goals and had no other types of leaks recorded in a detailed diary. This strict definition is why the numbers might seem lower than what you see in other reports.

After reading this, what should my next step be? Use this information as a starting point for a conversation with your specialist. This article gives you the background to ask smarter, more specific questions. Think about what matters most to you and write down your concerns. Your next step is to schedule a consultation to discuss your personal health history and goals, which will help you and your doctor decide on the right path forward.

Key Takeaways

  • The sling procedure is more effective for stopping leaks. A major clinical trial found that women who underwent a fascial sling surgery were significantly more likely to be completely dry two years later compared to those who had the Burch procedure.
  • Higher success rates come with different risks. While more effective, the sling procedure also presented a greater frequency of side effects, most notably a higher rate of urinary tract infections and issues with bladder emptying.
  • Your personal priorities will guide your decision. Despite the increased risks, women who received the sling reported greater overall satisfaction, highlighting the importance of discussing with your doctor whether the goal of complete dryness outweighs the potential for other complications.

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