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Burch Colposuspension

Burch colposuspension is a suture-based, mesh-free operation for female stress urinary incontinence (SUI). Sutures suspend the supportive vaginal tissues beside the bladder neck and proximal urethra toward Cooper's (iliopectineal) ligament. The aim is urethral support without excessive elevation or obstruction. It differs from the historical Marshall–Marchetti–Krantz (MMK) operation, which uses pubic periosteal fixation.[4]

Burch remains a surgical option in current AUA/SUFU and NICE guidance. It can suit a woman who wants to avoid both a mesh sling and fascial harvest, particularly when an abdominal pelvic operation is already planned. It is not limited to salvage surgery, and no one operation is best for every woman.[14][15]

For procedure selection, see the Female Stress Incontinence Database, Female Slings & Suspensions, and Urethral Bulking Agents.

Selection and Preoperative Assessment​

  • Confirm bothersome SUI or stress-predominant mixed incontinence, document stress leakage, and discuss pelvic-floor muscle training, continence devices and the available operations. Burch treats the stress component; urgency can persist or develop after surgery.[14][15]
  • Review prior continence/prolapse operations, voiding symptoms, postvoid residual, urinalysis, prolapse and tissue mobility. A fixed or scarred urethra/vagina may make colposuspension less suitable. Previous vaginal surgery or a narrow introitus does not by itself establish that Burch is the preferred operation.[4][14]
  • Urodynamics is not mandatory for every primary operation. AUA/SUFU permits omission in an otherwise uncomplicated index patient with clearly demonstrated SUI. Additional assessment is appropriate when the diagnosis is uncertain, emptying is impaired, urgency predominates, neurogenic disease is suspected, or prior surgery/prolapse complicates the presentation. NICE specifies preoperative cystometry for urge-predominant/unclear incontinence, voiding symptoms, anterior/apical prolapse or prior SUI surgery.[14][15]
  • For a fixed, immobile urethra, AUA/SUFU lists pubovaginal sling, retropubic midurethral sling, bulking or an adjustable retropubic sling as options; its discussion favors an autologous pubovaginal sling for a nonmobile urethra. A low leak-point pressure alone is not a reason to make an artificial urinary sphincter the default alternative.[14]
  • Discuss abdominal access and recovery, recurrent SUI, postoperative emptying problems, urgency and subsequent prolapse. A mesh-free operation still uses sutures and can cause suture-related complications.[4][10][14]

Anatomy and Operative Principles​

The retropubic space lies behind the pubic symphysis and in front of the bladder. Important structures include the bladder neck/proximal urethra, supportive anterior vaginal tissues, Cooper's ligament, the obturator neurovascular bundle, external iliac vessels and variable corona mortis vessels. Vaginal mobility and safe identification of these structures matter more than a fixed suture-distance recipe.[4]

Open Burch​

  1. Obtain retropubic exposure through a suitable lower abdominal incision and identify the bladder neck and proximal urethra. A catheter and vaginal assistance can help define the anatomy.
  2. Mobilize the bladder sufficiently to expose strong vaginal supporting tissue lateral to the bladder neck and proximal urethra. Avoid blind lateral dissection near the obturator/external iliac vessels and corona mortis.
  3. Place suspension sutures through the supportive vaginal tissue while avoiding the vaginal epithelium, bladder and urethra. A commonly described technique uses two sutures on each side; published techniques vary in number, material and exact position.
  4. Secure the sutures to the ipsilateral Cooper's ligament while supporting the vagina. Adjust the suspension without forcing the vaginal wall against the ligament or over-elevating/kinking the outlet. No fixed clamp, distance or tension rule replaces anatomic assessment.
  5. Perform cystoscopic inspection for bladder injury or intravesical sutures and check ureteral efflux. Address an abnormal finding before completing the procedure.[4]

Laparoscopic or Robotic Approach​

Transperitoneal or extraperitoneal access can reproduce the suture suspension; port number and configuration depend on the approach and accompanying operations. Laparoscopy generally permits faster recovery than an open incision, but the comparative evidence is strongest for short-term subjective continence. Do not infer equivalent long-term outcomes for every laparoscopic modification or for robotic surgery from these trials.[4][6][7]

The 2019 laparoscopic Cochrane review separates suture colposuspension from older mesh-and-staple colposuspension. Those are different interventions and should not be pooled uncritically when counseling about mesh-free Burch. The published “TOT-like Burch” report is an educational technique video; it does not establish that this modification reduces voiding dysfunction or improves durability.[5][6]

What the Comparative Evidence Shows​

Success depends on its definition, follow-up and the population studied. A strict composite of dryness, testing and no retreatment is not interchangeable with symptom improvement or satisfaction.

