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Evidence summaries

Surgery for Women with Apical Vaginal Prolapse

Sacral colpopexy appears to have slightly lower risk of awareness of prolapse, recurrent prolapse on examination, repeat surgery for prolapse, and postoperative stress urinary incontinence compared with vaginal procedures in women with apical vaginal prolapse. Level of evidence: "B"

Comment: The quality of evidence is downgraded by study limitations (unclear allocation concealment and blinding of outcome assessment in half of the studies).

Summary

A meta-analysis 2 included 50 trials (62 articles with 22 792 patients). Median follow-up was 1-5 years. Vaginal suspensions showed higher risk of overall and apical anatomic recurrence compared with sacrocolpopexy (RR 1.82, 95% CI 1.22 to 2.74 and RR 2.70, 95% CI 1.33 to 5.50), whereas minimally invasive sacrocolpopexy showed less overall and posterior anatomic recurrence compared with open sacrocolpopexy (RR 0.59, 95% CI 0.47 to 0.75 and RR 0.59, 95% CI 0.44 to 0.80, respectively). Different vaginal approaches, and hysterectomy and suspension compared with hysteropexy had similar anatomic success. Subjective POP recurrence, reintervention for POP recurrence and complications were similar between most procedures.

A Cochrane review [Abstract] 1 included 59 studies with a total of 6705 subjects. Vaginal procedures versus sacral colpopexy: After vaginal procedures, awareness of prolapse, recurrent prolapse, repeat surgery for prolapse, and stress urinary incontinence (SUI) were more common (table T1). There was no conclusive evidence that vaginal procedures increased bladder injury or repeat surgery for SUI (table).Vaginal surgery with mesh versus without mesh: There was no clear difference in awareness of prolapse, recurrent prolapse, or repeat surgery for prolapse (table T2). The confidence interval were very wide. There is probably little or no difference between the groups in rates of SUI (de novo) or dyspareunia; moderate-quality evidence).

Vaginal procedure versus sacral colpopexy for the repair of apical prolapse

OutcomeRelative effect(95% CI)Assumed risk - Control - Sacral colpopexyCorresponding risk - Intervention - Vaginal surgery (95% CI)No of Participants(studies) Quality of evidence
Awareness of prolapseRR 2.31(1.27 to 4.21)76 / 1000175 / 1000(96 to 318) 346(4) Moderate
Repeat surgery for prolapseRR 2.33(1.34 to 4.04) 61 / 1000142 / 1000(82 to 246) 497(6) Moderate
Recurrent prolapse on examinationRR 1.87(1.32 to 2.65)176 / 1000328 / 1000(232 to 465)422(5) Moderate
Intraoperative bladder injuryRR 0.46(0.13 to 1.63) 20 / 10009 / 1000(3 to 32)625(75) Moderate
Stress urinary incontinenceRR 1.86(1.17 to 2.94) 165 / 1000308 / 1000(193 to 486)263(3) Moderate

Vaginal mesh compared with no vaginal mesh for women with apical vaginal prolapse

OutcomeRelative effect(95% CI)Assumed risk - Control - Vaginal colpopexyCorresponding risk - Intervention - Vaginal meshNo of Participants(studies) Quality of evidence
Awareness of prolapse (3 years)RR 1.08 (0.35 to 3.30)179 / 1000193 / 1000(63 to 589)54(1) Low
Repeat surgery for prolapse (1 to 3 years)RR 0.57(0.30 to 1.06)102 / 100058 / 1000(31 to 108) 450(5) Low
Recurrent prolapse on examination (1-3 years)RR 0.36(0.09 to 1.40)504 / 1000181 / 1000(45 to 705)269(3) Low
Bladder injury3.00(0.91 to 9.89)14 / 100041 / 1000(12 to 135)445(4) Very low
SUI (de novo 1 to 3 years)RR 1.37(0.97 to 1.93)175 / 1000239 / 1000(169 to 337)463(6) Moderate

Clinical comments

Note

Date of latest search:2023-11-17

Primary/Secondary Keywords