Redefining Success: Burch vs Midurethral Sling at the Time of Sacrocolpopexy

INTRODUCTION: There is no agreed-upon definition of success for the surgical treatment of stress urinary incontinence (SUI). A recent study by Raju et al. (2024) suggests that less stringent definitions of surgical success better differentiate patient-assessed symptom improvement than stringent composite definitions that require negative cough stress test (CST), no urinary leakage, and no reoperation. The authors proposed defining surgical success as no re-treatment for SUI and one of three patient-reported outcome measures. OBJECTIVE: The objective of this study is to utilize these patient-centered definitions of surgical success for treatment of SUI to reanalyze the results of a 2016 randomized control trial comparing Burch retropubic urethropexy to synthetic midurethral sling placement at the time of abdominal sacrocolpopexy. METHODS: This study utilized data collected during a multicenter, single-blinded randomized trial comparing Burch with midurethral sling at the time of abdominal sacrocolpopexy with follow-up through 2 years. We evaluated 3 primary continence outcomes. Continence was defined as no retreatment for SUI and either 1) International Consultation on Incontinence Questionnaire, Short Form (ICIQ) ≤5; 2) Urinary Distress Inventory (UDI-6) ≤33.3; or 3) “no” or “mild” response to UDI-6 question 3. Primary outcomes were assessed with intention-to-treat (ITT), within-protocol (WPA), and last value carried forward (CF) analyses. Comparisons between groups were evaluated with χ 2 or Fisher exact test. RESULTS: Baseline features were similar between groups. At both 6 months and 2 years, there was no difference between the two procedures when continence was defined as no re-treatment and an ICIQ score ≤5 (Burch 60.7 % (34/56) vs midurethral sling 73.7% (42/57); p=0.069 for ITT analysis). However, when continence was defined as no re-treatment and UDI-6 score ≤33.3 or UDI-6 question 3 “no” or “mild,” women undergoing a Burch had significantly lower continence rates compared to those who had a midurethral sling at 6 months follow-up (Table 1). This difference was maintained at 2 years for the single-item UDI-6 definition (p=0.013), but not the UDI-6 ≤33.3 definition (p=0.144). CONCLUSIONS: Utilizing patient-centered, less stringent definitions of continence following surgical treatment of stress urinary incontinence at the time of sacrocolpopexy yielded improved continence scores following midurethral sling in two of three definitions of success. Although our results were not uniform across the patient-centric definitions, the information provided should facilitate future meaningful comparisons across continence studies.