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Also known as
Burch procedure, retropubic urethropexy, retropubic suspension, Burch retropubic urethropexy, Burch colposuspension procedure, retropubic colposuspension
Definition
Burch Colposuspension is a specific retropubic suspension surgery where the anterior vaginal wall is sutured to Cooper’s ligament (iliopectineal line) to treat stress urinary incontinence (SUI) in women, particularly when associated with urethral hypermobility.1 The procedure aims to elevate and stabilize the bladder neck and proximal urethra back into the intraabdominal pressure area behind the pubic symphysis.2 This elevation allows significant improvement of pressure transmission on the urethra, increasing the functional urethral length as well as the urethral closure pressure.3
The surgery involves placing two to four, preferably non-absorbable sutures on each side of the bladder neck.4 Traditionally, the proximal sutures are located 2 to 3 cm lateral to the bladder neck, while the distal sutures are placed 2 to 3 cm lateral to the proximal third of the urethra.5 These sutures apprehend the full-thickness of the vaginal wall, right under the mucosa, with the loose ends attached to the ipsilateral Cooper’s ligament.6 The vagina is elevated, and the knots are gently adjusted on top of the Cooper’s ligament without tension.7
Originally performed as an open surgical procedure, Burch Colposuspension was long considered the “gold standard” for the treatment of SUI before the introduction of midurethral slings.8 It can be performed through either an open abdominal approach or laparoscopically, with both methods showing comparable efficacy in treating stress urinary incontinence.9
Clinical Context
Burch Colposuspension is primarily used for the treatment of stress urinary incontinence (SUI) in women, especially when it is associated with urethral hypermobility.1 SUI is defined by the International Continence Society as “the complaint of involuntary urinary leakage on effort or exertion, or on sneezing or coughing.”2 This condition is highly prevalent, affecting approximately 17-45% of adult women in industrialized countries, and has a significant impact on women’s quality of life.3
Patient selection criteria for Burch Colposuspension include women with demonstrable stress urinary incontinence, particularly those with urethral hypermobility.4 Sufficient mobility and capacity of the vagina represent prerequisites for the success of colposuspension and must be considered particularly in patients after previous vaginal interventions.5 The procedure can also concomitantly treat mild forms of anterior wall prolapse, as noted in the original description by Burch.6
The surgical procedure can be performed through either an open abdominal approach or laparoscopically. The open approach involves a low transverse abdominal incision (Pfannenstiel) to access the retropubic space.7 Once the retropubic space is dissected, the bladder neck and the vaginal fascia underneath are identified. At each side of the bladder neck, two to four, preferably non-absorbable sutures are placed, apprehending the full-thickness of the vaginal wall.8 These sutures are then attached to the ipsilateral Cooper’s ligament, elevating the vagina with the knots gently adjusted without tension.9 A cystoscopy is typically performed afterward to rule out any potential damage to the bladder or the ureters.10
The laparoscopic approach offers advantages including lower morbidity, shorter hospital stay, faster recovery, and better cosmetic results.11 Studies have shown that laparoscopic Burch colposuspension may be as effective as the open procedure at 2 years post-surgery, with a non-significant 5% lower relative subjective cure rate.12
Expected outcomes for Burch Colposuspension show cure rates ranging from 68.9% to 88.0%, with recurrence rates remaining relatively low.13 However, it has been reported that the cure rate decreases steadily from 90% at 1 year to about 70% by 10 years postoperatively, reaching a plateau at 65-70% at a 20-year follow-up.14 Potential complications include hemorrhagic and infectious complications, erosions, and sinus tract formation.15 Long-term studies have shown a significant incidence of pelvic organ prolapse formation, with rectocele noted in 11-25% and enterocele in 4-10% of patients followed-up 10-20 years.16 The risk of de novo detrusor overactivity has been reported between 5% to 27%, with voiding dysfunction occurring in up to 22% of patients after Burch colposuspension.17
In current clinical practice, Burch colposuspension remains an option for secondary treatment after failed midurethral sling procedures.18 Open Burch colposuspension can be considered for those patients in whom a laparotomy is required concurrently with surgery for SUI.19 With the recent scrutiny of midurethral slings due to mesh-related complications, Burch colposuspension may regain prominence as a first-line treatment option.20