A Cochrane review [Abstract] 1 included 56 studies on surgery in the management of pelvic organ prolapse, with a total of 5 954 subjects.
For upper vaginal prolapse (uterine or vault), abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77; 2 studies, n=169) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86; 3 studies, n=106). These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. In single studies the sacral colpopexy had a higher success rate on examination and lower reoperation rate than high vaginal uterosacral suspension and transvaginal polypropylene mesh.
For the anterior vaginal wall prolapses (cystocele), a variety of 21 surgical procedures was compared in 10 trials. Standard native tissue anterior repair was associated with more recurrent cystoceles than when supplemented by polyglactin mesh inlay (RR 1.39, 95% CI 1.02 to 1.90, statistical heterogeneity, I2 =57%; 2 studies, n=226) or porcine dermis mesh inlay (RR RR 2.08, 95% CI 1.08 to 4.01), but data on morbidity and other clinical outcomes were lacking. Standard anterior repair was associated with more anterior compartment failures on examination than for polypropylene mesh repair as an overlay (RR 2.14, 95% CI 1.23 to 3.74; 3 studies, n=251) or armed transobturator mesh (RR 3.55, 95% CI 2.29 to 5.51; 3 studies, n=361). No differences in subjective outcomes, quality of life data, de novo dyspareunia, stress incontinence, re-operation rates for prolapse or incontinence were identified. Blood loss (MD 64 ml, 95% CI 48 to 81), operating time (MD 19 min, 95% CI 16 to 21), recurrences in apical or posterior compartment (RR 1.9, 95% CI 1.0 to 3.4) and de novo stress urinary incontinence (RR 1.8, 95% CI 1.0 to 3.1) were significantly higher with transobturator meshes than for native tissue anterior repair. Mesh erosions were reported in 11.4% (64/563) and surgical interventions being performed in 6.8% (32/470).
Data from three trials compared posterior vaginal repair and transanal repair for the treatment of posterior compartment prolapse (rectocele). The posterior vaginal repair had fewer recurrent prolapse symptoms (RR 0.4, 95% CI 0.2 to 1.0) and lower recurrence on examination (RR 0.2, 95% CI 0.1 to 0.6) and on defecography (MD -1.2 cm, 95% CI -2.0 to -0.3).
Data from 3 trials compared native tissue repairs with a variety of total, anterior, or posterior polypropylene kit meshes for vaginal prolapse in multiple compartments. While no difference in awareness of prolapse was able to be identified between the groups (RR 1.3, 95% CI 0.6 to 1.7) the recurrence rate on examination was higher in the native tissue repair group compared to the transvaginal polypropylene mesh group (RR 2.0, 95% CI 1.3 to 3.1). The mesh erosion rate was 35/194 (18%), and 18/194 (9%) underwent surgical correction for mesh erosion. The reoperation rate after transvaginal polypropylene mesh repair of 22/194 (11%) was higher than after the native tissue repair (7/189, 3.7%) (RR 3.1, 95% CI 1.3 to 7.3).
Sixteen trials included significant data on bladder outcomes following a variety of prolapse surgeries. Women undergoing prolapse surgery may have benefited from having continence surgery performed concomitantly, especially if they had stress urinary incontinence (RR 7.4, 95% CI 4.0 to 14) or if they were continent and had occult stress urinary incontinence demonstrated pre-operatively (RR 3.5, 95% CI 1.9 to 6.6). Following prolapse surgery, 12% of women developed de novo symptoms of bladder overactivity and 9% de novo voiding dysfunction.
Comment: The quality of evidence is downgraded by inconsistency (heterogeneity in interventions and outcomes) and by indirectness (clinically important patient outcomes not reported).
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