Oct 12, 1982 - A clinical and urodynamic assessment of the Burch colposuspension for genuine stress incontinence. P. HILTON* Clinical Research Fellow ...
British Journal of Obstetrics and Gynaecology October 1983, Vol. 90, pp. 934-939.
A clinical and urodynamic assessment of the Burch colposuspension for genuine stress incontinence P. HILTON* Clinical Research Fellow & S . L. S T A N T O N Honorary Senior Lecturer,
Urodynamic Unit, Department of Obstetrics and Gynaecology, St GeorgeS Hospital Medical School, London Summary. Twenty-five women having a Burch colposuspension operation were assessed before and after the operation by urodynamic investigations including urethral pressure measurements at rest and on stress. After 3 months, t h e objective cure rate was 88%. An increase in voiding difficulty and urodynamic evidence of outflow obstruction w a s seen after the operation. The operation does not induce any significant change in resting urethral profile variables. T h e stress profile showed accentuation in pressure transmission ratios, most marked in the proximal urethra. These changes are likely to be mechanical in origin and m a y be responsible for voiding difficulties in those women who initiate voiding by straining.
The earliest documented surgical approach to stress incontinence was by Baker Brown (1864) and since his description, over 100 different operations have been devised for the treatment of this condition (Stanton 1978). This reflects not merely uncertainties of the mechanism of cure but also inadequacies of any single procedure to deal satisfactorily with all cases. Bonney (1923) considered that the main effect of the vaginal repair was to tighten the pubo-cervical fascia and this is still an important aim of vaginal incontinence surgery. In addition, elevation of the bladder neck and an increase in urethral resistance have been considered important aspects of any incontinence operation (Stanton 1978). Although the aims of incontinence surgery may have been defined, there is little information as to the extent these are achieved by the various operative techniques. Cure rates of between 40 and 97% have been reported (Green 1980). Those aspects of the procedure and of urethral function ~~
*Present address: Senior Lecturer, Department of Obstetrics and Gynaecology, Princess Mary Maternity Hospital, Great North Road, Newcastleupon-Tyne NE2 3BD, UK.
0306 5456/83/1000-0934%02.00 0 1983 British Journal of Obstetrics and Gynaecology
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which determine success or failure are still poorly understood. Obrink et al. (1 9 78) recorded urethral pressure profiles before, during and after a pubococcygeal repair operation. Whilst marked changes were noted during the course of the operation in both functional urethral length and maximum urethral closure pressure, there were no significant differences between the profiles performed before and at 3 months after operation, even though 15 of their 16 patients were symptomatically cured. In a later study, extended to include urethral profiles under stress, the same authors noted improvements in mid-urethral pressure transmission from 65% pre-operatively to 80% postoperatively (Bunne & Obrink 1978). Similar findings have been made for suprapubic operations. Henriksson & Ulmsten (1978) compared the effects of the MarshallMarchettikKrantz urethrocystopexy and the Zoedler vaginal sling operation and found no significant changes in resting profiles. During stress profiles, however, they and Obrink & Bunne (1978) found both procedures caused an improvement in pressure transmission and improved urethral closure on stress. The nature of the improvement in urethral pressure transmission following surgery is uncer-
The Burch colposuspension tain. Whether the effect is due to restoration of the proximal urethra into such a position that it is again subject to passive transmission of intraabdominal pressure rises, or whether the approximation of pubocervical fascia or pubococcygeus improves the efficiency of the pelvic floor reflex on coughing, or whether some additional mechanical factor is introduced has not been shown. Similarly, why operations fail, when the anatomy has apparently been restored to normal, remains unclear. Burch (1961) described a suprapubic operation which corrected stress incontinence and anterior vaginal wall prolapse. Although bladder function has been investigated before and after this operation (Stanton & Cardozo 1979), the effects on urethral function as measured by resting and stress urethral pressure recordings, have not been assessed.
Method Twenty-five women who complained of stress incontinence, with or without other urinary symptoms, were studied. They were between 34 and 69 years of age (mean 47.2 years) and had a mean parity of 2.7 (range 0-7). All the women were assessed before operation, this included a full history; clinical examination; bacterial culture of a mid-stream urine specimen; videocystourethrography (Bates et al. 1970); a modified Urilos nappy test (Stanton & Ritchie 1977) and cystourethroscopy. All patients had genuine stress incontinence. Urethral pressure measurements at rest and on stress were made as described previously (Hilton & Stanton 1983) From the stress profiles, pressure transmission ratios were calculated at four equidistant points along the functional urethral length and a pressure transmission profile was constructed from the bladder neck to the external urethral meatus. The operative procedure was a modified Burch colposuspension as described by Stanton & Cardozo (1979). After the operation the bladder was drained continuously with a Bonanno suprapubic catheter for 48 h: thereafter it was clamped during the day and removed when the residual volume was
