Surgical management of pelvic organ prolapse in women

• Published in: Cochrane database of systematic reviews 2010-04 (4), p.CD004014-CD004014
• Main Authors: Maher, Christopher, Feiner, Benjamin, Baessler, Kaven, Glazener, Cathryn Ma
• Format: Article
• Language: English
• Subjects: Female; Gynecologic Surgical Procedures - methods; Humans; Pelvic Organ Prolapse - surgery; Randomized Controlled Trials as Topic; Rectal Prolapse - surgery; Secondary Prevention; Surgical Mesh; Suture Techniques; Urinary Bladder Diseases - surgery; Urinary Incontinence - surgery; Uterine Prolapse - surgery
• ISSN: 1469-493X
• DOI: 10.1002/14651858.CD004014.pub4

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. To determine the effects of the many different surgeries used in the management of pelvic organ prolapse. We searched the Cochrane Incontinence Group Specialised Register (9 February 2009) and reference lists of relevant articles. We also contacted researchers in the field. Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse. Trials were assessed and data extracted independently by two review authors. Six investigators were contacted for additional information with five responding. 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 r