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The MMK, the first retropubic urethropexy popularized, at least in the United States, is where stitches are placed from the vagina very close to the urethra or actually the urethra itself to the symphysis pubis. This has initial success rates of around ninety percent and good longevity five years later in eighty percent of people. Here, stitches typically with the original MMK description and the modified Simmons method at Mayo clinic, where they open the bladder neck to see, three stitches placed right along the urethra, along its length, going up to the pubic symphysis. This can result in osteitis pubis in anywhere from one to nine percent of patients and is why John Burch originally did the Burch procedure, to try to avoid that complication.
Another retropubic urethropexy of sorts is the paravaginal repair. George White originally described this procedure in 1908, calling it the obturator shelf repair using sutures from the anterolateral vaginal sulcus to the arcus tendineus fascia of the pelvis. People talk about cure rates in the ninety percent range with this procedure. However, in prospective studies that have been done of small series, the cure rate may be as low as thirty-five percent. Here again, if you think about this operation, where you place suture with multiple simple sutures or figure-of-eight sutures, to reduce the number needed, of a permanent of absorbable suture of the anterolateral vaginal sulcus, back to the arcus tendineus fascia, in most of the patients that I see, the anterior vaginal wall may be as wide as 6 cm. If that is the case and you have someone who has marked urethral hypermobility, even if it is from a paravaginal defect, and you suture 3 to 4 cm away on either side to the arcus, that may restore normal anatomy of the anterior vaginal wall, but if there is some central relaxation, there still may be enough urethral hypermobility that many of these people stay incontinent, especially if they have decreased urethral intrinsic function. Certainly, if you are going to use this operation, you would love to do it as an anti-incontinence operation in people with very good urethral intrinsic function and they may be able to withstand some degree of urethral hypermobility.
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In two prospective comparative trials, both by Columbo and his group in Italy, in 1994 they reported on a prospective randomized trial looking at MMK versus Burch after two to seven years of follow up with an objective cure rate in the MMK group of sixty-five percent and eighty percent in the Burch group. These were not significant due to type 2 error and low numbers. They looked at Burch versus paravaginal repair after one to three years; they went and studied with Bobbie Shoal and then had Bobbie Shoal come to Italy to look at how they were doing these operations. He signed off on this with Burch procedure one hundred percent objective cure rate versus sixty-one percent objective cure rate for the paravaginal group that was statistically significantly different.