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Surgical management of pelvic organ prolapse in women.

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 the prolapse.

OBJECTIVES

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

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (9 February 2009) 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 review authors. Six investigators were contacted for additional information with five responding.

MAIN RESULTS

Forty randomised controlled trials were identified evaluating 3773 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). However there was no statistically significant difference in re-operation rates for prolapse (RR 0.46, 95% CI 0.19 to 1.11). The vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The three trials contributing to this analysis were clinically heterogeneous.For anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented with a 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 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) or armed transobturator mesh (RR 3.55, 95% CI 2.29 to 5.51). Data relating to polypropylene mesh overlay were extracted from conference abstracts without any peer reviewed manuscripts available and should be interpreted with caution. 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 with transobturator meshes was significantly higher than for native tissue anterior repair. Mesh erosions were reported in 10% (30/293) of anterior repairs with polypropylene mesh.For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele or enterocele, or both, than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64); although there was a higher blood loss and post-operative narcotic use. No data exist on efficacy or otherwise of polypropylene mesh in the posterior vaginal compartment.Meta-analysis on the impact of continence surgery at the time of prolapse surgery was performed with data from seven studies. Continence surgery at the time of prolapse surgery in continent women did not significantly reduce the rate of post-operative stress urinary incontinence (RR 1.39, 95% CI 0.53 to 3.70; random-effects model).

AUTHORS' CONCLUSIONS

Abdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse and dyspareunia than with 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 reduces the risk of recurrent anterior wall prolapse, on examination. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The value of the addition of a continence procedure to a prolapse repair operation in women who are dry before operation remains to be assessed. Adequately powered randomised controlled clinical trials are urgently needed on a wide variety of issues and particularly need to include women's perceptions of prolapse symptoms.

Authors+Show Affiliations

Wesley Urogynaecology Unit, Wesley Hospital, Sandford Jackson Building - Level 4, Suite 86, 30 Chasely Street, Auchenflower, Queensland, Australia, 4066.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Meta-Analysis
Review
Systematic Review

Language

eng

PubMed ID

20393938

Citation

Maher, Christopher, et al. "Surgical Management of Pelvic Organ Prolapse in Women." The Cochrane Database of Systematic Reviews, 2010, p. CD004014.
Maher C, Feiner B, Baessler K, et al. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2010.
Maher, C., Feiner, B., Baessler, K., Adams, E. J., Hagen, S., & Glazener, C. M. (2010). Surgical management of pelvic organ prolapse in women. The Cochrane Database of Systematic Reviews, (4), CD004014. https://doi.org/10.1002/14651858.CD004014.pub4
Maher C, et al. Surgical Management of Pelvic Organ Prolapse in Women. Cochrane Database Syst Rev. 2010 Apr 14;(4)CD004014. PubMed PMID: 20393938.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Surgical management of pelvic organ prolapse in women. AU - Maher,Christopher, AU - Feiner,Benjamin, AU - Baessler,Kaven, AU - Adams,Elisabeth J, AU - Hagen,Suzanne, AU - Glazener,Cathryn Ma, Y1 - 2010/04/14/ PY - 2010/4/16/entrez PY - 2010/4/16/pubmed PY - 2010/5/22/medline SP - CD004014 EP - CD004014 JF - The Cochrane database of systematic reviews JO - Cochrane Database Syst Rev IS - 4 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 the prolapse. OBJECTIVES: To determine the effects of the many different surgeries used in the management of pelvic organ prolapse. SEARCH STRATEGY: We searched the Cochrane Incontinence Group Specialised Register (9 February 2009) 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 review authors. Six investigators were contacted for additional information with five responding. MAIN RESULTS: Forty randomised controlled trials were identified evaluating 3773 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). However there was no statistically significant difference in re-operation rates for prolapse (RR 0.46, 95% CI 0.19 to 1.11). The vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The three trials contributing to this analysis were clinically heterogeneous.For anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented with a 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 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) or armed transobturator mesh (RR 3.55, 95% CI 2.29 to 5.51). Data relating to polypropylene mesh overlay were extracted from conference abstracts without any peer reviewed manuscripts available and should be interpreted with caution. 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 with transobturator meshes was significantly higher than for native tissue anterior repair. Mesh erosions were reported in 10% (30/293) of anterior repairs with polypropylene mesh.For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele or enterocele, or both, than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64); although there was a higher blood loss and post-operative narcotic use. No data exist on efficacy or otherwise of polypropylene mesh in the posterior vaginal compartment.Meta-analysis on the impact of continence surgery at the time of prolapse surgery was performed with data from seven studies. Continence surgery at the time of prolapse surgery in continent women did not significantly reduce the rate of post-operative stress urinary incontinence (RR 1.39, 95% CI 0.53 to 3.70; random-effects model). AUTHORS' CONCLUSIONS: Abdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse and dyspareunia than with 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 reduces the risk of recurrent anterior wall prolapse, on examination. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The value of the addition of a continence procedure to a prolapse repair operation in women who are dry before operation remains to be assessed. Adequately powered randomised controlled clinical trials are urgently needed on a wide variety of issues and particularly need to include women's perceptions of prolapse symptoms. SN - 1469-493X UR - https://www.unboundmedicine.com/medline/citation/20393938/Surgical_management_of_pelvic_organ_prolapse_in_women_ L2 - https://doi.org/10.1002/14651858.CD004014.pub4 DB - PRIME DP - Unbound Medicine ER -