In the Ward–Hilton study , 91% of women reported symptoms of bothersome urgency incontinence prior to Burch urethropexy that decreased post-procedure to 34% at 6 months and 2 years. On urodynamic testing, the number of women who developed unstable detrusor contractions increased from 1% pre-op to 10% 6 months following a Burch colposuspension. Similarly, persistent urgency incontinence was found in 18% of women enrolled in the Burch arm of the SISTEr trial and new-onset urgency incontinence remained low at 3%.

Possible etiologies of de novo urgency incontinence include UTI, obstructive voiding, and the presence of a foreign body in the lower urinary tract. In women whose symptoms persist after 6 weeks and post-void residuals are normal, conservative treatment for urgency incontinence can be considered including anticholinergics and behavior modifications. A woman who is not responsive or whose symptoms appear severe might benefit from a cystoscopic examination to rule out the presence of a foreign body in the lower urinary tract. Women, who have undergone a laparoscopic Burch procedure and have evidence of a foreign body in the bladder, may have undergone the procedure using metal helical “tackers” to suspend the bladder neck (Fig. 13.2). These are often placed or migrate into the bladder causing symptoms. If operative notes are not available, then an anterior/posterior and lateral plain x-ray will allow visualization of the offending material.

In his initial description of the surgical procedure, Burch reports the surgical complication of uterine or vaginal vault prolapse. As described previously, 18% of women developed symptomatic prolapse, and 4.8% underwent surgical correction over the 24 months of the Ward–Hilton study [13]. This is believed to be due to the anterior orientation of the vaginal apex. As a result, all women undergoing surgical correction of stress incontinence should have a complete physical exam including the evaluation of vaginal topography ideally in the standing-straining position. Women, who demonstrate apical or uterine descent of greater than 3 cm from optimal position with Valsalva effort, would more likely benefit from a synthetic or autologous suburethral sling since they have not been shown to increase the risk of POP. When a patient is undergoing treatment of POP following an incontinence procedure, care should be taken to not “over-correct” the apical support since this may result in incontinence .

Rates of voiding dysfunction following retropubic suspensions vary based on the definitions used, duration of the studies, and whether women with preexisting voiding dysfunction were excluded from enrollment. The Ward–Hilton study [13] defined a woman as having a voiding dysfunction when two of the three measurements were found on 6-month postoperative urodynamic studies (UDS) : peak flow < 15 mL/s, maximum voiding pressure > 50 cm H₂O, and residual volume > 100 mL. Of the women who underwent postoperative UDS, 7% were diagnosed with a voiding dysfunction. Thirty-three percent of women required catheterization (suprapubic, urethral, or intermittent) a week after surgery and this continued to diminish over time to 13% at 1 month, 8% at 6 months, and 2.7% at 24 months. There were no reports of surgical intervention for voiding dysfunction.

The SISTEr trial also had a gradual return to self-voiding in women undergoing the Burch procedure. While only 56% of women passed their first voiding trial, the authors reported low rates (2%) of voiding dysfunction > 6 weeks after surgery and no surgical revisions for voiding dysfunction in the 329 women who had undergone Burch procedure. As the series above demonstrate, most voiding dysfunction resolves by 6 weeks and can be treated conservatively with intermittent or indwelling catheterization. In addition, many patients may benefit by undergoing pelvic therapy specifically aimed at pelvic floor relaxation techniques [16].

When obstructive voiding symptoms persist, patients may benefit from filling cystometry and pressure-flow studies to determine if the etiology is obstructive or due to decreased detrusor function. In centers with fluoroscopy, imaging can be helpful. A cystoscopy at the same time would rule out suture placement in the urethra (although this is a rare phenomenon). The etiology is typically obstructive from sutures pulling the bladder neck ; sutures placed distally resulting in urethral kinking or scarring of the bladder neck to the back of the pubic bone.

Women who clearly demonstrate obstruction on UDS should be considered for an urethrolysis. In women who have physical exam findings of an indentation of the anterior vaginal wall where sutures have been placed, we consider a transvaginal urethrolysis. A midline vaginal incision is made ~ midurethra and carried to the level of the bladder neck . The dissection continues using sharp and blunt dissection as if making the sling tunnels for a rectus fascial sling. Tissue that is adherent to pubic bone is swept lateral to medial using the surgeon’s index finger. Since it is customary in our practice to use a permanent suture, we can palpate the suture as it travels from the proximal urethra and bladder neck to its attachment on the pubic bone (MMK) or Cooper’s ligament (Burch). A scissors is then guided to the level of the sutures behind the pubic bone by the surgeon’s index finger and the sutures are transected on each side.