The authors of this trial (Vol 107, April 2000)1 should be congratulated on their comprehensive reporting of clinically relevant outcome measures relating to a trial of surgery for urinary incontinence in women with cystocele. They rightly focus on long term cure rates, which show that abdominal retropubic suspension is better than anterior colporrhaphy for genuine stress urinary incontinence. This adds more weight to the evidence supporting the abdominal approach2.
They found that 19/35 women had a recurrence (or persistence) of prolapse after the Burch colposuspension. In contrast, only one (of 33 women) had a recurrent cystocele after anterior vaginal repair, and she was continent and asymptomatic. However, none of the 19 women consented to a subsequent repair, including the six who were deemed symptomatic, presumably because they were not sufficiently troubled by it. Therefore, we do not feel that this ‘disadvantage’ of the Burch colposuspension is sufficient grounds for recommending concomitant primary (vaginal repair) surgery, as the authors suggest. Indeed, combining the data with those from the one other study which reported it2,3 (3/83 after anterior repair vs 5/140 after abdominal retropubic suspension), gave an aggravated relative risk of having further prolapse surgery of 1.26, 95% CI 0.31–5.06. This highlights one of the pragmatic drawbacks of objective scoring systems for conditions versus subjective complaint. Also given that hysterectomy was undertaken by different routes in each arm, this in itself could have a confounding influence.
On the other hand, the authors found that dyspareunia was more common in the anterior repair group. However, all women who had the vaginal approach also had a posterior repair, whereas only 12/35 women in the Burch group had this additional procedure. Not all the women were sexually active. Could the authors clarify the incidence of dyspareunia amongst the 24 sexually active women in the Burch group who did have a posterior repair, and also compare the consequent shortening of the vaginal lengths in these women with those who had an anterior repair? This would lend weight to their conclusion that routine posterior repair should be abandoned, and only performed after careful consideration of symptoms in sexually active women.