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Surgical management of pelvic organ prolapse in women.
Cochrane Database Syst Rev. 2007 Jul 18CD

Abstract

BACKGROUND

Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with prolapse.

OBJECTIVES

To determine the effects of the many different surgeries in the management of pelvic organ prolapse.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 3 May 2006) and reference lists of relevant articles. We also contacted researchers in the field.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse.

DATA COLLECTION AND ANALYSIS

Trials were assessed and data extracted independently by two reviewers. Six investigators were contacted for additional information with five responding.

MAIN RESULTS

Twenty two randomised controlled trials were identified evaluating 2368 women. 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) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86), but the trend towards a lower re-operation rate for prolapse following abdominal sacrocolpopexy was not statistically significant (RR 0.46, 95% CI 0.19 to 1.11). However, the vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The data were too few to evaluate other clinical outcomes and adverse events. The three trials contributing to this comparison were clinically heterogeneous. For the anterior vaginal wall prolapse, standard 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) or porcine dermis mesh inlay (RR 2.72, 95% CI 1.20 to 6.14), but data on morbidity, other clinical outcomes and for other mesh or graft materials were too few for reliable comparisons. For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele and/or enterocele than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64), although there was a higher blood loss and postoperative narcotic use. However, data on the effect of surgery on bowel symptoms and the use of polyglactin mesh inlay or porcine small intestine graft inlay on the risk of recurrent rectocele were insufficient for meta-analysis.Meta-analysis on the impact of pelvic organ prolapse surgery on continence issues was limited and inconclusive, although about 10% of women developed new urinary symptoms after surgery. Although the addition of tension-free vaginal tape to endopelvic fascia plication (RR 5.5, 95% CI 1.36 to 22.32) and Burch colposuspension to abdominal sacrocolpopexy (RR 2.13, 95% CI 1.39 to 3.24) were followed by a lower risk of women developing new postoperative stress incontinence, but other outcomes, particularly economic, remain to be evaluated.

AUTHORS' CONCLUSIONS

Abdominal sacrocolpopexy is associated with a lower rate of recurrent vault prolapse and dyspareunia than the vaginal sacrospinous colpopexy. 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. The use of mesh or graft inlays at the time of anterior vaginal wall repair may reduce the risk of recurrent cystocele. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The addition of a continence procedure to a prolapse repair operation may reduce the incidence of postoperative urinary incontinence but this benefit needs to be balanced against possible differences in costs and adverse effects. Adequately powered randomised controlled clinical trials are urgently needed.

Authors+Show Affiliations

Maher C
Sandford Jackson Building - Level 4, Suite 86, 30 Chasely Street, Auchenflower, Queensland, Australia, 4066. chrismaher@urogynaecology.com.au
Baessler K
No affiliation info available
Glazener CM
No affiliation info available
Adams EJ
No affiliation info available
Hagen S
No affiliation info available

MeSH

FemaleGynecologic Surgical ProceduresHumansProlapseRandomized Controlled Trials as TopicRectal ProlapseSurgical MeshSuture TechniquesUrinary Bladder DiseasesUrinary IncontinenceUterine Prolapse

Pub Type(s)

Journal Article
Meta-Analysis
Review
Systematic Review

Language

eng

PubMed ID

17636742

Clinical Trial Links

SIS Graft and Traditional Repair in Vaginal Wall Prolapse

Citation

Maher, C, et al. "Surgical Management of Pelvic Organ Prolapse in Women." The Cochrane Database of Systematic Reviews, 2007, p. CD004014.
Maher C, Baessler K, Glazener CM, et al. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2007.
Maher, C., Baessler, K., Glazener, C. M., Adams, E. J., & Hagen, S. (2007). Surgical management of pelvic organ prolapse in women. The Cochrane Database of Systematic Reviews, (3), CD004014.
Maher C, et al. Surgical Management of Pelvic Organ Prolapse in Women. Cochrane Database Syst Rev. 2007 Jul 18;(3)CD004014. PubMed PMID: 17636742.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Surgical management of pelvic organ prolapse in women. AU - Maher,C, AU - Baessler,K, AU - Glazener,C M A, AU - Adams,E J, AU - Hagen,S, Y1 - 2007/07/18/ PY - 2007/7/20/pubmed PY - 2007/10/19/medline PY - 2007/7/20/entrez SP - CD004014 EP - CD004014 JF - The Cochrane database of systematic reviews JO - Cochrane Database Syst Rev IS - 3 N2 - BACKGROUND: Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with prolapse. OBJECTIVES: To determine the effects of the many different surgeries in the management of pelvic organ prolapse. SEARCH STRATEGY: We searched the Cochrane Incontinence Group Specialised Trials Register (searched 3 May 2006) and reference lists of relevant articles. We also contacted researchers in the field. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse. DATA COLLECTION AND ANALYSIS: Trials were assessed and data extracted independently by two reviewers. Six investigators were contacted for additional information with five responding. MAIN RESULTS: Twenty two randomised controlled trials were identified evaluating 2368 women. 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) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86), but the trend towards a lower re-operation rate for prolapse following abdominal sacrocolpopexy was not statistically significant (RR 0.46, 95% CI 0.19 to 1.11). However, the vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The data were too few to evaluate other clinical outcomes and adverse events. The three trials contributing to this comparison were clinically heterogeneous. For the anterior vaginal wall prolapse, standard 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) or porcine dermis mesh inlay (RR 2.72, 95% CI 1.20 to 6.14), but data on morbidity, other clinical outcomes and for other mesh or graft materials were too few for reliable comparisons. For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele and/or enterocele than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64), although there was a higher blood loss and postoperative narcotic use. However, data on the effect of surgery on bowel symptoms and the use of polyglactin mesh inlay or porcine small intestine graft inlay on the risk of recurrent rectocele were insufficient for meta-analysis.Meta-analysis on the impact of pelvic organ prolapse surgery on continence issues was limited and inconclusive, although about 10% of women developed new urinary symptoms after surgery. Although the addition of tension-free vaginal tape to endopelvic fascia plication (RR 5.5, 95% CI 1.36 to 22.32) and Burch colposuspension to abdominal sacrocolpopexy (RR 2.13, 95% CI 1.39 to 3.24) were followed by a lower risk of women developing new postoperative stress incontinence, but other outcomes, particularly economic, remain to be evaluated. AUTHORS' CONCLUSIONS: Abdominal sacrocolpopexy is associated with a lower rate of recurrent vault prolapse and dyspareunia than the vaginal sacrospinous colpopexy. 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. The use of mesh or graft inlays at the time of anterior vaginal wall repair may reduce the risk of recurrent cystocele. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The addition of a continence procedure to a prolapse repair operation may reduce the incidence of postoperative urinary incontinence but this benefit needs to be balanced against possible differences in costs and adverse effects. Adequately powered randomised controlled clinical trials are urgently needed. SN - 1469-493X UR - https://www.unboundmedicine.com/medline/citation/17636742/Surgical_management_of_pelvic_organ_prolapse_in_women_ L2 - https://doi.org/10.1002/14651858.CD004014.pub3 DB - PRIME DP - Unbound Medicine ER -