EvidenceResultInterpretation
SISTEr, multicenter randomized trial: 329 Burch and 326 autologous rectus-fascial sling assignmentsAt 24 months, Kaplan–Meier overall success estimates were 38% Burch vs 47% sling; stress-specific success was 49% vs 66%The sling improved continence more, with more morbidity. These percentages are time-to-event estimates, not raw fractions of all randomized women; 520 women had a known 24-month outcome.[3]
E-SISTEr, observational extension of the randomized cohortFive-year Kaplan–Meier continence estimates were 24.1% Burch vs 30.8% sling under the extension's stringent composite definition482 women enrolled and 357 completed five-year follow-up; incontinent women were more likely to enroll. Satisfaction remained higher than strict dryness: 126/172 Burch and 148/179 sling respondents were satisfied at five years.[16]
2019 Cochrane: laparoscopic suture vs open colposuspensionSubjective cure within 18 months: RR 1.04, 95% CI 0.99–1.08; 6 trials, 755 womenHigh-certainty evidence for this short-term endpoint; longer-term comparative evidence and many harm estimates remain uncertain.[6]
Karmakar 2021, matched observational cohortNo ongoing SUI reported by 279/336 (83.0%) after open Burch and 857/1,008 (85.0%) after retropubic MUSMean follow-up differed: 13.1 vs 10.1 years. This was not a randomized equivalence trial, excluded intrinsic sphincter deficiency, and used different endpoints from SISTEr. Later prolapse surgery was more frequent after Burch.[10]

SISTEr's overall success required a negative pad test, no leakage in a three-day diary, a negative stress test, no self-reported stress-incontinence symptoms and no retreatment. Stress-specific success omitted the pad-test and diary requirements. E-SISTEr used no diary leakage, no self-reported stress symptoms and no surgical retreatment; its outcome is not identical to the original trial endpoint.[3][16]

Long-term cohorts support durability for some women but cannot supply a universal cure rate: in Ye's 14-year cohort, 39/57 respondents reported no SUI, but only 57/84 original participants completed follow-up. Conrad's 90.5% result combined cure or substantial improvement, rather than dryness alone.[11][12]

A small 2026 open-label trial reported more 12-month failures after laparoscopic Burch than transobturator tape (34.6% vs 7.7%; 26 women per arm). Its abstract adds short-term comparative information, but cannot overturn the broader evidence or establish superiority of every sling route. The 2017 open-colposuspension review and 2019 laparoscopic review also have older search dates; their conclusions must be read alongside current guidelines and later trials.[1][6][13][14][15]

Concomitant Prolapse Surgery​

First distinguish existing symptomatic SUI, occult SUI after prolapse reduction, and no demonstrable SUI. Discuss a combined operation versus reassessment and staged continence treatment; an abdominal route alone is not an indication for prophylactic Burch.[14][15]

CARE randomized 322 women without preoperative stress-incontinence symptoms who were undergoing abdominal sacrocolpopexy. The journal's 2016 correction changed the three-month composite SUI endpoint to 33.6% with Burch vs 57.4% without Burch after correction of stress-test coding. The endpoint included symptoms, stress testing or treatment; it was not simply bothersome leakage. The previously published 23.8%/44.1% rates should not be used.[8][17][18]

The 2026 Cochrane prolapse/continence review judged the evidence for prophylactic Burch in stress-continent women uncertain: two abdominal-sacrocolpopexy trials gave a two-year SUI RR of 0.72 (95% CI 0.53–0.99), with substantial inconsistency (I² = 75%) and low certainty. This review does not establish five- or ten-year cure rates for isolated Burch. Its favorable findings for concomitant midurethral slings in symptomatic/occult SUI concern different populations and procedures.[2]

CARE should not be assumed to prove the same benefit during every minimally invasive sacrocolpopexy. A 2025 nonrandomized interim cohort had only 20 women, mixed preoperative continence states and patient-selected treatment; it cannot resolve the question. Use individualized counseling about postoperative SUI risk, additional operative morbidity and staged treatment.[9][14][15]

Complications and Follow-up​

  • During and soon after surgery: bleeding, bladder injury, intravesical suture, infection, wound problems and impaired emptying. Burch is not uniformly safer than every MUS route. The laparoscopic review found uncertain comparative bladder-injury and voiding-dysfunction estimates.[4][6]
  • Emptying: arrange a postoperative voiding assessment and a catheterization plan when needed. Persistent obstruction warrants reassessment. In SISTEr, protocol-defined voiding dysfunction was less frequent with Burch than with autologous sling (2% vs 14%); do not transfer this comparison to every sling material or technique.[3][14]
  • Urgency/UUI: pre-existing urgency may persist and new symptoms can occur. SISTEr's excess treated postoperative UUI with sling was mainly persistent disease; new treated UUI occurred in 11 women in each arm (about 3%). Urgency symptoms and urodynamic detrusor overactivity are different outcomes.[3]
  • Later prolapse: in Karmakar's cohort, subsequent prolapse surgery occurred in 11/336 (3.3%) after Burch and 11/1,008 (1.1%) after retropubic MUS; 9 of the 11 Burch repairs involved the posterior compartment. These are rates of prolapse surgery, not the prevalence of any anatomical prolapse.[10]
  • Later recurrent SUI, pain, dyspareunia or urinary symptoms: investigate the cause, including emptying dysfunction, recurrent prolapse and suture exposure or bladder erosion when indicated. Persistent/recurrent symptoms require review rather than a fixed long-term complication percentage drawn from unrelated cohorts.[4][10][11][14]

