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Burch Colposuspension

The Burch colposuspension (retropubic urethropexy) is the foundational mesh-free surgical option for female stress urinary incontinence (SUI), first described by John Burch in 1961. Permanent sutures elevate the anterior vaginal wall lateral to the urethra and bladder neck and are anchored to Cooper's ligament (iliopectineal ligament), restoring urethral support and increasing bladder-outlet resistance.[1][2][3] It is distinguished from the Marshall-Marchetti-Krantz (MMK) procedure, which anchors sutures to the periosteum of the pubic symphysis.[2][3]

For the broader female-SUI ladder, see Female Stress Incontinence Database. For mesh-free sling alternatives, see Female Slings & Suspensions. For office-based bulking, see Urethral Bulking Agents.

Mechanism and Anatomy​

Two to four non-absorbable sutures are placed through the paraurethral / paravaginal tissue on each side and tied to the iliopectineal (Cooper's) ligament on the pelvic sidewall, lifting the bladder-neck region and proximal urethra in the retropubic space (space of Retzius).[2][4][5] The result is restoration of urethral support and increased outlet resistance — distinct from the MMK pubic-symphysis-periosteum anchor, which carries an osteitis-pubis risk that helped drive Burch adoption historically.[2][3]

Indications​

  • Urodynamic SUI after failed or declined conservative management (PFMT, behavioral, pessaries).[3][11][1]
  • Vaginal access limited (prior vaginal surgery, narrow introitus).[12]
  • Concurrent intra-abdominal surgery planned (e.g., abdominal / laparoscopic sacrocolpopexy).[13]
  • Mesh contraindicated or patient declines mesh.[7][12][17]
  • Urethral hypermobility present — Burch is less effective for ISD-predominant SUI; in that subset, autologous fascial PVS or AUS is preferred.[5]

Technique​

Open retropubic Burch​

Pfannenstiel or low midline incision; enter the space of Retzius; expose paraurethral / paravaginal tissues; 2–4 non-absorbable sutures per side through the vaginal wall lateral to the urethra and bladder neck, then through Cooper's ligament; tie sutures to elevate the vaginal wall without excessive tension (avoid over-correction, which drives voiding dysfunction).[2][4][5]

Laparoscopic Burch​

2–3 trocars; transperitoneal approach (incise median umbilical ligament and vesicoumbilical fascia) or extraperitoneal entry into the retropubic space; same suture placement under laparoscopic visualization. Decreased blood loss, less pain, shorter hospital stay vs open at equivalent short-term efficacy.[8][9][10]

Modified "TOT-like" laparoscopic technique​

Sutures placed more laterally to mimic the transobturator-tape vector, potentially reducing voiding dysfunction.[8]

Intraoperative checks​

Cystourethroscopy is recommended to verify ureteral patency and absence of intravesical suture material.[11]

Concomitant Use with Sacrocolpopexy​

The landmark CARE trial (Brubaker 2006 NEJM) — abdominal sacrocolpopexy ± Burch in women without preoperative SUI — showed Burch reduced postoperative SUI from 44% → 24% at 3 mo.[13] ACOG supports offering a concomitant continence procedure during prolapse repair with appropriate counseling.[11] Preliminary contemporary data from laparoscopic sacrocolpopexy suggest the benefit is less clear in the minimally invasive setting given added operative time and complication risk.[14]

Outcomes​

EndpointBurchComparatorSource
Overall cure (SR, 12 trials)74%82% (MUS)Wu 2021 NEJM / Lapitan Cochrane[1][2]
Long-term SUI-free at mean 13.1 yr83%85% (retropubic MUS at 10.1 yr)Karmakar 2021[15]
14-yr subjective cure68.4%—Ye 2022[16]
5-yr cure82%—Baessler 2026 Cochrane[4]
10-yr cure55–69%—Baessler 2026[4]
Patient satisfaction (PGI-I) at 13 yr84.1%82.0% (retropubic MUS)Karmakar 2021[15]
24-mo overall success (SISTEr)38%47% (autologous fascial sling)Albo 2007 NEJM[5]
24-mo stress-specific success (SISTEr)49%66% (autologous fascial sling)Albo 2007[5]

