Comparing Surgical Options for Bladder Control in Women

A growing number of women who face difficulties with bladder control opt for surgery to correct the problem. But few studies have compared different treatment options. Now, the largest, most rigorous clinical trial of its kind has compared two common surgical procedures to restore bladder control and identified one — known as the fascial sling — that more successfully treats urinary incontinence and leads to greater patient satisfaction.

Up to half of American women have urinary incontinence, according to some estimates. At least 50% of those affected have a condition known as stress incontinence, in which urine accidentally leaks during physical exertion — like coughing, laughing, sneezing or lifting heavy objects. Incontinence can sometimes be remedied through medication or pelvic muscle exercises. But over the past 2 decades, a steadily increasing number of women have been undergoing surgery to restore bladder control. Two common surgical procedures — the fascial sling and the Burch colposuspension — have long been used to treat urinary incontinence in women. The sling procedure uses a strip of the patient's own connective tissues to lift and properly position the urethra, the tube that carries urine from the bladder to the outside of the body. The Burch technique involves attaching sutures to pelvic structures to support the urethra. The cure rates for both procedures have been estimated at 60-90% in previous clinical studies, but the relative benefits and drawbacks of each have been unclear. The new findings are the first clinical trial results from the Urinary Incontinence Treatment Network, a group of clinical centers funded by NIH's National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institute of Child Health and Human Development (NICHD) and Office of Research on Women's Health. As reported in the May 24, 2007, issue of the New England Journal of Medicine, researchers randomly assigned 520 women to receive either the sling or the Burch surgery to treat their urinary incontinence. Two years after surgery, overall cure rates were significantly higher for the sling procedure (47%) than for the Burch technique (38%). These success rates are lower than those reported from previous clinical trials, a difference that could be due to the current study using a more rigorous standard for defining success. Interestingly, the higher success rates in the sling group were offset by higher rates of complications, including difficulties with urination and persistent urge incontinence, which involves a strong, sudden urge to urinate followed by a bladder contraction that results in leakage. The most common unwanted side effect was urinary tract infections, which affected 63% of women with a sling compared to 47% of the Burch group. Despite the side effects, 86% of the women who received the sling procedure said they were satisfied with the results of the surgery, compared to 78% of the Burch group. The researchers say their findings provide important information that will help physicians and patients make more informed decisions about the tradeoffs involved in different surgical options for improving bladder control.