Review continence, urgency, emptying, residual urine, pain, healing and sexual function after surgery. AUA/SUFU recommends early contact for significant problems and an examination within six months; longer-term access to reassessment remains important because recurrence and complications may appear later.[14]

References​

1. Lapitan MCM, Cody JD, Mashayekhi A. Open retropubic colposuspension for urinary incontinence in women. Cochrane Database Syst Rev. 2017;7:CD002912. doi:10.1002/14651858.CD002912.pub7.

2. Baessler K, Christmann-Schmid C, Haya N, et al. Surgery for women with pelvic organ prolapse with or without stress urinary incontinence. Cochrane Database Syst Rev. 2026;2:CD013108. doi:10.1002/14651858.CD013108.pub2.

3. Albo ME, Richter HE, Brubaker L, et al. Burch colposuspension versus fascial sling to reduce urinary stress incontinence. N Engl J Med. 2007;356(21):2143-2155. doi:10.1056/NEJMoa070416.

4. Veit-Rubin N, Dubuisson J, Ford A, et al. Burch colposuspension. Neurourol Urodyn. 2019;38(2):553-562. doi:10.1002/nau.23905.

5. Aleksandrov A, Meshulam M, Rabischong B, Botchorishvili R. Laparoscopic TOT-like Burch colposuspension: back to the future? J Minim Invasive Gynecol. 2021;28(1):24-25. doi:10.1016/j.jmig.2020.04.018.

6. Freites J, Stewart F, Omar MI, Mashayekhi A, Agur WI. Laparoscopic colposuspension for urinary incontinence in women. Cochrane Database Syst Rev. 2019;12:CD002239. doi:10.1002/14651858.CD002239.pub4.

7. Hill AJ, Jallad K, Walters MD. Laparoscopic Burch colposuspension using a 3-trocar system: tips and tricks. J Minim Invasive Gynecol. 2017;24(3):344. doi:10.1016/j.jmig.2016.08.816.

8. Brubaker L, Cundiff GW, Fine P, et al. Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med. 2006;354(15):1557-1566. doi:10.1056/NEJMoa054208.

9. Oyama K, Ikeda S, Yuda M. Does concurrent Burch colposuspension reduce postoperative stress urinary incontinence in laparoscopic sacrocolpopexy? An interim analysis. J Minim Invasive Gynecol. 2025;32(9):807-814. doi:10.1016/j.jmig.2025.05.009.

10. Karmakar D, Dwyer PL, Murray C, et al. Long-term effectiveness and safety of open Burch colposuspension vs retropubic midurethral sling for stress urinary incontinence — results from a large comparative study. Am J Obstet Gynecol. 2021;224(6):593.e1-593.e8. doi:10.1016/j.ajog.2020.11.043.

11. Ye Y, Wang Y, Tian W, et al. Burch colposuspension for stress urinary incontinence: a 14-year prospective follow-up. Sci China Life Sci. 2022;65(8):1667-1672. doi:10.1007/s11427-021-2042-9.

12. Conrad DH, Pacquee S, Saar TD, et al. Long-term patient-reported outcomes after laparoscopic Burch colposuspension. Aust N Z J Obstet Gynaecol. 2019;59(6):850-855. doi:10.1111/ajo.13048.

13. Abughanima MF, Elazab AS, Shalaby M, et al. "Laparoscopic Burch Colposuspension Versus Transobturator Tape for the Treatment of Stress Urinary Incontinence in Egyptian Women: A 12-Month Randomized Controlled Trial." Neurourol Urodyn. Published online August 11, 2026. doi:10.1002/nau.70403

14. American Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. Surgical Treatment of Female Stress Urinary Incontinence. 2017; amended 2023. Official guideline.

15. NICE. Urinary incontinence and pelvic organ prolapse in women: management. NG123. Recommendations, especially 1.3.15–1.3.16, 1.5.1–1.5.3 and 1.9.1–1.9.2.

16. Brubaker L, Richter HE, Norton PA, et al. Five-year continence rates, satisfaction and adverse events of Burch urethropexy and fascial sling surgery for urinary incontinence. J Urol. 2012;187(4):1324-1330. doi:10.1016/j.juro.2011.11.087. Full text.

17. Correction: Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med. 2016;374:2297-2298. doi:10.1056/NEJMx160015.

18. Brubaker L, Brown MB, Weber AM. Corrections to report of a trial of Burch colposuspension. N Engl J Med. 2016;374:2295. doi:10.1056/NEJMc1605817. University-hosted journal correspondence.