SISTEr conclusion (Albo 2007): the autologous fascial sling resulted in higher successful treatment of SUI but greater morbidity than Burch.[5]

Karmakar 2021 (n = 1,344, mean 13.1 yr) — no significant difference in success, satisfaction, or complications between Burch and retropubic MUS; reoperation ~ 3.6% in both groups.[15]

Complications​

Perioperative​

  • Hemorrhage, wound complications.
  • Bladder or urethral injury (lower than with MUS).[1]
  • UTI.
  • Bowel injury (rare).

Long-term​

  • Voiding dysfunction — 10.3% (range 2–27%); 10.5% in 14-yr follow-up.[3][16]
  • De-novo OAB / urgency — ~ 5–17%.[3][15][16]
  • Posterior-compartment prolapse / enterocele — 7–13.6%; significantly higher than after MUS (3.3% vs 1.1%, p = 0.01) — well-recognized consequence of anterior-vaginal-wall elevation altering pelvic-support dynamics.[3][15]
  • Dyspareunia — ~ 4%.[16]
  • Repeat incontinence surgery — 3.5–5.3%.[15][16]
  • Chronic pain — rare.[15]

Current Role and Evolving Perspective​

Burch was historically a gold-standard procedure for SUI alongside the autologous PVS.[3][6] Use declined sharply with widespread adoption of midurethral synthetic mesh slings (TVT, TOT).[1] Following increased scrutiny of synthetic mesh — and the FDA actions restricting transvaginal mesh for prolapse — there has been renewed interest in Burch as a mesh-free alternative.[7][17][12] Current guidelines position it as a viable option, particularly as a secondary treatment or when mesh is contraindicated, and recommend its inclusion in fellowship training programs.[7][11][12]

Wu 2021 NEJM — Burch is less effective than MUS (overall cure 74% vs 82% in 12 trials) and is associated with longer hospitalization and similar or higher peri-operative risks, with the exception of bladder / urethral perforation and mesh exposure (more common with MUS).[1]

Summary​

Burch colposuspension lifts the anterior vaginal wall lateral to the bladder neck to Cooper's ligament, restoring urethral support and improving SUI without synthetic mesh. 74% overall cure in pooled Cochrane data; durable PGI-I satisfaction at 13 yr (84.1%) comparable to retropubic MUS. The defining limitations are higher rates of voiding dysfunction (~ 10%), de-novo urgency (~ 5–17%), and posterior-compartment prolapse (3× higher than after MUS). Best modern uses: at the time of abdominal / laparoscopic sacrocolpopexy (CARE trial), mesh-averse patients, and patients with limited vaginal access.[1][2][5][7][13][15]

References​

1. Wu JM. Stress incontinence in women. N Engl J Med. 2021;384(25):2428-2436. doi:10.1056/NEJMcp1914037.

2. 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.

3. Norton P, Brubaker L. Urinary incontinence in women. Lancet. 2006;367(9504):57-67. doi:10.1016/S0140-6736(06)67925-7.

4. 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.

5. 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.

6. Rogers RG. Urinary stress incontinence in women. N Engl J Med. 2008;358(10):1029-1036. doi:10.1056/NEJMcp0707023.

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

8. 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.

9. 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.

10. 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.

11. ACOG Practice Bulletin No. 155: urinary incontinence in women. Obstet Gynecol. 2015;126(5):e66-e81. doi:10.1097/AOG.0000000000001148.

12. Sohlberg EM, Elliott CS. Burch colposuspension. Urol Clin North Am. 2019;46(1):53-59. doi:10.1016/j.ucl.2018.08.002.

13. 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.

14. 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. doi:10.1016/j.jmig.2025.05.009.

15. 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.

16. 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.

17. 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.