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A randomised trial of two surgical procedures for stress incontinence found that a pubovaginal sling fashioned from the rectus fascia works better than a Burch colposuspension, but it also causes more complications. Women who had a fascial sling were more likely to be cured of incontinence after two years (47% v 38%, P=0.01), but they were also more likely to develop voiding problems (14% v 2%, P<0.001). Urinary infections (305/326 v 203/329, P<0.001) and urge incontinence (27% v 20%, P=0.04) were both more common in women who had a sling procedureprocedure.
Overall success rates were lower than expected in this trial, and fell steadily during the two years of follow-up, possibly because the authors used a strict definition of cure—no self reported incontinence, no further treatment of any kind, a negative stress test, and a negative pad test. Success rates for stress incontinence alone were higher in both groups, but again the fascial sling outperformed the Burch colposuspension (66% v 49%, P<0.001). Eighty six per cent of women who had a fascial sling and 78% of those who had a Burch procedure said they were completely or mostly satisfied with the results after two years (P=0.02).
Both procedures are standard options for women with severe stress incontinence, and this rare randomised comparison is an important step forward in the evaluation of both, says an editorial (pp 2198).